At this year's 9th Annual Society of Trauma Nurses' conference in Las Vegas, entitled "Trauma Nursing: Realities and Practicalities," at the Advanced Trauma Care for Nurses open forum, the guest speaker was Dr James Styner (Figure 1). As many trauma nurses are aware, Dr Styner was instrumental in developing the Advanced Trauma Life Support (ATLS) program 28 years ago. This program was developed out of the need to provide appropriate trauma care to injured victims in the rural setting. This became obvious to Dr Styner after he and his family were involved in a plane crash in the cornfields of rural Nebraska. The Society of Trauma Nurses owes a great thanks to Dr Styner; through his tragedy grew a great program: ATLS. Other programs have been modeled after ATLS, such as the Advanced Trauma Care for Nurses (ATCN) and Prehospital Trauma Life Support (PHTLS). At present the ATCN program is now being taught in over 20 states, encompassing over 70 sites within the United States and 4 international sites. If you would like information on how to bring ATCN to your facility, contact us at ATCN@traumanursesoc.org.
The following is the story of how ATLS came to be, as told by Dr Styner at the 2006 Society of Trauma Nurses conference.
Richard Henn, RN, BSN, MEd Chair, ATC Committee
Good afternoon, thank you for inviting me. Hopefully, today, I can tell you a story that will entertain you, educate you, and make you feel good about what you do as nurses, especially in the field of trauma.
It has been my observation and perhaps yours as well that people, groups, and even nations tend to drift closer together if they adopt or develop something in common, usually through some type of alteration in a preexisting discipline or the creation of a new discipline. By chance, I participated in such an event. As with so many situations where change occurs, it started with a tragedy, which resulted in the recognition of a need for change.
Our story begins 30 years ago, when there was an airplane crash. Out of the mass of metal, the injured, and the dead, ATLS was born. The following is a chronicle of what took place, as I remember it.
It was February 17, 1976, we left Los Angeles, California, to return home to Lincoln, Nebraska, after attending a Valentine's Day wedding. The 6 of us were flying in a 6-seat Beach Barron twin. We flew east over southern California, crossed Arizona, and landed in Farming, New Mexico, to refuel. We preceded around the southern Rockies and turned North across Texas, over Oklahoma, and into Kansas, where we noted a sand storm over the northern part of the state. In Nebraska, we intercepted a low, thin cloud layer. I was not IFR (instrument flight rules) rated and chose to stay below the clouds. I did not want to turn around because of the weather behind us.
My wife, Charlene, was sitting in the copilot seat, she was 32, 10 years my junior. Our 10-year-old son, Christopher, was sitting behind me facing the oxygen bottle strapped to the back of the pilot's seat. Kimberly, his 3-year-old sister, was sitting on his lap, having just been placed there by his mother. Chris buckled the lap belt around the 2 of them. Charlene turned back but did not have time to buckle herself in. Randal, 7 years old, sat in the back to the right next to the rear luggage door. Richard, 8 years old, was next to him. At 5 hours into the flight, I became disoriented and lost altitude. It was 6:00 pm and already dark. We flew over a pond and into a row of trees at 168 miles per hour. The wings were ripped off and the fuel tanks emptied. A large hole was torn in the right side of the aircraft. We dropped onto a thicket that cushioned our landing and rocketed onto a field. The airplane traveled 294 ft; it rotated 180° and stayed upright. We faced so that a mild breeze was against the left intact side of the aircraft. The temperature dropped to 26°F that night.
At impact, Charlene was ejected from the airplane; a piece of prop off the left engine came through the pilot window, missed me, and hit her in the head. She died instantly. She came to rest 306 ft from the impact site. Kim impacted the oxygen bottle with her head. She sustained a blowout fracture of the right orbit and a forehead laceration. She was unconscious for 7 days. Chris crashed into her back and was spared a head injury but had both a bone fracture of the right forearm and a severe laceration of the dorsum of the right hand. Rick had a laceration of the forehead and a laceration of the right supraorbital nerve. He also remained unconscious for 7 days. Randy sustained an open depressed skull fracture. His right leg came out of the luggage door and was impaled at the popliteal fossa by a piece of metal from under the aircraft. He remained in coma for 3 days. My face was planted against the steering wheel and dash. What seemed like eternity took 2 1/2 seconds. There was a tremendous noise; I waited for the end to come, and then there was silence. I sustained fractured ribs over the spleen. My forehead and face were lacerated, my left eye was closed, and I had difficulty seeing out of the right. The right zygomatic arch had an open fracture. I had a left frozen shoulder from a fall when I was skiing 2 months earlier that had resulted in a fracture of the greater tuberosity of the humerus. The watch on my left wrist was smashed, but my arm had no marks (Figure 2).
I don't know how long I sat there after the world became silent; it seemed like just a second. The first thing I thought about after "you're still alive" was fire; I evacuated to the right into the opening and ran into barbwire that entangled the aircraft. This got my attention and my next thought was "the kids are still in there!" I saw Randy and started to extract him when I realized he was pinned under the fuselage. Chris tried to give me Kim and discovered his right arm was fractured. I set Kim away from the aircraft and removed Rick. I then turned my attention to Randy. I used only my hands to dig the leg out. I don't know how hard the ground was but there were no marks on my hands. His leg fell off the impalement and I waited for the bleeding, it never started. Chris was able to extract himself.
