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22/11/2015

ATLS: Encore rebof

Ongoing military evolution of Trauma Life Support

Mercer SJ et Al. Anaesthesia. 2015 Nov;70(11):1332-3

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Encore un avis sur l'apport de l'ATLS et son caractère très basique et probablement non adapté au contexte de la médecine tactique, du moins pour les personnels devant s'y confronter réellement. Des jugements à méditer car l'impact budgétaire d'enseignements tels qu'ATLS, PHTLS, .... n'est pas négligeable.

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We read with interest the editorial by Wiles [1], illustrating that the Advanced Trauma Life Support Course (ATLS) has not evolved in line with current UK trauma management. In the Defence Medical Services (UK-DMS), our own Battlefield Advanced Trauma Life Support Course (BATLS) [2] diverged significantly from ATLS in 2005 to reflect our high-threat working environment and the blast and ballistic mechanisms that predominated. There was also a paradigm shift in the initial assessment and management of casualties to <C> ABC from the traditional ABC [3], where <C> represents the need to control catastrophic haemorrhage on the battlefield first, with soldiers trained to apply limb tourniquets and topical haemostatic dressings.

We have addressed a number of the concerns raised by Wiles [1] in our Military Operational Surgical Training (MOST) Course [4] that has now been running since 2010. This consists of an intensive 5-day programme designed for the whole of the complex trauma team, emphasising team resource management issues [5] and evolving rapidly to incorporate current research and new experience from the deployed environment. Until recently, this course focused on deployments to Afghanistan, but it has recently changed to allow preparation for contingency deployments anywhere in the world.

Activities include multidisciplinary workshops in the Royal College of Surgeons cadaver laboratory, allowing the link between anatomy and surgical techniques as part of the integrated damage-control resuscitation – damage-control surgery sequence [6], focusing on decision-making, communication and teamworking. Workshops also cover topics such as the management of difficult airway in trauma, damage-control resuscitation, near-point testing in resuscitation and anaesthesia with limited resources. There is also the opportunity to discuss ethical issues, paediatrics, critical care, acute pain, pre-hospital and in-transit care, and to practise regional anaesthesia techniques specifically for trauma.

We firmly believe that it is best to train in the teams that are going to deploy together, and fully immersive simulation scenarios allow the trauma team to rehearse together in the actual roles that they will fulfil on deployments. Post-scenario debriefs allow the opportunity for in-depth discussion of complex issues that may be encountered in the post-Afghanistan era. This allows the development of mental models and we are able to manipulate scenarios further to alter timelines for resupply and casualty evacuation, and discuss the actual implications to the medical facility of performing surgery.

In 2013 we designed a Level-3 Continuous Professional Development matrix that was published by the Royal College of Anaesthetists (RCoA) [7] and our trainees are expected to complete the Military Anaesthesia Higher Module [8] before CCT. The MOST course is mapped across competences in both of these and we are grateful to the RCoA for its support, as it is invaluable for the revalidation of military anaesthetists.

We agree that ATLS is a very basic course. Within the UK-DMS we continue to look to exercise and test the whole system and have a suite of courses that include advanced pre-hospital care on the Medical Emergency Response Team [9] (MERT) course, through BATLS and MOST to the Hospital Exercise HOSPEX [10] which allows a whole-system macro-simulation, crucial for those just about to deploy or commence a standby commitment.

  • Wiles MD. ATLS: Archaic Trauma Life Support? Anaesthesia 2015; 70: 893906.
  • Mercer SJ, Whittle CL, Mahoney PF. Lessons from the battlefield: human factors in Defence Anaesthesia. British Journal of Anaesthesia 2010; 105: 920.
  • Hodgetts TJ, Mahoney PF, Russell MQ, Byers M. ABC to <C>ABC: Redefining the military trauma paradigm. Emergency Medicine Journal 2006; 23: 7456.
  • Mercer SJ, Whittle C, Siggers B, Frazer RS. Simulation, human factors and Defence Anaesthesia. Journal of the Royal Army Med Corps 2010; 156(S1): 3659.
  • Mercer SJ, Arul S, Pugh H, Midwinter MJ. Performance improvement through best practice team management – human factors in complex trauma. Journal of the Royal Army Medical Corps 2014; 160: 1058.
  • Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philosophical Transactions of the Royal Society B: Biological Sciences 2010; 366: 192203.
  • Mercer SJ. Training and revalidation in Defence Anaesthesia. Bulletin of the Royal College of Anaesthetists 2013; 80: 168.
  • 8Woolley T, Birt DJ. Competencies for the military anaesthetist. Bulletin of The Royal College of Anaesthetists 2008; 52: 26616.
  • Haldane A. Advanced airway management - a Medical Emergency Response Team perspective. Journal of the Royal Army Medical Corps 2010; 156: 15961.
  • 10 Arora S, Sevdalis N. HOSPEX and concepts of simulation. Journal of the Royal Army Medical Corps 2008; 154: 2025

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