James K. Styner: How a tragedy created the ATLS

The ATLS is a health care professionals training for treating traumatized patients in the early stages of hospitalization. Developed by the American College of Surgeons it originated in 1976.

Remembering James Styner, and how he changed medicine's approach to trauma

The Advanced Trauma Life Support (ATLS) is a program to prepare physicians and nurses to treat traumatized patients in the early stages of hospitalization, developed by the American College of Surgeons. ATLS originated in the United States in 1976, when James Styner, an orthopedic surgeon, was piloting a light plane and crashed it into a field in Nebraska, USA.

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In 2020, any trauma patient is received in a hospital by staff specifically trained for such cases. Every physician and hospital professional knows what they have to do and act in unison, coordinated by a team leader, and following a protocol treatment procedure called ATLS (Advanced Trauma Life Support).

This procedure, based on repeated, schematic and simple assessments of specific signs and symptoms and the immediate recognition and treatment of life-threatening complications, allows standardizing the response to trauma, to frame the patient from the point of trauma and bring “the right patient, to the right hospital, at the right time", to optimize response resources (think, for example, of those who decide whether or not to fly a helicopter rescue or to decide when, and if, to do CT diagnostics or go directly to the operating room) and, ultimately, to optimize patient outcome.

But how did we get here? This is the story of Dr. James Styner and how his personal story changed the approach to trauma.

The plane crash

To fully understand the evolution of events, we need to take a leap through space and time. We go to Nebraska (USA), a state that extends for 200,520 square kilometers and that at the time of our story, had 1,490,000 inhabitants (with a population density of about 7 inhabitants per square kilometer). Nebraska is part of the "great plains", a region in the US with extensive pastures, with very few densely populated zones, and very large areas of...nothing.

The year is 1976. "Someone flew over the cuckoo's nest" by Miloš Forman wins the Oscar for best film; the Eagles, Bob Dylan, and Queen plays on the radio. The SIMCA 1307-1308 is the Car of the Year and the mobile phone is still nothing more than a prototype. The pre-hospital rescue system in the US at the time is still essentially based on non-centralized volunteer activities, by untrained personnel, with makeshift vehicles, almost always civilian: in some cases, the gravediggers' cars were even used, as they were the only ones that could be adapted to load a stretcher.    

Dr. James Styner is a traumatologist practicing in Lincoln, Nebraska. One February afternoon Dr. Styner, who is also a pilot, boarded his plane with his family (wife and four children) to return to Lincoln after a trip to California. The pilot has already five hours of flight time behind him, is tired, and stopped for refueling, but decided to leave quickly because of a storm, which he wants to leave behind.    

At 18:00 hours, while flying over Nebraska, he meets a layer of low clouds. It is dark and Dr. Styner has no instrument clearance, but cannot turn back because of the storm. He then decides to lower his altitude in an attempt to get out of the clouds. It takes seconds: he loses too much altitude, becomes disoriented, impacts with a row of trees, and the plane slams to the ground.

styner_atls.jpg
Credits: American College of Surgeons

His wife, Charlene, is hit in the head with a piece of an engine and dies instantly. Of the four children, only the eldest, Chris, 10 years old, remains conscious, with a fractured arm, while the other three (Randal of 8, Richard of 7 and Kimberly of 3) suffer severe head trauma and lose consciousness. Styner himself reports chest trauma and a fractured orbit in his skull.

Terrified, blind in one eye, and in pain, Styner has only one thought: his family. With the help of his eldest son, he pulls the three unconscious children out of the rubble of the plane, pulling them away from what he perceives as the first, great danger: fire. He finds his wife about 100 meters away from the plane, but he immediately realizes that there is nothing more to do to help her.

Once he is certain that the fire will not be a problem, and that his children, though unconscious, have no visible external bleeding, Styner identifies a new potential danger in hypothermia (the temperature was in fact below zero). He collects as much clothing as possible from their suitcases, creates a nest where he places the children and waits with them for help (the plane had a tracking system and the alarm had been triggered). But help arrives too late.

After eight hours since the moment of impact, the clouds have thinned out and the full moon allows a glimpse of a road, not far away. Styner decides to go for help himself. He leaves his eldest son with his siblings, telling him not to go looking for him and not to move for any reason, and heads towards the road.

Two travelers passing by, named Rick and David, notice a screaming man, covered in blood, in the middle of the road at two in the morning. The two decide to stop and help. They put Styner and the children in the car (indeed seven people are now crammed together, five of them traumatized, of which four are pediatric patients) and head to the nearest hospital. What looked like the end of a terrible nightmare was just the beginning.

Trauma management before ATLS

The hospital where they arrived had an ER, but it was closed. The nurse on duty, visibly agitated and without the slightest idea of what she had to do, called two physicians (which were general practitioners), who were on duty call. The physicians Dr. Pembry and Dr. Bunting rush to the hospital, but they, too, are disoriented and act confused. One of the children, Richard, becomes agitated by the head trauma. He is picked up and taken to the radiology area, where a skull X-ray is performed (the first CAT scans were only installed in 1974, and certainly not in rural Nebraska). The physician returns with joy announcing that there are no fractures. They do not immobilize the spine, nor investigate for any spinal fractures, and do not touch it, simply because they did not realize that they should have done it.

Dr. Styner at this point has had enough and decides to take matters into his own hands: he calls his friend and colleague Bruce Miller, asking for immediate help to get to Lincoln Hospital. The Lincoln Air National Guard sends a transport helicopter for what is the first civilian rescue operation in the area. The medical team consists of Dr. Pembry (the hospital's GP) and a nurse.  At 8 a.m., 14 hours after the trauma, Dr. Styner and his children arrive at Lincoln Hospital, where they are met by his friend Bruce Miller and a team of surgeons. Styner and all his children survive the accident.

Dr. Styner, a traumatologist, decides to go beyond this experience and ponders after such events, on how to provide better care. He realized that in the scene of the crash he provided better and more relevant care than the one he and his children received at the primary care facility. For him, these indicated that there was something wrong with the system, and it needed to change.

The birth of the ATLS

And Dr. Styner, being a traumatologist, and a man of action instead of words, decides to change the system. He involves the director of the emergency department of Lincoln Hospital, Dr. Ron Craig, vascular surgeon Dr. Paul (Skip) Collicott, and a nurse, Jodie Bechtel, and they decide to build on the work of Steve Carveth, who in those years had invented the Advanced Cardiac Life Support (ACLS) course. They work together in devising and promoting a similar protocol (schematic, by points, based on a few basic parameters) for trauma, calling it ATLS.

Nothing new, no innovative technique: the greatness of this project is in the simplicity, in its approach of putting an order to the chaos of the things to do and the people who have to do them, standardizing the treatment especially in terms of priorities and sequences: what is the first, fundamental action since the event, that is the "golden hour" that can save a life, or prevent disastrous damage to survivors.

The first ATLS students were physicians in rural Nebraska in 1978. The course was a success. The following year the American College of Surgeons Committee on Trauma adopted the project, and the course, which was modernized and revised in the light of new scientific and technological discoveries.

Sources:
1. APA Styner, James K. MD The Birth of Advanced Trauma Life Support, Journal of Trauma Nursing: April-June 2006 - Volume 13 - Issue 2 - p 41-44
2. ATLS Student Course Manual: Advanced Trauma Life Support, The American College of Surgeons, 10 ed.

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