ATLS® International Meeting MinutesOctober 22-23, 2011 ⦁ San Francisco, CA

Saturday, October 22, 2011

Welcome – Dr. John Kortbeek

Tribute to Dr. Brent Krantz – Dr. Brent Eastman (former COT Chair, 1990-1994)Krantz led in a very articulate way and sometimes with brute force. He had a vision for ATLS; he saw that ATLS had international implications. It was Brent that had the vision, passion, and energy to take ATLS to where it is today. Brent was an innovator and leader of men and women and played an integral role in this program. If Brent were here today he would say, “Get out there! We have ATLS business to take care of!”

Revisions for 9th Edition – Dr. Karen Brasel1. 9th Edition revisions underway

a. Content, format2. E-version and 9th Edition to be released in October 2012

a. Shows the new 9th Edition Student Manual cover3. New Content

a. Table: A brief summary of Wright, et al. Levels of Evidence JBJS(A)b. Initial Assessment

i. Team trainingii. Huddle

iii. Checklistiv. Debrief

c. Airway (pediatric)i. Uncuffed tubes infants (<12 mo.)

ii. Cuffed tubes1. Children2. Toddlers

d. Circulationi. Balanced resuscitation

1. Hypotensive2. Early use of plasma, platelets3. Until bleeding controlled

ii. Angioembolization emphasizediii. Tourniquetiv. No aggressive resuscitation

e. Initial Assessment scenariosi. At least 8 new scenarios

1. Geriatric focus2. Pelvic trauma

3. Rib fracturesii. Standard template for current scenarios

4. New Formata. Pelvic traumab. Abdominal evaluationc. Combined shock & surgical skills

5. Educatorsa. National Educator Group

i. 2 reps from North Americaii. 2 reps from each international region

b. Revise Instructor coursei. Emphasis on assessment, feedback

c. Input on e-course format6. ATLS E-Learning

a. 1-Day formatb. 2-Day format

7. App, mobile websitea. Will include chapter key points, pitfalls, summaries, videos, formulas,

and algorithms

Educator Update – Dr. Wesam Abuznadah (on behalf of Dr. Bonvin)1. Major revisions have been made to the feedback/assessment content in the

Instructor course.2. Continue to work on the 9th edition Instructor course and Refresher course.3. Provide guidance on the e-course and other educational activities.4. Senior Educator Advisory Board

a. 2 representatives for each Regionb. 1 chair – Dr. Bonvin

ATLS Middle East & KSA 20th – Dr. Wa’el Taha1. Country and trauma statistics are provided.

a. Trauma is leading cause of deaths – 6,000 annually.2. There are many challenges to the system.

a. No hospital or trauma system, lack of cooperation3. ATLS has helped increase the number of trained physicians

a. 1991: 0ne centerb. Currently: 20 centers

4. ATLS is now a requirement for residents (surgical, emergency med, and family)

5. Developed new collaborations with the Ministry of Health to train physicians and nurses.

Promulgation Challenges in MENA – Dr. Subash Gautam1. An overview of the new Region 17 boundary and listing of countries is

provided.2. Safety continues to be a concern.

3. Country GNP data is provided.4. Many countries cannot afford ATLS. This is our challenge for the future. Cost

of surgical practicum is extensive. We need a low-cost option.

Educator Perspective in the Middle East – Dr. Wesam Abuznadah1. Culture and education citations are extensive.2. Dedication in MENA is outstanding.

Australian Instructor Course – Dr. Philip Truskett1. There has been growth in course numbers, faculty, and Coordinators since

2006.2. Philosophy

a. To promote excellence in teaching using:i. Best practice educational methodology

1. Opportunities for practice2. Feedback3. Clear assessment criteria

ii. ATLS contentiii. Modeled educational practices by Faculty

b. Centralized location for all Australasiac. Strong collaboration between Course Director and Educatord. Consistent Faculty – attend entire course (all faculty types)

2. Overviewa. 2 ½ day course Fri – Sunb. Pre-course requirement - ATLS contentc. 16 participantsd. One course Director, one Educator, one Coordinator and 5 Instructorse. Always one committee member

