Portal de Periódicos da CAPES

Training for trauma

2007; Wiley; Volume: 62; Issue: 9 Linguagem: Inglês

10.1111/j.1365-2044.2007.05229.x

1365-2044

David Southern, Aruni Sen,

Abdominal Trauma and Injuries

Life-threatening polytrauma, defined as Injury Severity Score [1] in excess of 15, is a rare event forming just 1% of cases presenting to the typical Emergency Department. The rarity of the condition is no reason for complacency; poor treatment of these patients is a potent cause of mortality and morbidity. These factors make a strong case for doctors to learn trauma skills in a controlled environment and to practise these skills on simulators before having to use them for real in a life or death situation. Numerous studies have shown that trauma patients are better managed by doctors who have attended the Advanced Trauma Life Support (ATLS) [2] course [3, 4]. Despite this evidence the course has not been unanimously endorsed by all trauma clinicians in the UK, who have become polarised into supporters and detractors of ATLS. This division of opinion has not prevented success on an ATLS course from becoming a prerequisite for appointment to the registrar grade for most specialties that are involved in trauma care. The recent development of other trauma courses prompts several questions: Is ATLS an appropriate assessment of competence for doctors of all specialties who care for the trauma patient? Are other courses more appropriate for some specialties? What course would best suit a trainee with a specialist interest in trauma? What training is available for prehospital trauma care? What is the situation nationally and internationally? ATLS began in the USA in 1977 and was introduced into the UK in 1989. It used educational methods that were a revolutionary departure from traditional lectures. Skill stations based on small group tutorial principles ensured that candidates not only knew about interventional procedures, they were actually taught the manual skills to perform them. ATLS also introduced assessment by simulation; an actor played the role of a trauma patient in a ‘moulage’ scenario for assessment of a candidate's competence on completion of the course. Throughout the 1990s, ATLS represented the standard of care for the management of trauma patients. More than half a million doctors have trained as ATLS providers internationally and the ATLS approach has become the common language of trauma patient management. Passing an ATLS course now forms an essential component of training for surgeons and emergency medicine trainees as well as being a highly desirable entry qualification to the registrar grade for anaesthetists. ATLS has been a mixed success in the UK. When the English Royal College of Surgeons adopted the ATLS course, it was prevented from anglicising the syllabus because of copyright restrictions. The syllabus is designed for application in the USA and fulfils the needs of a single-handed, surgically trained practitioner working ‘up-state’ away from a Level-1 trauma centre. For instance, it encourages the use of a surgical cut-down for access to the saphenous vein but advises extreme caution with rapid sequence induction of the head-injured patient. In its patient management scenarios, the course endorses tracheal intubation of the trauma patient without the use of induction agent or neuromuscular blockers. Intubation under these conditions is virtually impossible, detrimental to the patient and is entirely inappropriate in Britain and Europe, where the trauma patient is managed by a team including a skilled anaesthetist. Indeed, ‘trauma team’ is a term that receives little mention in the ATLS manual. The American approach is also difficult to practise in developing countries which lack expensive facilities (e.g. CT scanners, a key component of diagnosis in the ATLS syllabus). The ATLS course is a significant drain on the study leave budget of trainees and of professional leave for instructors. Course fees are relatively high because of additional registration costs payable to the American College of Surgeons. This, and the initial high set-up costs, make ATLS unaffordable in many developing countries. The need for instructors to attend all 3 days of each ATLS course they teach and to teach a minimum of three courses every 2 years to revalidate, add up to a significant demand for professional leave. Many hospital Trusts are questioning whether they can afford to lose so much consultant time when training is a low priority compared to financial and waiting-time targets. Under this pressure, many consultants have stopped instructing on ATLS courses, adding to the waiting period almost a year for trainees enrolling as candidates [5]. (Admittedly, the same pressures affect other courses; some are shorter at 2 days duration but most are not significantly cheaper). ATLS has also been criticised for not meeting its title ‘advanced’ and for failing to incorporate recent developments. The course teaches essential trauma care skills needed for most specialty trainees but adds little to the ‘skill-set’ of an advanced Specialist Trainee who may function in the trauma team. There was a long delay between the publication of the 6th edition of the course manual in 1997 and the next edition in 2004. The 7th edition failed to incorporate important developments such as permissive hypotension in management of the shocked patient. The once revolutionary teaching methods have been somewhat weakened by poor quality Powerpoint® (Seattle, USA) slides. Even the most enthusiastic ATLS instructors have been disappointed. In the context of disillusionment with ATLS, trainees and instructors are looking to other trauma courses. The organisation Anaesthesia Trauma and Critical Care [6] was established in 1998 to address the failing of ATLS to consider the role of anaesthetists working in trauma teams in British hospitals. ATACC teaches ‘state-of-the-art’ trauma care from an anaesthetic perspective and has also become popular among Emergency Medicine doctors who are embracing the value of rapid sequence induction of the trauma patient in the resuscitation room. ATACC teaches advanced skills using high fidelity simulators for such techniques