Presentations

1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,From,Teaching,to,Coaching,,Markus,Rall,
From
Teaching to Coaching
for Patient Safety
Marcus Rall
TPASS
Centre for Patient Safety and Simulation Tubingen
Department of Anaesthesiology and Intensive Care Medicine
University of Tubingen, Germany
Modern Simulation Team Training
to enhance patient safety
Man
Technique Organisation
Optimizing
the Interactions
Simulation
Focus on
Team
Human Factors
CRM
Debriefing with
- Facilitation techniques
- Self-reflection (video)
- Double-loop learning
What ? How ?
New trends / interest in
Human Factor based Simulation
Team Training
NATO SOF Medical
AHA Sim/CRM Italy
To err is human

the consequences are variable
It is risky to be a patient and:
The problem remains big
Disappointing, but no surprise (Landrigan):
Patient harm is frequent and wide spread
The incidence did not decrease in the last years!
18% of hospitalized patients are harmed by care
More than 60% of the cases are preventable
1,5 to 2,4% of incidents resulted in death (1:50 bis 1:100)
(medical error was causal or contributing)
Causes of accidents in medicine
70 % due to Human Factors
(preventable?)
Not a lack of medical knowledge
But problems with transfering theoretical
knowledge into meaningful actions in the
real world
Problems with Complexity
Team, Communication

(Not yet appropriately reflected in medical education !)
2
Resuscitation & Reality
Chest
compressions in
only 48-76% of
available time
Correct depth of
compression
28-63%
Wik L: Quality of CPR, JAMA 2005; Abella BS: Quality of CPR, JAMA 2005
Crisis Resource Management
(CRM is derived from Aviation)
Definition

The ability to translate the knowledge
of what needs to be done into
effective team activity in the complex
and ill-structured real world of
medical treatment
David Gaba, Stanford
CRM and
Non-technical Skills (NTS)
Know the
environment
Anticipate and plan
Call for help early
Exercise leadership
and followership
Distribute the
workload
Mobilize all
available resources
Communicate
effectively
Use all available
information
CRM Key Points
Nach Rall, Gaba
in: Miller, Anesthesia
6th Edition (2005)

Prevent and manage
fixation errors
Cross (double) check
Use cognitive aids
Re-evaluate
repeatedly
Use good teamwork
Allocate attention
wisely
Set priorities
dynamically
Communication + CRM
Meant
is not said
Said
is not heard
Heard
is not understood
Understood
is not done
This is true for Sender and Receiver !
Close
the loop !
M. Rall, TPASS
Components of CRM
Individual,
cognitive Elements
Limitations of Human Factors
(Allocation of Attention, cognitive aids,
checklists)
Dynamic Decision Making
Planing & Antizipation
Use all available Information
Fixation error
Team Management
and Communication
Leadership & followership
Assertiveness
Effective Communication (!)
Distribution of workload
Call for help early
Use all available resources
M. Rall, TPASS
3
Anatomy of
Safe Medical Patient Care
Medical(
Outcome((
(correct,and,.mely ,
treatment,of,the,pa.ent),
Medical(Exper2se(
(Knowledge(&(Skills)(
Human(Factors(&(CRM(
(Knowledge,(Skills,(
ACtude)(
Unexpected!*
Problem!*
Error*!*
M. Rall, TuPASS

The Aircraft Carrier:
The Prototypical HRO
(High Reliability Organisation)
It works !
Carriers achieve
nearly failure-free
record despite
multiple hazards
ppt from D. Gaba, Stanford
Daily fire drills !
Train together who work together
! Simulator-Team-Training

Train where you work
! mobile in-situ Simulator-Training
Simulation Team Training
Adult
Learning
Principles
Why should I change anything?
The adult learner
has to feel
a need to change !

(from self-reflection)
Love your participants!
General Assumption:
All participants are highly motivated,
trained and skilled
adult professionals
4
Stress, Reality,
Relevance !
Simulation Control Room
Self-
Reflective
M. Rall, TPASS
Debriefing
The Heart and
Soul of Sim-
Training, but...
Debriefing can
make or break
the sim session
ACRM-Training in OR CRM-Training on ICU
5
Simulation to Prepare
for the Unexpected:
Medical Response to
Chemical Terrorism
Mobile Simulation Controlroom
(with German Air Rescue DRF)
Mobile Simulation in Lear Jet
Mobile Simulation Debriefing
Live
transmission
&
Video-assisted
Debriefing
CRM-Training in Ambulance

TPASS
6
Team Team Team
Dream Teams
are made,
not born!
Performance =
years of deliberate practice