3. Course Overview, Day 1a. EMST Icebreakerb. Lesson Planning/learning objectivesc. Making ATLS interactived. Questioning techniquese. How to give effective feedbackf. Practice Session – teaching

4. Course Overview, Day 2a. Managing the difficult participantb. Principles of teaching a skillc. Practice Session – teaching a skilld. Assessment methodologye. Assessment – Teaching a skillf. Practice Initial Assessment station

5. Course Overview, Day 3a. Assessment - Microteaching – assessed by the educatorb. Assessment - Initial Assessment station – assessed by instructors

6. Microteaching

a. Given an ATLS topicb. 8 minute presentation that must demonstrate:

i. Set/Body/Closureii. Time Management

iii. Interaction of participantsiv. Innovation

c. Instructor Candidates provided with individual feedback (written and verbal) and DVD of performance for subsequent reflection

7. Initial Assessment Stationa. Assessed as an Instructor running the Initial Assessment Station:

i. Briefing Patientii. Briefing Nurse

iii. Briefing Candidateiv. Facilitating the scenariov. Providing Candidate with feedback

vi. Assessing the Candidate8. Assessment

a. Clear criteriab. Individual assessment components and overall course assessmentc. Candidates nominated by experienced Faculty to do the course

i. Not always the right peopleii. Candidates do occasionally fail

RTTDC Promulgation in India – Dr. Mahesh MisraIndia is receiving the heaviest injury in rural areas.

1. Course Designa. Duration- one day course with 2 distinct sessionsb. Morning session- consists of clinically focused didactic lectures on

airway, breathing, circulation, disability, exposure and environment, as well as special considerations such as pregnancy, pediatrics, burns and geriatrics.

c. Afternoon session- covers Performance Improvement and Patient Safety (PIPS) initiatives, followed by interactive small group case-based team scenarios designed to stimulate critical thinking and application of knowledge. 

d. Communication module emphasizing the importance of effective communication between the trauma center and rural center

e. Between Next Appropriate Level Hospital – Able to cater to the needs of the patient

f. Trauma Team Leaders – Made aware of the need to recognize the need for transfer and where to transfer

g. Good communication makes for a good team - works for the benefit of the patient.

2. India at a glance a. In the last 5 years there has been an 8% increase in road deaths.

b. In 2009 over 350,000 people lost their lives in accidental deaths, which is an increase of 31.3%

c. India records the highest number of deaths in RTA in World. i. 14 deaths per hour; these are numbers from 2009.

3. India – Most Suited for RTTDCa. 70% to 80% of people in India live in rural areasb. Trauma care is one of the most common reasons for families going

into debt.c. India is well-suited for the RTTDC program because of the absence of

prehospital care in rural areas. This program can improve the chances of patients’ survival.

4. Other Coursesa. Promulgated ATLS in 2009

i. 4 sitesb. Promulgated ATOM in 2010

5. RTTDC in India a. The Instructor course was held on 4-19-2011b. Participants- verified ATLS & ATCN faculty

i. 18 participants were verified as RTTDC Instructors c. Inaugural RTTDC course was on 4-20-2011d. 25 Participants

6. Participant’s Feedbacka. 92% of the participants will seek additional information on this

subject following the course.b. The modules on Performance Improvement & Patient Safety (PIPS)

and communications were rated as most relevant. c. 100% participants indicated their intentions to improve

communication for the benefit of the patient and to evaluate outcomes for improving patient care.

d. The cost ($50) of the manual is an issue in India.e. Potential solutions from the participants

i. A substantial decrease in the cost of the manual for developing countries

ii. Print the manuals in India.f. Language of Manual is also an issue, as some of the health care

providers in rural settings are not fluent in English; so we need to obtain permission to translate & print the text in native language (Hindi) and other recognized regional languages of India if we want this to be adapted across India and South Asia.

