Introduction:

Trauma is a major medical problem faced by all societies. It is the third cause of death in all age groups in the United States and first cause of death in the first four decades of life.

Trauma has no respect for age, is swift in onset and slow in recovery. It presents many difficulties for the physician responsible for the care of the injured patient. Trauma is merciless in its lethal and disabling effects on our young and potentially productive members of society. Prevention, of course, is the best approach, but when prevention fails, the physician must be sufficiently knowledgeable to meet the injured patient’s needs so as to reduce the mortality and morbidity of trauma.

In Saudi Arabia, trauma is the second cause of death in all age groups and it is the first cause of death in the first four decades of life. Although, MVC account for 48% of trauma in United States, it constitutes 80-85% of trauma in the Kingdom. Unfortunately, the number of injuries in Saudi Arabia is increasing. The traffic police statistics in 1999 has shown that there were 364,326 motor vehicle crashes with an increase of 110,599 from the last year. The number of injured in 1999 traffic police statistics were 31,059 with an increase of 2,915 from 1998. Mortalities reported in the 1999 traffic police statistics were 4,290 with an increase of 816 deaths from 1998. Traffic police recorded deaths are considered to be those occurring at the scene or after arrival to the hospital i.e. within two hours of the injury and excluding the people who died in the operating room or in the hospital within one month after the injury. If we look at the statistics, this only contributes to 48% of the mortality from trauma. So the corrected figure amounts to 8000-9000 mortalities per year from car crashes alone in Saudi Arabia. This number is very high if we consider the population and the number of cars, as about 3 million cars were registered last year in Saudi Arabia.

The ATLS® Program is sponsored through the American College of Surgeons and we have developed a very successful program in training Saudi Surgeons, Emergency physicians, as well as Primary Care physicians who deal with surgical emergencies.

The first ATLS® course in the Kingdom of Saudi Arabia was conducted in Riyadh in October 1991.

The ATLS® courses were initially held in Riyadh and then began to promulgate kingdom wide. The first course conducted outside Riyadh was in Buraidah in February 1994, followed by Abha in June 1994, Jeddah in April 1995, Medina in March 1996, Dhahran in May 1996, Taif in February 1997, Tabuk in February 1998, Bahrain in September 1998, Gizan in February 1999 and Hafer Al Batin in November 1999.

From the establishment of the ATLS Program in October 1991 through 31st December 1999, the ATLS Saudi Arabian Chapter has conducted a total of 140 ATLS Provider and 20 Instructor Courses, see Figure 1.

Figure 1

The number of candidates that attended the ATLS Course since its inception is shown in Figure 2. A total of 2,003 have been recorded.

Figure 2

The pass rate (SP) is 86% making a total of 1,715 physicians 271 of those were designated incomplete repeat course (IRC) which is about 13%, and 1% has been recorded to be (IRM) incomplete remedial which means the candidates are given a chance to redo that part of the course i.e. skill stations or post test, that is required in order to obtain the ATLS documentation of successful completion o f the program. See Figure 3.

Figure 3

Since the beginning of the course, we have trained 178 instructors, and we have approximately 40 candidates on the waiting list for future Instructor Courses, refer to Figure 4.

Figure 4

The majority of courses have been conducted in Riyadh. This amounts to 62 courses conducted since October 1991. Jeddah follows with 19 courses, Dhahran 18, Abha 8, Medina 4, Taif 3, Tabuk, Gizan and Hafer Al Batin with 2 courses each. In the State of Bahrain, 6 courses conducted since its inception, refer to Figure 5.

Figure 5

Difficulties / Challenges:

Since the beginning of the course, we have been strongly committed to improving training of physicians in trauma care. We found that the ATLS course is a very good tool for satisfying this purpose. It was our goal to establish and disseminate this vital course kingdom wide

Financial difficulty:

Initially, the ATLS Course was fully supported by the National Guard Health Affairs, i.e. provider registration fees and other related expenses. Within two to three years of establishing this course, a significant number of students enrolled. The National Guard Health Affairs decided to sponsor only 50% of the course expenses, mainly supporting the ATLS staff, the Coordinator and Secretary. The courses are now self-funded largely through student fees.

The enthusiasm and interest are generated through contacts with colleagues at other hospitals in and outside Riyadh including residents and interns. We have also approached the Saudi Medical Council Office to consider this course as a pre-requisite, for all residents, particularly those in the surgical and emergency departments. As a result, the Saudi Council now requests all residents to take the ATLS Course.

- Maintaining the enthusiasm and interest of the ATLS Instructors.