(with reflective feedback)
Shortness
of breath
MI? History Exams Treatment
Nitro, ASS,
Betablocker, etc
???
???
???
???
harmful?
w
r
o
n
g
w
r
o
n
g

w
r
o
n
g

w
r
o
n
g

Mental Model
or Frame
The Why
Debriefing Goal identifying
and changing mental models
Errors are not
the cause of accidents
E

C
1

C
2

C
3

E
CF
5
CF
4
M. Rall, TPASS
Double-loop Learning
(to achieve deep, long-lasting training effects)
Adapted from Rudolph et al 2008 & W. Eppich
Mental
model
or Causes
Desired
performance
Inquire Observe
Educator
Performance
gap
Actual
performance
Single loop
Double loop
7
Instructors:
You are not a god
" You have no power
over your participants!
" You cant impose
on them what to do!
" They have cared for
patients yesterday and
will do so tomorrow!
Do we critique colleagues and
tell them what was wrong ?
Yes !
But:
- with exact observable behaviours
- in a respectful manner
- without any assumptions
- focused on finding out Why
Modern Simulation Team Training
to enhance patient safety
Man
Technique Organisation
Optimizing
the Interactions
Simulation
Focus on
Team
Human Factors
CRM
Debriefing with
- Facilitation techniques
- Self-reflection (video)
- Double-loop learning
What ? How ?
A revolution for
healthcare and
education
Human Factors (CRM) centered
facilitated Sim-Team-Training
B
A
The lightbulb is
not a continuous
improvement of the
candle!
M. Rall, TPASS
Contact-Info
Marcus Rall, M.D.

Email:
marcus.rall@med.uni-tuebingen.de
mrall@web.de

Center for Patient Safety and Simulation (TuPASS)
Department of Anaesthesiology and Intensive Care Medicine
University Hospital Tuebingen
University of Tuebingen Medical School

Hoppe-Seyler-Str.3, D-72076 Tuebingen
Tel +49 (0)7071/29 86733, Fax 29 49 43
Mobile: +49 171 388 9700

www.tupass.de

8
TPASS
Center for Patientsafety
and Simulation
Effect of initial Block-Team-Training
Avoiding
Subthreshold Training Effects

Double-loop Learning
(to achieve deep, long-lasting training effects)
Adapted from Rudolph et al 2008 & W. Eppich
Mental
model
or Causes
Desired
performance
Inquire Observe
Educator
Performance
gap
Actual
performance
Single loop
Double loop
Take-home-message:
Wir passen beide aufeinander auf:
Nachfragen
Bedenken ussern
Gefahren klren
Medikamente sicher applizieren etc.

Es ist nett, wenn jemand nachfragt,
nachhakt, Zweifel hat, Bedenken
ussert etc!
Expertise - real existierende Tatsachen
Anzahl
Inakzeptabel --- schlecht ----<--- Expertise --->----- sehr gut ------ Spitzenklasse
Advantages of in-situ simulation team training
Training of actual team interdisciplinary
Training in the real environment
Optimizing of Equipment/Layout
and Processes !
Working area = Learning area
Safety culture boost
Positive Team Intervention
Long lasting effects
(self-sustaining from inside the team)
Instructor Courses
HF, CRM, Facilitation, Video,
Day 1
Mini-ACRM
Theory and
Practice

Day 2
Mini-ACRM
Reflection
Simulation
for real

Day 3
Scenarios and
Debriefings
with feedback
patient safety

Day 4
Scenarios and
Debriefings
with feedback
training theory

TuPASS, EUSim-Cooperation & many others
Day 5
Coaching

M. Rall, TPASS
Scenario Design
Relevance
not
Reality
M. Rall, TPASS
9
M. Rall, TuPASS, Germany
Humans do err
Zero-Error-Strategy is the wrong goal!

(Kpt. M. Mller, 2007, Director Flight Safety German Lufthansa)

Mean Time Between Failure
(Human Performance Messungen)

Routine, used task 30 min
Complex Tasks, no Stress 5 min
Complex Tasks, + Stress 30 sec
Example: Emergency team, 4 people,
working for 20 min:
a) Common team + Stress:
4 x 20 x 2 = 160 ERRORS !
b) CRM/Sim-Trained Team (no stress):
4 x 20 x 0,2 = 16 Errors ! (10-fold decrease!)
CRM Simulation Team Training
Know the environment
Anticipate and plan
Call for help early
Exercise leadership and
followership
Distribute the workload
Mobilize all available
resources
Communicate effectively
Use all available
information
CRM Key Points strong science behind
From Rall, Gaba
in: Miller, Anesthesia
6th Edition (2005)