7. Acknowledges Dr. Jameel Ali and Dr. Subash Gautam.8. Future Directions

a. To disseminate RTTDC course across India and South Asia Regionb. To study the impact of RTTDC on improving trauma care

i. Need to design a study comparing RTTDC trained rural hospitals versus non RTTDC trained rural Hospitals

2011 Promulgations

Lebanon – Dr. George Abi Saad1. Lebanon is a small country with about 4 million to 4.5 million2. Site Visit- November 2008: Dr. Chris Kaufmann & Dr. Claus Falck Larsen3. Went to Fujairah for the Student and Instructor course in 2009. We

graduated in October of 2009.4. The Inaugural Course – November 8, 2010

a. Both courses: Student Course and Instructor Course provided back to back

b. International Faculty and Coordinators, mainly from Chicago and the Middle East Chapter – Saudi Arabia and UAE

5. Later coursesa. February 2011b. May 2011 – Iraqi Doctorsc. October 2011 – sponsored by “Roads for Life” foundation

6. May 17, 2011 – Saudi Arabia Regional Meetinga. Committees were formed b. Celebration of the 20th year anniversary of ATLS in SA

7. Challengesa. Other courses: German course given by another University in town.

Short & different but it’s an alternative. Costs less.b. ATLS is not a prerequisite in University programs, Trauma centers, or

different Emergency Departments.c. Relatively expensived. Doctors are convinced that they’re “ok without it”e. Hospitals in the nation are not properly classified, Trauma or

otherwise.f. There is a fight against ATLS and its “exclusivity”.g. Language problems.h. The course is not endorsed by the Lebanese Order of Physicians or

Ministry of health.i. Sometimes we have an issue with the volume of trauma victims.

8. We have a strategy and funds for other courses like ATCN and ATOM. We’d like to help bring ATCN and PHTLS to Lebanon.

Slovenia – Dr. Roman Kosir1. Slovenia is a very small country and maybe twice the size of Lebanon. We

have about 5,000 physicians taking care of all the patients. 2. Reads a copy of the 1997 Edition of the ATLS Student Manual–this is what

caught his interest in the ATLS Program. 3. Inaugural ATLS course was held in 2010.4. Held 4 Student courses and 1 Instructor course in 2011.

Dr. Kortbeek says he is always struck by the variety of countries who are involved in ATLS and how we all share common problems.

Egypt – Dr. Hakim El-Kholy1. The inaugural course was held in June of this year.2. The second ATLS course was held last September, and the third course was

in October.3. Trauma is one of the biggest reasons for death in Egypt.

Sunday, October 23, 2011

Region Reports

Latin America1. Countries with ATLS

a. 14 countries2. Countries without ATLS

a. 27+ countries3. Population

a. Region 14: 569 millionb. Countries with ATLS: 485.6 millionc. Countries without ATLS: 83.4 million

4. Annual Region 14 Meetingsa. The 1st annual Region 14 meeting was held in Buenos Aires, Argentina

in 2009b. 2nd annual meeting was held in Santa Cruz de La Sierra, Bolivia in

2010c. 3rd annual meeting was in Bonito, Brazil in 2011d.

5. 25th anniversary of ATLS in Mexico – May 19-21, 2011 in Acapulco, Mexico6. Honduras Promulgation 2011

a. Student course & Instructor course for Honduras was held in Costa Rica

7. Promulgation – Other Coursesa. DMEP Promulgation in Latin America

i. September 2011: 2nd and 3rd courses in Brazilb. ATCN Promulgation in Colombia

i. June 2011: Student course and Instructor course in Brazilii. November 2011: Student course in Colombia

c. ATCN Promulgation in Paraguayi. November 2011: Course in Paraguay during Panamerican

Trauma Congressd. PHTLS Promulgation in Ecuador

i. September 2011e. TOPIC Promulgation in Brazil

i. December 2011f. ATOM Promulgation in Brazil

i. November 2010

ii. 2nd course in July 2011iii. A course was held during Panamerican Trauma Congress in

Paraguay8. Thanks to Paraguay, Peru, Trinidad & Tobago, Uruguay, Venezuela

Chairpersons and others, the Chicago office, etc.