Now that all were away from the aircraft and fire was not a problem, I realized we had a potential for hypothermia. We gathered clothing from scattered suitcases and made a bed in the back compartment, placed the kids on top, and piled more cloth over them. Chris and I sat in the front and waited for help; it never came.
I went looking for my wife 3 different times and found her on the third try, checked her, and confirmed she was gone. The overcast skies dissipated and we had a clear sky with a near full moon. I went back to check her 3 more times to be sure she was gone.
While sitting in the aircraft, we could see a road to the left some distance away. After waiting until about 2:00 am, I decided to go for help. I instructed Chris to stay with the children. We talked about my rib injury and the possibility of a spleen problem. He was instructed not to come looking for me if I did not return, but to stay with the children. Both of us handled the entire experience without any outward emotion. I walked about 5/8 of a mile along a dirt road next to the pond to the highway and flagged down a car after 2 trucks failed to stop. I had to jump into a roadside ditch as the trucks passed to keep from getting hit. As I approached the car, the occupants saw the dried blood on my face and thought it might be a mask; they chose to wait. Their names were Rick and David. I told them what had happened. We drove back to the accident site and loaded up the kids. I cannot recall how we assembled 7 in the car or how much protection we gave their necks.
While I was digging out my son's leg from under the airplane and lifting the kids, I felt no pain. After help arrived, I was unable to lift because of chest and shoulder pain. I don't recall any facial pain. Amazing what adrenaline can do for you.
While at the crash site, first, I had to worry about fire, then about hypothermia. The wounds were possible bleeding problems. We protected the necks as best we could. I did most of the lifting; because of Chris's fractured arm, he acted as my eyes. Without him, the task would have been next to impossible. We splinted his arm, I said goodbye to my wife, and we drove to a local community hospital, a few miles south.
We arrived at the hospital, a rather motley crew, with clothes tattered and torn muddy and wet and our faces bloody. We went up to the emergency room door of this rural hospital. It was locked. We knocked, and the night nurse opened the door and was quite startled. We explained our predicament and ask her if we could get the kids inside. She informed us that we would have to wait until the doctors arrived. Obviously, she did not know what to do and just reacted. I cannot remember our response, but we gained entrance. I was not about to lose one of the children at this point, especially in a car sitting next to the hospital. A little later, the doctors arrived. They were 2 general practitioners in this small farming community: Dr Pembry and Dr Bunting both responded. I remember standing at a mirror picking dried blood off my face and trying to help. Rick was becoming more agitated. This had started at the crash site and was one of the reasons for the evacuation. One of the doctors picked him up by the shoulders and the knees and took him into the x-ray room. Try to picture the motion of his head and neck with this maneuver. A little while later, he brought the patient back and announced that there was no skull fracture. The cervical spine had not been considered. He then began to suture the 9-hour-old facial laceration. An IV was placed in Richard and he was given Valium. I don't remember anyone else receiving IVs. I don't remember becoming hostile, but I am told that I would not let them treat my family further. I called my partner in practice and the airplane, Bruce Miller, and told him what had happened and that we would get to Lincoln as soon as possible; he notified the hospital, it was about 4 am.
It was evident the doctors and the staff had little or no preparation for this kind of a situation. There was an obvious lack of training for proper triage and treatment. Of course, this occurred before ATLS and, in fact, was the catalyst for it.
SEARCH AND TRANSPORTATION TO LINCOLN
Now, I want to go back and tell you something about the search and rescue. A sheriff helicopter piloted by Larry Russell, who had been a patient, was assigned to aid in the search or had volunteered to join in the search, after it was suggested he not go, I am not sure which. A search aircraft called looking glass came down from South Dakota, picked up our emergency locator bacon, and directed the helicopter to the crash site. He landed about 1/2 hour after we had vacated. He proceeded to the hospital after being notified of our arrival there. I am told he had about a thimble full of gas left at landing.
The civil air patrol (CAP) was now also searching. There were 2 groups looking in different areas. They arrived at the crash site some hours later. The search started about midnight. The FAA (Federal Aviation Administration) rule was that all the airports in the area had to be physically checked first, and then a search and rescue could begin. This took about 6 hours!
The helicopter pilot assessed the situation at the hospital and suggested we ask the Lincoln Air National Guard to transport. They arrived at the hospital with a transport helicopter and we were loaded into the aircraft for the 110-mile flight to Lincoln. There was a crew of 3, Dr Pembry, a nurse, and the 5 of us. Rick and David, who picked us up at the crash site, disappeared and I never saw them again. We departed and I noted the IV had been discontinued. This was the first medical air evacuation by the Air National Guard in that area. The CAP, from its formation in the 1950s to 1976, responded to its first crash where there were survivors.