Prevent and manage
fixation errors
Cross (double) check
Use cognitive aids
Re-evaluate repeatedly
Use good teamwork
Allocate attention wisely
Set priorities dynamically
Situation
Awareness
Effective (critical)
Communication
Dynamic
(naturalistic)
Decision Making
Fixation
Error
Human
error
Human
limitations
Team-
Work
Team cognition etc
Task
Management
Why things
go wrong
Hypothesis from 10 years
of simulation training:
Medical teams are
too fast
Diagnosis !
Problems ?
Problem,
Team, Facts,
Plan,
Distribute
The 10 seconds for 10 minutes concept
10 sec!
Rall, Glavin, Flin:
BJA Bulletin 2008
Scenario Design
Trainiere nicht
das Schlimmste und Seltenste

Trainiere die common killers:
= kritische Routinesituationen

Verwende Daten aus IRS:
Aber: Train the causes
not the cases
(Ursachen, nicht Flle)
1 x 50% = 0,5 P
100 x 25% = 25 P
10
Patienten harm = Error
Error = Guilt
Error = stupid (stupid is - stupid does)
Stupid action = stupid person
Stupid = too lazy to learn
lazy = bad attitude
b.a. = bad character (person)
b.c. = bad human being
b.h. = unacceptable out !
Dilemma of Errors & Safety Culture
Tip of Iceberg Phenomenon of Behavioural vs. Mental Change
From Reason 2003
Mental change
Behavioural
change
1.Sim-
Training
2.Sim-
Training
Scenario Design
" Do not train
the worst & rarest
" Do train the common killers
Critical routine situations
" Use data from IRS:
But train the causes
not the cases
100 x 25% = 25 P
1 x 50% = 0,5 P
1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,From,Teaching,to,Coaching,,Marzellus,Hofmann,
1
From%Teaching%to%Coaching
%
%
2
Time%schedule%
! 9.00%%9.20%Keynote%presentation%(M.%Rall)%
! 9.20%%9.30%Short%discussion%
! 9.30%%9.45%Short%introduction%to%the%group%
work%(Marzellus%&%Hayley)%
! 9.45%%10.30%Group%work%
! 10.30%%11.00%WrapLup%session%
3 4
What%are%the%goals%of%this%session?%
! Participants%can%explain%the%difference%
between%teaching%and%coaching.%%
%
! Participants%are%able%to%give%examples%of%
coaching%methods%with%respect%to%ATLS%
courses.%
%
! Participants%will%take%home%coaching%
tools%to%work%with%in%the%ATLSLsetting.%
5
Teaching%&%Coaching%%whats%the%difference?%
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Teaching%&%Coaching%%whats%the%difference?%
By(separating(teaching(from(learning,(we(
have(teachers(who(do(not(listen(and(students(
who(do(not(talk.(
Based%on%Palmer%P,%The%Courage%to%Teach,%1998%
The(more(the(student(becomes(the(teacher(and(
the(more(the(teacher(becomes(the(learner,(the(
more(successful(are(the(outcomes.(
John%Hattie,%Visible%Learning,%2009%
2
ATLS%Europe,Mee.ng,Berlin,,April,2012,,From,Teaching,to,Coaching,,Marzellus,Hofmann,
7
What%characterises%coaching?%
coaching(is(unlocking(a(persons(potential(
to(maximise(their(own(performance.(It(is(
helping(them(to(learn(rather(than(teaching(
them.(Whitmore,%1992%
Coaches(play(a(part(in(learning(as:(
!%Activators%
!%Facilitators%
!%deliberate%change%agents%
!%Companions%.of%the%learning%process%through%FEEDBACK(
8
What%characterises%coaches?%
Coaches(are:%%
! highly%experienced,%%
! highly%reflective,%
! Reevaluating%methods%and%
procedures,%%%
! Capable%of%adapting%methods%
and%strategies%to%fit%the%
needs%of%the%individual%
learner%
! Authentic%
! Values%the%learners%
9
Beginning%with%the%end%in%mind!%
Personal(development/(
processJside(
Companionship:%
!%support%&%encouragement%
!%sharing%frustration%and%success%
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10
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!%Active%listening%
!%Asking%openLended%quesitions%(reflection)%
!%Individualisation%
!%Show%relevance%
!%FEEDBACK(!!(
11
ATLS%2020%%where%are%we%heading?%
In%your%groups%pease:%
1. Briefly%describe%the%current%feedback/coaching%sytems
used%in%your%countries.%
2. Review%the%Pendleton%plus%model%outlined%in%the%
session%introduction.%
3. Evaluate%the%feedback/coaching%practice%in%your%
country%in%the%light%of%the%given%material%%L%develop
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12
TakeLHomeLMessage%
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7
1.Howdoyouthinkthatwent?
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5.ActionPlan
ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