Middle East1. About the Region

a. Newly created regionb. Established in May 2011c. Covering all the Middle East regionsd. 1st meeting held May 17th during the ATLS 20th anniversary in Saudi

Arabiae. 1st elect President (Region Chief): Saud Al Turkif. 1st elect Secretary: Subash Gautamg. Middle East central office – Trauma Programs office, KAMC, Riyadh,

Saudi Arabiah. Current Members

i. Saudi Arabia – October 1991ii. UAE

iii. Lebanon – November 2010iv. Syria – January 2011v. Oman– April 2011

vi. Egypt – June 20112. ATLS Promulgation in Nigeria (June 2010) was initiated with the support of

international faculty3. Promulgation

a. Inaugural coursesi. AUB, Beirut – November 201

ii. Hama, Syria – January 2011iii. Cairo, Egypt – June 2011iv. Oman – April 2011

b. Site Visitsi. Iran – December 2010 (estimated promulgation December

2011)c. Other Requests

i. Iraqii. Sudan

iii. Jordaniv. Libya

4. Next ATLS M.E. Region Meeting will be held to coincide with the AMESCON 2012 Conference – Dubai, UAE - March 14-17, 2012

Europe1. ATLS Europe

a. Board

i. Inger Schipper (NL)ii. Raphael Bonvin (CH)

iii. Ruth Dyson (UK)iv. Laura Bruna (IT)

b. Committeesi. Promulgation

1. Bob Winter (UK)2. Roman Kosir (SL)3. Giorgio Olivero (IT)

ii. External Affairs1. Olaf Roise (NW)2. Endre Varga (HU)3. Jose Maria (ES)

c. Region 15 Chief: Clause Falck Larsend. Members

i. 17 countries2. Promulgation

a. New members since 2010i. Slovenia – 2010 inaugural courses

ii. France – July 2010 inaugural coursesiii. Czech Republic – 2012 inaugural coursesiv. Georgia – 2012 inaugural courses

b. Promulgation statusesi. Bosnia – training courses pending

ii. Croatia – application approvediii. Poland – application approvediv. Islandv. Finland

vi. Romaniavii. Ukraine – demonstration course

c. Other activitiesi. Research on cost-effectiveness of different methods of

promulgation in Europeii. Information on EU funding possibilities for the promulgation

process3. External Affairs

a. Recent eventsi. Cooperation with ESTES (member of the board, educational

committee, guest symposia)ii. Involvement with ETC

4. ATLS Europe Meeting – May 20-21, 2011 in Madrid, Spaina. Day 1

i. Updates on Europe, Region 15, ATLS Internationalii. Annual general assembly

iii. Promulgation, ETC, role in terrorist attack, ATLS-ATCNb. Day 2

i. Professional development for ATLS Instructorsii. Surgical skills DVD

iii. Interregional grants for ATLSiv. Presentation of 2012 venue

5. ATLS Europe Meeting 2012: April 27-28 in Berlin, Germany6. ATLS Europe Data

a. Number of 2010 courses held in each countryb. Other course information broken down by “Self-Reported” or

“Reported to ACS”7. Other Activities

a. II Moscow International Congress of Trauma & Emergency Surgery on March 24-25, 2011

Asia and Australasia1. Myanmar2. Promulgation initiated in Bangladesh3. Region 16 meeting in Pattaya, Thailand, July 2011

a. Concurrent Regional Trauma Meetingb. Residents Papers Competitionc. Business Meetingd. Coordinators Meetinge. Preparation Triage & Initial Assessment Scenariosf. Policy Developmentg. Outcomes

i. Initial local policy decisions1. Non-surgical Directors2. Medical Educators

ii. National reports with identification problemsiii. Resident Papers Competition

1. Dr. Chih Yun Lin, Taiwan2. Predicting prognosis of burn patients by assessing heart

rate variability4. Australian/New Zealand Director Workshop5. Common Problems

a. Costb. Instructor burnoutc. Surgical Skill Station esp. Simulationd. Educators