as the surgical airway. Its lectures are constantly updated and reference contemporary controversies such as the role of hypertonic fluids in resuscitation and the developing role of the focused abdominal sonography for trauma (FAST) scan. ATACC covers all aspects of trauma management from ‘Roadside to Critical Care’ and thus addresses the needs of trauma doctors who are part of prehospital emergency response teams. The ATACC organisation has a small faculty based in the North-West of England. The course has the capacity to enrol 100 candidates annually, which is insufficient to meet the needs of all trainee anaesthetists, let alone other specialties. About one-third of the syllabus is on prehospital trauma care and therefore superfluous to the needs of some anaesthetic trainees (although it may be of particular value to emergency medicine doctors). ‘Graduates’ from the ATACC course will possess skills making them eminently suitable to be members of the Medical Emergency Response Teams (MERITs) envisioned by the Department of Health [7]. ATLS deals only with management of the trauma patient in the resuscitation room – it does not teach operative surgical techniques that are difficult to acquire during the general surgical curriculum. The Royal College of Surgeons of England (together with the Royal Centre for Defence Medicine and the Health Sciences Faculty of the US Uniformed Services University) addressed this deficit by establishing the Definitive Surgical Trauma Skills course. This is an advanced level course enrolling consultant surgeons and senior surgical trainees. With capacity for just 40 candidates annually at a cost of over £1000 per student for a 3-day course, it is designed specifically for the budding trauma surgeon. Unregulated expansion of motorised transport is causing a pandemic of trauma in the developing world. There is a desperate need to improve trauma care in many countries that cannot afford the high price of the ATLS course. These same countries cannot afford the expensive hospital infrastructure (e.g. access to CT scanners) that is assumed in the American system of management of trauma patients. This situation prompted a group of altruistic doctors to establish the Primary Trauma Care Foundation [8] and PTC Course. This course is designed to train surgeons, anaesthetists and other health professionals involved in the prevention and early management of severe trauma using the basics of primary and secondary survey but tailored to the confines of their time, experience and local resources. The first course was run in Fiji in 1997 and it has spread rapidly throughout South-East Asia and East Africa. It has been a highly successful course with appropriate use of available technology for many developing countries. The Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh established the Dip IMC in 1988 as the standard of competence for doctors and other healthcare professionals working in the prehospital environment, such as those with the British Association for Immediate Care (BASICS). The Diploma is an exam assessing knowledge, fundamental skills such as tracheal intubation and includes a patient management scenario. It is concerned entirely with prehospital medicine and approximately half of the syllabus is trauma. All parts of the exam are taken on the same day so, unlike an ATLS course, the Diploma is not designed to teach a candidate new skills. The Faculty of Pre-hospital Care runs a number of training courses designed to coach students through the exam. Diplomates would be competent to take part in MERIT teams; those with a continuing practice in the prehospital environment are eligible to sit for the Fellowship in Immediate Medical Care. The examination and courses do not address any of the advanced skills required for trauma care. The European Resuscitation Council established the European Trauma Course in 2006 and has recently run the first two courses in Europe. It will be launched at the Second London Trauma Conference in July and is likely to hold courses in the UK later in 2007. Some faculty members of the Advanced Life Support Group (ALSG) have contributed to the British component of the course that has drawn support from trauma care doctors and current ATLS instructors throughout Europe. The syllabus has been designed to meet the needs of trainees working in Britain and the rest of Europe. Its educational perspective differs from ATLS in that it teaches trainees to apply their existing skills to the trauma situation and dwells on current UK and European practices of trauma care. It is a 2-day course consisting mainly of scenario-based teaching with very few didactic lectures. It remains to be seen whether ETC will displace ATLS as the standard of competence in managing the trauma patient in the UK. By way of summary, we would like to offer our own answers to the questions posed at the beginning of this editorial. ATLS and ETC both offer the “core curriculum” of trauma care required by junior doctors caring for patients with life-threatening injuries. Doctors who passed the ATACC course or the Dip IMC exam have already demonstrated competence in trauma management at least equal to that required by the ATLS and ETC courses. Anaesthetists and Emergency Medicine specialists with an interest in trauma management should be encouraged to do the ATACC course. Surgeons with a specialist interest in trauma management should be encouraged to do the Definitive Surgical Trauma Skills course. Doctors with an interest in pre-hospital trauma care should do the ATACC course and acquire the DipIMC. Both qualifications are suitable for doctors intending to be part of a MERIT team. The Primary Trauma Care Course is currently the most suitable course for doctors with a trauma interest practising in developing countries. Once the ETC is fully established, it has the potential to spread worldwide as the new common language of trauma care. ETC will need to overcome the rigid constraints of copyright, syllabus and registration that the American College of Surgeons have allowed to strangle the life-blood out of the once so-promising ATLS course. Both authors are ATLS Instructors. Dr Southern is a founder member of ATACC.