Evidence in Polytrauma Management
- The German Clinical Practice Guidelines
Bertil Bouillon
Department of Trauma and Orthopaedic Surgery
Witten/ Herdecke University, Cologne Merheim Medical Center
boaring !
Guidelines are
too complicated !
too unspecific !
unnecessary !
far away from reality !
background
the favourite
Anteil von Femurschaftfrakturen, die primr mit einem Fixateur versorgt wurden
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9
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a
l F
ix
a
t
io
n
hospitals
82%
8%
?
Rixen, J Trauma 2005
5. Grafische Klinikvergleiche
- Hospital performance: observed vs predicted outcome -
Difference between observed and predicted mortality rate
Mortality below
prognosis
Mortality above
prognosis
Predicted mortality calculated via RISC Score
DGU
-3,7%
-20
-15
-10
-5
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Traumanetwork
Germany
www.dgu-traumanetzwerk.de
Traumanetwork
Germany
structure
whitebook,
audit of hospitals,
certification of regional
traumanetwork systems
process of care
courses (PHTLS, ATLS, ATCN, DSTC),
clinical practice guidelines,
tele consulting
outcome
trauma registry
quality improvement project
http://www.awmf.org/leitlinien/detail/ll/012-019.html
Published by the Committee of the Scientific Medical Societies
! start 2004, relaunch 2009, final 2011
! 97 authors
! 11 scientific medical societies
! 445 pages (the book)
! 3 phases: pre hospital, emergency room, emergency surgery
! 264 key recommendations
! 66 pre hospital, 103 emergency room, 95 emergency surgery
clinical practice guideline the facts
definition of a guideline (AWMF)
Guidelines are recommendations that have been
developed systematically. They contain the actual
knowledge. They should help physicians and patients
in the decision making process for adequate
treatment of a specific injury or disease.
www.awmf.org
Participating scientific medical societies

Level of guidelines (S1-S3)
S1: expert group
S2: evidence based
S3: evidence + consensus
Literaturrecherche
Systematic literature review
Level of evidence
Oxford Centre of Evidence-based Medicine
Level 1: RCT
Level 2: prospective studies
Level 3: retrospective studies
Level 4: case studies
Level 5: expert opinion
Grade of recommendation (GoR)
! GoR A: must (soll)
! GoR B: should (sollte)
! GoR 0: can (kann)
Consensus
high consensus > 95% participants agreed
average consensus > 75% participants agreed
low consensus > 50% participants agreed
no consenus 50% participants agreed
dissemination of guideline
! internet
! booklet (participants of the traumanetwork system)
! publications (journals)
! presentations, workshops, courses

guideline:
examples prehospital
airway and breathing
Recommendations :
! in severely injured patients with respiratory insufficiency (RR<6)
endotracheal intubation and ventilation must be performed in the pre
hospital setting
!in severely injured patients with the following indications endotracheal
intubation and ventilation should be performed in the pre hospital setting
! hypoxia (sat. < 90%) despite oxygenation and exclusion of a tension
pneumothorax
! severe head trauma (GCS < 9)
! hemodynamic instability (BPsys < 90mmHg)
! severe chest trauma with respiratory insufficiency (RR>29)

GoR A

GoR B
ventilation and capnography
Recommendations:
! capnography must be performed in the pre- and inhospital setting for
control of correct tube position in case of endotracheal intubation
! in patients with endotracheal intubation normoventilation must be
performed.
! in hospital (emergency room and thereafter) ventilation must be
monitored with control of arterial blood gases (ABGs)

GoR A

GoR A

GoR A
Prehospital airway and ventilation management: a trauma score and injury
severity score-based analysis.DP Davis, J Peay, MJ Sise, R Coimbra;
J.Trauma 69: 294-301 (2010)
- Trauma registry with 11.000 patienten with head trauma (AIS3)
- groups: endotracheal intubation vs others
- outcome: expected vs observed mortality Mortalitt
- results:
- no difference in both groups
- in the more severely injured patients advantages if intubated
- patients who were treated by helicopter crews performed better

problem: wrong position of endotracheal tube
A. Timmermann. Anaest Analg 2007
literature
guideline:
examples emergency room
organization
Trauma teams in the ER
must follow a standardized
and systematic work up.
They must be trained.
chest trauma: diagnostics
what is the role of clinical evaluation of the chest ?
Recommendation
! a clinical examination of the chest must be performed GoR A
! auscultation should be performed as part of the clinical examination GoR B
Comment:
Even if there are only scarce scientific evaluations on the role of the clinical examination
of the chest in trauma patients the experts agree that clinical examination is a
prerequisite for rapid detection of relevant injuries that could be life threatening and
necessitate rapid intervention. This is also true for reevaluation when arriving in teh
emergency room, even if a thoracic drain had already been placed in the prehospital
setting because of possible changes of the patients status.
chest trauma: radiological work up
If a chest trauma cannot be excluded a
radiologic evaluation must be performed in
the ER .
A CT of the chest with contrast medium
should be performed in any patient with
signs of a severe chest trauma.

