- The Nebraska Concept

             I have known about ATLS my whole life.  I thumbed through my dad’s research as it was being born.  I heard him talk about it from time to time.  I knew at least vaguely what it was about and what it was for.

            Something like this:  Many years ago some doctors determined that there was a disease that wasn’t really being recognized for what it was.  This was a special disease, because unlike other diseases, this one didn’t inflict itself primarily on the weak and old.  In fact, the victims of this disease were more often the young and the strong.  Often they were people in the prime of their life.  And it was killing them by the thousands and thousands.

They called the disease trauma.  It was unique because in its individual pieces it appeared as auto accidents and gunshot wounds.  Kitchen knife lacerations and falls from roofs.  Individual accidents and emergencies.  Not diseases in the traditional sense of the word.  But nobody was looking at these single cases from a larger perspective.  When they did, they quickly realized there were common threads that ran through all of them.  And when pulled that thread, an epidemic appeared.

They decided that if it was a disease, then there could be a common way to treat trauma in all its forms.  They began to study the disease, figure it out, and they found a way to fight it.  Simple facts that had not been considered about the disease and new way of looking at trauma treatment in general began to emerge.  ATLS was born soon after.

Before, there was no standard of care for the trauma patient in the United States, or anywhere else for that matter.  The primary accepted method for any emergency room patient including a trauma victim was the same for all cases, and generally consisted of a diagnosis of the patient starting at the head and working down to the toes, then considering the findings from the complete exam and basing the treatment on that complete diagnosis of the whole patient.

Hopefully while all of this was done your patient didn’t die.  ATLS changed that.  As they found how trauma worked, a new treatment philosophy was developed.  It was based largely on the fact that what looks bad on a patient at first glance may not be the worst of their worries, and the real problem may not be apparent at all.  A system of treatment was needed to recognize the priorities of what would kill them the fastest. 

For example, upon my arrival to UCI a series of diagnostic events occurred in a specific order and in the same way they are done in every emergency room throughout the United States and in many other countries throughout the world.  The ABC’s of trauma (actually it’s A, B, C, D and E):

            In a nutshell, the first thing they did was to protect my cervical spine (with that goddamn collar) and then immediately checked if I could mechanically breathe – assessment of my airway, which is A.  Then they checked to make sure I was really breathing (which is B), and that the undamaged airway was actually functional.  Then, when they saw I was breathing, they quickly searched me for serious bleeding (C for Circulation).  Then they diagnosed my spine, head, and neck for injury (D for Disability).  Then they made sure I had external resources to quickly receive fluids (or suck them out), medication, and oxygen, as well as to monitor my vitals (that’s E, for Environment).

Everything happened in a set and specific order, and each problem was found and fixed before the next was diagnosed.  They (the system) also got me there to the hospital within the ‘golden hour’ of the injuries, after which serious problems tend to become exponentially worse and more dangerous with each passing moment.

These are the basic tenants of Advance Trauma Life Support.  It is now the standardized method of treating trauma throughout much of the world.  It is based on a very simple principle:  Know what will kill a patient fastest, and treat that first - before moving to the next thing. 

If, say, my trachea was crushed there would not have been much sense in treating anything else because lack of oxygen due to severe trauma will kill a human being quicker and more surely than almost anything else.  Quicker than blood loss, quicker than a non-immediately fatal head injury, quicker than anything.  So it makes sense to treat that and only that first.  Focus your resources; attack one target at a time, then move to the next one.

They found that trauma deaths generally occur in one of three stages.  The first stage is the victim killed very quickly of grave injuries before intervention can arrive.  The second stage is within a few hours of the initial trauma as the initial injury begins to cause periphery system failure.  The third stage is in the weeks following the injury due to infections and sepsis.  From this, they determined that although there was not a lot they as physicians could do during the first stage they could work to improve the response process and equip the EMTs and paramedics in the field to better care for the patient at the scene.  This would automatically increase the chances of victims avoiding stage 2 death.  And thereby, if they could improve the treatment of the patient entering the emergency room from the scene, the victim would have a better chance of avoiding stage three death.

They tried it-and it worked, better than they could have ever imagined.  Lives began to be saved by the thousands and thousands. 

For those who study trauma now, it seems like a basic concept.  But in reality it was one that was pretty much unknown in the medical community until one fateful night roughly halfway through the 1970’s.  Until the events of that night, nobody had really ever thought about it, at least to the extent of doing anything about it.    

ATLS is not unique insomuch as it exists; there have been many such advances in medicine over the years.  Consider the massive advances in sciences like neurology or cardiology or oncology, for example.  Or stem cell research.  But it the genesis of the inspiration of ATLS that is different and significant, or at least I think so. 

It is a story not of laboratories and research or funding grants and committees.  Instead it is the story of that moonlit and twisted airplane smashed in that dead and frozen field.  It is smeared with the blood of a family. 

Every doctor trained in ATLS has read about the event.  It is discussed in the History section of the ATLS Student Manual in the words that Irvine Hughes wrote, which strike the reader hard pulling them down to the moment, down to that field.  Doctors who read it say that those words carry an impact that made them understand the gritty nature of trauma medicine.  Made them understand what force it was in themselves that drew them to this vocation - and which was more powerful than the stress or the long hours or the horrors at the center of it all that they would witness.  In their brilliantly simple way, those words capture it:

“The Nebraska Concept and Inception:

The Delivery of trauma care by doctors in the U.S. was at best inconsistent before 1980.  A tragedy occurred in February 1976 that changed trauma care in the ‘first hour’ for the injured patient in the U.S. and in much of the rest of the world.  An orthopedic surgeon, piloting his plane, crashed in a rural Nebraska cornfield.  The surgeon sustained serious injuries and 3 of his children sustained critical injuries, and 1 child sustained minor injuries.  His wife was killed instantly.  The care his family received was inadequate by the day’s standards.  The surgeon, recognizing how inadequate his treatment was, stated:  ‘When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed’”

 That led to one of the most revolutionary advances in trauma care ever, and one which is still being practiced relatively unchanged today.  It has saved countless lives all over the world.

But to me, the words of that passage smell of dark and cold and mud.  To me, they mean everything.  I was there, a child critically injured in that field.  I was freezing against that cold.  That mud packed itself into the ripped tissue of my body.  That was my mom, my dad, and my siblings. 

And I have carried the scars of the birth of ATLS with me through my entire life.  I look at them every day.