6. Regional COT Coursesa. ATLS, DMEP, ATOM

7. PHTLS8. ATLS Future Promulgation

a. Not just collecting stampsb. Need to understand individual nations and their peoplec. Genuinely ask what is best for each situation

ATCN – Ms. Cristiane Domingues1. The Start

a. June-July, 2008 - Student and Instructor Courses in Lisbon, Portugal2. ATCN in Brazil

a. May 2009 - Student and Instructor Courses in Brazilb. 40 Instructors trainedc. 5 Course Directors; 3 Director Candidatesd. 43 Student courses helde. 5 Instructor courses heldf. 652 nurses trainedg. ATCN Student Manual in Portuguese is availableh. Challenges: high failure rates

3. ATCN has also been held in Colombia and Paraguay

Disaster Planning in Bangkok – Dr. Rattaplee Pak-Art1. Protests in Thailand between old and new PMS

i. Background1. April 2010 protests involving hospital2. Bombs3. Result—downsize hospital

a. Discharge early to home or nearby hospitalsb. Limit admissionc. No elective operation

4. Policies for Hospitala. Protect patients, teams, ourselvesb. Don’t fightc. Take evidence

5. Must think about when, where, & how to evacuate.a. There were rumors of gas tanks, explosives, etc.

no evidence6. April 27, 2010 7am – gas tanks confirmed7. Shows map of area of protest8. April 28, 2010 Searched building for signs of danger and

asked authorities for guidance—conclusion: they could only rely on themselves

a. Hospital has no security for patients so they planned to evacuate the hospital April 29

9. Transferred 600 patients in under 1 hour—first time in hospital’s history having no patients

10. Made plans to give signals to teams for guidance on what to do and where to go each day

11. Had to wear comfortable clothes, wear backpacks, and protect faces from tear gas

12. Hospital was surrounded and not accessible13. Shows map of hospital and block surrounding it

a. Found the hospital was “under siege”14. Stabilized on the floor15. Ran low on food16. Threat of truck explosion less than 1 km from hospital17. Used Google maps and FB to communicate with one

another18. May 19, 2010: Government announced end of protest

which spurred on more violence19. Bombs 100 meters from the ER20. 50+ docs to help the injured in the ER

ii. Crisis is a great opportunity to learn how to protect our patients and team, that there is so much more knowledge to be obtained, and how much the hospital is loved.

WHO Trauma Recognition in Qatar – Dr. Ahmad Zarour1. Background

i. Trauma major cause of death and disabilityii. According to IRF Qatar has one of higher road traffic deaths in

world at 19 deaths per 100,00 populationiii. Falls closely below second most common cause of death

2. Is there a problem with trauma at HGHi. Prior to Nov 2007 manage of traumatize patients was

inconsistent.ii. Clinical assess & arrangement was in conflict without leader

iii. No contemporary trauma registryiv. Trauma system concept was nonexistent

3. The initiativei. Started 1/11/2007

ii. Four teams, 5-nhospital trauma surgeons4. Trauma Leadership5. Trauma team--Composition of the trauma team (including response

and support members)6. Prehospital

i. Established 5-7 years before trauma serviceii. Travel time of 20 minutes; 200 ambulances

7. Patient Flow

i. EMS & Private to Trauma Room1. Determine from there where to transport patients

8. Number of cases 2008-20109. Registry10. Statistics11. What do we do?

i. Case examples of injuries1. Most cases are blunt trauma

12. Trauma ICU13. Annual report 201114. Injury prevention

i. MVCii. Pedestrian

iii. ATViv. FOHOv. FFH

vi. Child safetyvii. Alcohol related injuries prevention program

15. Trauma PIPSi. TPIC

ii. TSIC16. Rehabilitation17. Fellowship and Education18. International fellowships—not an easy journey19. Fellows of 2010 with the current leadership of trauma surgery section20. Resident & Fellows Graduation Day21. Research & publications—striving to be more active

i. Receiving funding for support and stimulating members to write more and do more research

