Training in advanced trauma life support

Senior house officers should be trained before working in accident and emergency

Advanced trauma life support offers clear protocols for managing major trauma and is now regarded as a common international language of trauma care.1-3 In 1993 Teanby et al highlighted the generally poor care given to trauma victims in Britain and recommended that protocols for advanced trauma life support should be instituted in prehospital care as well as accident and emergency departments.4 Most, if not all, major British accident departments now use the protocols in their resuscitation rooms. Similarly, the number of advanced trauma life support courses have expanded since the first one in Britain in 1988 (Royal College of Surgeons, personal communication). But is this training being provided to those who need it most?

Despite the maturation of accident and emergency medicine as a specialty and the formation of trauma teams in many hospitals, a senior house officer is often still the first doctor to assess and provide initial care for multiply injured patients.5 As front line providers of trauma care, they should have received training in advanced trauma life support.6 Yet a survey we conducted in January 1996 of all accident and emergency departments in England seeing more than 30 000 patients a year (95% response rate) showed only 16.7% of senior house officers had been trained in advanced trauma life support and a further 26.8% were on a course waiting list. Only 38% of all respondent hospitals had a dedicated trauma team.

These nationwide data confirmed a trend previously seen in the South West region.7 As well as highlighting the low proportion of senior house officers with advanced trauma life support certification, they clearly show that most have not even applied for a course. This probably reflects difficulty in gaining access to training. Firstly, waiting lists for advanced trauma life support courses are long8 and many senior house officers will have finished their accident and emergency attachments before being trained. Secondly, doctors are expected to use study leave time and money to attain this basic training requirement. The advanced trauma life support course therefore competes with other courses that demand the trainee's attention. Our experience is that many senior house officers defer training in trauma life support until they have completed their accident and emergency attachment. Thirdly, places on courses are still preferentially offered to middle and higher level trainees.9 Initially this was necessary to create a core of senior doctors who were familiar with the principles and to increase the number of instructors. In 1996, however, the records of the Royal College of Surgeons of England show that almost half the doctors gaining certification in advanced trauma life support were more senior than senior house officers, despite their smaller numbers, and among the senior house officers only a third were actually working in accident and emergency departments (personal communication). Whatever the reasons, the result is that many doctors in accident and emergency medicine work without being trained in advanced trauma life support.

Certification in advanced trauma life support should be a prerequisite for appointment to a post as a senior house officer in accident and emergency or be incorporated into accident department induction courses, as occurs in some units. As a substitute for a full course, the teaching of advanced trauma life support principles is a useful stopgap but has been shown to be inferior.10 Even better if doctors were exposed to the principles at an earlier stage as medical students or very junior doctors, as was originally envisaged. In America, the birthplace of advanced trauma life support, the course is increasingly taught in the undergraduate curriculum.11 It can be argued that this is too early to teach such skills and that the preregistration year is probably a better time.

We believe that the principles of advanced trauma life support, along with those of advanced life support and advanced paediatric life support, should be introduced to undergraduates, perhaps as a generic resuscitation course. This should be followed by a formal course in the preregistration year and refresher courses at the start of senior house officer posts, similar to refresher cardiac life support updates. The multispecialty culture of advanced trauma life support will thus be introduced to all doctors at an early stage. Undergraduate deans and the General Medical Council will then have a responsibility to ensure that the training is completed. This may not solve the financial issues but may help unblock some of the staffing and resource difficulties of study leave. Individual patient care in the “golden hour” will improve and the numbers of avoidable trauma deaths will continue to fall.12