We landed at Lincoln airport and were transported to Lincoln General Hospital by ambulance. The emergency room was ready and the operating rooms were kept open. We arrived about 8:00 am, 14 hours after the crash. Waiting for us was the emergency room physician, Ron Craig, who I will talk about a little later on, my partner, Bruce Miller, and a plastic surgeon, Larry Ruth, who I was skiing with when I fractured my shoulder. The team of doctors and nurses who had been waiting about 4 hours acted like a coiled spring that had been released. Finally, I could become a patient and let someone else do the work. I can describe this experience as coming out of a hostile dark hell into civilization. So ended the longest night of my life.
ATLS IS BORN
For the next year or so, we tried to heal our physical and emotional scars. Folks around Lincoln probably got tired of my criticism of the treatment we received prior to arriving in Lincoln. It was not so much that I was complaining about the care at any particular facility but of the lack of a delivery system to treat the acute trauma patient in the rural setting. The statement in the ATLS manual "When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed" emphasizes this observation. Simply put, you have to train them before you can blame them.
So, Ron Craig, the ER physician who was responsible for triage and assessment upon arrival at Lincoln General Hospital, and I started talking about how to prevent my experience from happening again. He probably said something like "Styner, quit your griping and put your money where your mouth is." We decided we wanted to educate rural physicians in a systematic way to treat trauma. The 2 of us got together with Jodie Bechtel, then a nurse with the Lincoln Area Mobile heart team, which is now a paramedic group. The 3 of us decided to do a training course for rural Nebraska. We were influenced by the work Steve Carvith had done in creating the ACLS (Advanced Cardiac Life Support) course. He was also from Lincoln. Jodie had worked with him on that project. We decided to use a similar format and call it ATLS. Not so original, but it seemed to catch on. We all became ACLS instructors in order to learn more about the course and how it was organized. A lot of help was needed. A syllabus had to be created and arranged into a logical approach to trauma. Somewhere along the way, we got the idea of seeing a problem and fixing it before attacking the next problem, rather than look at every system involved, making a diagnosis, then going back to provide treatment. This approach was developed after much controversy but seemed to be appropriate in life-threatening trauma situations.
Among those that joined in was a mobile heart team nurse named Irvene Hughes. She is now the manager of the ATLS program for the American College of Surgeons Committee on Trauma, a job she took in 1982. Another individual who was with us from the beginning was a peripheral vascular surgeon, Paul (Skip) Collicott. He had the political know-how to get things going and took the lead. Several doctors joined us, and we each wrote chapters focused on our specialties for the syllabus. The ABCs of trauma was developed as a way to prioritize the order of assessment and treatment. Nothing new was added. We just took what was known and organized it in a different, more efficient approach for treating the trauma patient. The prototype course was field tested in Auburn, Nebraska, in 1978 with the help of several groups and individuals. Skip presented the course to the University of Nebraska, who was supportive and helped with the inclusion of the hands-on surgical skill lab using live, anesthetized dogs. Next, Skip got The American College of Surgeons Committee on Trauma involved. We took the finished course to the 13 regions of the college and presented our work. It was then arborized within each region.
Twenty-eight years have gone by since that first course in Auburn and ATLS keeps on spreading and growing. What we thought would be a course for rural Nebraska became a course for the world in all types of trauma settings, from the rural hospital to the level 1 trauma center to the military. Besides the nurses, the paramedics now also have ATLS-based courses, PHTLS. Everyone involved with the trauma victim speaks the same ATLS "language." This ability to communicate and anticipate at all levels decreases morbidity and mortality in the "golden hour."
I want to deviate for a minute to tell you about a personal experience as to how the "language" of ATLS made a difference. I was doing a medical mission in Ayacucho Peru 3 years ago. Peru is a member of the ATLS family. About 100 miles from the hospital, a fire fight occurred between the Peruvian marines and the insurgents known as the Shinning Path. Two of the marines became causalities. One marine had an AK47 GSW to the abdomen and the right brachium, shattering the humerus. The other had stepped on a land mine, partially amputating the left leg and sustaining a severe soft tissue injury to the opposite member and the left hand. In the rather primitive ER, I helped stabilize the patients. The benefits of ATLS were obvious. The marine personnel and native doctors spoke Spanish, working along with Americans doctors that spoke English. There was only 1 doctor who was bilingual. The common thread was the ATLS "language" that was used by both groups, enabling efficient, effective assessment and stabilization…so different from our 1976 experience.
From the origination of ATLS, 500,000 doctors have been trained in 46 countries, and 25,000 courses have been taught; 24,000 physicians graduate worldwide each year.
Since 2001, ATCN has trained 4,500 nurses in 5 nations, and at present, about 1,200 graduate each year. It looks like we're on a roll. I think we might want to introduce it to the Moon and Mars next.
Compared to what happened during the 9-11 terrorist attacks, the recent tsunami in Asia, the disaster in the Gulf of Mexico from hurricane Katrina, and the other nature and man-made disasters that have occurred in the past 20 to 30 years throughout the world, our experience was just child's play. Hopefully, what we have done, all of us together as part of the ATLS family, has played a part in saving some of these soles.