22. Hamad International Training Center—where most of the training take place

23. Numbers of docs in Qatari. Total 2500

24. ATLS Course under Saudi Chapter teaching25. ATOM

i. 15 coursesii. 50 Candidates trained so far

iii. First course in Nov 200726. TOPIC course – May 201127. Challenges

i. Increasing populationii. Implementation of prevention programs

iii. Verification by ACS28. WHO recognition 201029. Stars of Excellence Award

Breakout Sessions Presentations

Coordinators – Mrs. Lesley Dunstall1. Overview

i. Diana Skaff from Lebanon discussed facing the fear of her first course ii. Chad McIntyre from Florida discussed leadership, ethics, and

stakeholders iii. Laura Bruna presented on an Italian perspective on coordinating.iv. Rich Henn from Arizona discussed ATCN, from its beginning to the

challenges of the ATLS 9th editionv. Lesley Dunstall presented on strategic planning: coordinators’

response to surveyvi. Cristiane Domingues presented on ATCN in Brazil, as well as other

Latin American countries like Colombia and Paraguayvii. Ruth Dyson from the UK asked the question, “If it were you, what

would you do”, to which the group answered by going through several case studies.

viii. Claire Leidy and Jim Brown from Maryland discussed the golden standard of ATLS and demonstrated the passion that goes along with it.

ix. Jasmine Alkhatib from Chicago and Vilma Cabading from Saudi Arabia presented on the ATLS inaugural course in Egypt.

x. Natalie Torres and Jasmine Alkhatib from Chicago presented on the new Senior Coordinator Representative role.

Educators & Scenarios – Dr. Raphael Bonvin 1. 14 countries represented

i. Historyii. Designation of members

iii. Roles & dutiesiv. Dr. Ali covered history and background of groupv. Discussed how to represent all countries—must all work

together for that to happen2. IC—2D

i. 2-day versus 1.5-day Instructor courseii. Feedback used for improvements and change

iii. Theory, practice, feedback, response Experiment/experience

iv. 1.5 experiment not included3. Selection of potential Instructors

i. Interpretation of perception of what IP is varies1. Many influences2. Seniority was discussed; discrimination against

young docs who show potentialii. Recruitment needs

iii. Age of programiv. Some Instructor courses have high fees and others have

funding from national organization and can offer lower fees1. Affects people wanting to become Instructors

v. Performance motivationvi. Regional needs

1. “Failing”?a. Must keep level of selection high to maintain

integrity of coursevii. ICs teaching a Student course

viii. Eligibility4. Scenarios

i. Writing a moulage requires a lot of workii. Went through 6 moulages

1. Candidate is sole doctor in rural hospital, treat patient, and set up transfer

iii. Moulages must be focused; write moulage around objectives

iv. Moulages must be realistic1. “Realistic” is regional and cultural; different in each

countryv. They must test core knowledge and must be accurate—

match content in chaptersvi. Patient report—using “MIST”? standard ABCDE formats

1. Some info is not consistent format2. Use universal units

E-Learning – Dr. Julie Dunn

1. Where we’re at now2. Course Format3. What needs to be done4. Decisions to be made5. Concerns

i. Financial impact on College and chaptersii. Possibility of Spanish and Portuguese versions simultaneously

iii. Instructor course will need to changeiv. Possible change in teaching credit systemv. Language translation—validating appropriateness

vi. Current chapter prototype is not interactive enoughvii. Simplify opening of site

viii. Validating identity of Student signed up for courseix. Consideration of “telemedicine” model for skills (on-site

portion) in countries with vast geographic distances6. Suggested E-Learning rollout

i. Phase 11. Adjunct to traditional course to obtain feedback

ii. Phase 21. Identify beta test sites in several countries

iii. Phase 31. Offer course as free standing product

7. Still need primary script writers and secondary reviewers for teaching modules

8. Dr. Dunn provides a demo on the E-Learning website.

MCQ – Dr. Inger Schipper1. Seven step approach to test development

i. Get 7 steps2. MCQ revision II

i. Three written examsii. Test 1 will still be pretest

3. Breakout sessioni. 12 questions revised

ii. 2 questions deleted (out pregnancy)iii. 2 new questions

4. Future plans—development of question bank