This is one of the most difficult challenges we face, as the instructors tend to be initially very active and then burn out with time. We have tried many ways of maintaining Instructors’ enthusiasm i.e. through sending letters of appreciation, conducting an ATLS® Day, where certificates of appreciation were presented to all Instructors. In 1998, an honorarium fee for ATLS® Instructors was introduced. We also gave privileges to some senior Instructors to have their own choice of facility where they wanted to teach and took them out to dinner or social events after the course. These also attracted Instructors and increased their interest.

Maintaining the quality as requested by American College of Surgeons (A.C.S) guidelines (e.g. the strict adherence to rules and regulations particularly in regard to the course schedule and minimal criteria for skill stations with direct supervision by the main ATLS® Office in Riyadh), involves the senior coordinator visits to the different centers while the course is being conducted. We continue to face difficulties with certain areas particularly those centers where fewer courses are conducted. We face difficulty with coordinators who sometimes forget the principles of running their courses because of a long time between courses and/or lack of enthusiasm and support from the local administration. We have handled each area individually through communicating directly and indirectly with the key people in the area who tend to help to some extent with running those courses.

Generally, we have had no problems communicating with the A.C.S., although sometimes we have faced delays in processing instructor cards, approving Course Authorizations, and addressing other issues with regard to processing ATLS paperwork. Additionally, due to some concerns on the part of the A.C.S, we have faced some difficulties with the promulgation of the ATLS® Course in the Gulf States, particularly the State of Bahrain.

Bahrain and Qatar, at that time, had invited us to establish an ATLS® Center in their respective countries, as both are very small countries without a recognized Surgical body and, therefore, are incapable of setting up an independent ATLS® Program. With this in mind, and in the spirit of the Gulf Cooperation Council charter, the ATLS® Saudi Arabian Chapter answered the call to assist in establishing centers there. As mentioned earlier, the A.C.S., ATLS® Division has very strict guidelines regarding the promulgation of the Program to other countries, and in recognition of these guidelines, great care was taken to address the matter through direct communication with the American College of Surgeons prior to conducting the ATLS® courses in these countries. This issue has been resolved by conducting a course in Bahrain and Qatar, with monitoring by a subcommittee member, to consider approving both sites as official ATLS® Centers, under the umbrella of the ATLS® Saudi Arabian Chapter.

Discussion:

Trauma is one of the main medical problems faced by healthcare providers, it is the third cause of death in the USA and the second cause of death in Saudi Arabia, where motor vehicle crashes constitute 80% of all trauma mortalities. Of course, prevention is better than cure, but when prevention fails (despite the availability of methods and modalities to prevent most injuries), it is important that the physician dealing with the trauma victim is equipped with the necessary knowledge and skills to handle trauma. There are many courses available to train physicians, paramedics and nurses and others dealing with trauma on how to handle trauma at each different phase, including BCLS, PHTLS, ATLS®, etc. ATLS® has developed an international reputation since it is designed to teach physicians how to handle trauma victims during the most critical time, or what is called "the Golden Hour", during which lives can be saved and morbidity reduced through adoption of assessment and management priorities and with applications of simple techniques e.g. opening of airways, oxygenation, ventilation, stopping bleeding with restoration of volume depletion, and prevention of secondary brain injuries. The ATLS® Course emphasizes that injuries kill in certain reproducable time frames e.g. the loss of an airway kills more quickly than does the loss of the ability to breathe. The latter kills more quickly than the loss of circulating blood volume etc. The ATLS® Course addresses this concern and as such, it has been adopted with enthusiasm in Saudi Arabia and has been spread to the different cities and regions. In disseminating the course throughout the Kingdom, we faced many difficulties and challenges. The initial challenge was to convince other institutions of the importance for implementing the course, and subsequently, maintaining the quality of the course was a major challenge. Another ongoing difficulty has been to maintain the instructors’ enthusiasm to continue teaching in the different ATLS Courses. As a result of the well establish reputation of the ATLS® Course, the number of candidates applying to the course has increased, leading to a steady increase in the number of courses conducted. The certification of the ATLS® Course is for four years, after which, candidates need to be recertified by attending a refresher course or attending the entire course. Because the course and the manual are revised every four years, students whose certification expires prefer to take the course again, which has maintained a steady demand for the course.

We believe that the ATLS® Course has some impact on the management of trauma and certainly changes the physicians’ attitude towards management of the trauma patient. In small isolated areas, it has been noticed that mortality and morbidity has been decreased after running the third course of the ATLS®. This needs to be looked at to ensure that there is a relationship between conducting the ATLS® courses, and the improvement in the trauma management.

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