indication for thoracotomy
Thoracotomy can be performed in
case of initial blood loss of >1.500
ml or in case of blood loss of
>250ml/h for more than 4 hours.
emergency room thoracotomy
In patients with blunt trauma and
without vital signs at the site of the
accident ER thoracotomy should
not be performed
posttraumatic coagulopathy
Posttraumatic coagulopathy has negative
influence on outcome. It must be detected
and treated immediately in the ER .
Thrombelastography/-metry (ROTEM/
ROTEG) can help to monitor and monitor
treatment of posttraumatic coagulopthy
treatment of coagulopathy
A massive transfusion protocol should be
implemented and used.
In case of coagulopathy the RBC/ FFP ratio
should be 2:1 to 1:1 if FFP is used.
Fibrinogen should be given if values fall
below 1.5g/l (150mg/dl)
! is an interdisciplinary guideline
! ... should help in daily practice and for case review
! documents the available evidence
! experts judge this evidence and give recommendations
! will be published in English within the next 3 months
! is open for discussion
! must be updated regularly
the clinical practice guideline polytrauma
http://www.awmf.org/leitlinien/detail/ll/012-019.html
07.05.12
1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,ATLS,and,S3,Guideline.,Does,it,t?,,,MaChias,Mnzberg,,Ber.l,Bouillon,,
ATLS and S3 Guidline
Does it fit?

BG Unfallklinik Ludwigshafen, Klinik fr Unfallchirurgie und Orthopdie - Luftrettungszentrum Christoph 5
Activation of the trauma bay
Airway and C Spine Protection
A
A
A
07.05.12
2
Breathing
B
Breathing
B
S3: prehospital
Breathing
B C
Breathing/Circulation
C
Circulation
C
Circulation
C
Circulation
07.05.12
3
C
Circulation
C
ATLS: STOP THE BLEEDING
Circulation
C
Circulation
D
Disability
D
Circulation
E
Environment
07.05.12
4
ATLS is nearly conform to the S 3 guidline

minor deviation:

CT diagnostic
DPL
Optimization of the intubation sequence
Summary
07.05.12'
1'
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1.'My'ATLS''registra4on'details'
2.'ATLS'learning''13'chapter'guidelines'
3.'ATLS'Videos''Procedural'videos'
4.'Calculators''GCS,'Parkland'etc'
5.'Favorites''list'of'saved'favorites'
6.'Ques4on'Bank''sample'MCQs'
7.'Sehngs''
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Username.
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!!!!!Home!Page!
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!4My ATLS!
!4ATLS!Learning
!4Videos!
!4Calculators!!
!4Favorites!
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!!!ATLS!Learning
1.Assessment!and !
Management!
2.Airway
3.Shock!
4.Thoracic!Trauma!
5.Head!Trauma!
6.Spine!and!Spinal!
Cord..!
13.Transfer!to!
DeniOve care
!
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!!!!!Chapter 1
Assessment!and !
management
4ObjecOves!
4PiSalls!
4Primary Survey
4Secondary Survey
4Chapter summary
4appropriate video
link!
'
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'
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'
User'specic'to'some'extent.'
To'incorporate'ATLS'course'history,'reverica4on'
advice'and'alert.'
Calendars,'events'and'no4ca4ons.'
Appropriate'links'eg.'instructor'links/resources'and'
Na4onal'contacts.'
'
07.05.12'
3'
'
ATLS'light''interac4ve'companion'to'book.''
Consists'of'the'13'ATLS'chapters'condensed'into'
objec4ves,'key'illustra4ons'and'interac4ve'
algorithms'and'calculators.'
Includes'links'to'appropriate'videos'and'other'
graphics.'
''''
'
!!!!!Chapter 7!
4Dermatomes!
4Myotomes
4Muscle strength grading.!
4C4Spine X4rays.!
4Videos!
4Summary.!
!
'
''
'
'
'
,Dermatomes''tap'to'view'map.'
,Myotomes''tap'to'view'aected'areas'
,Muscle'strength'grading'table'
,Skill'Sta4on'X''Cervical'Spine'X,rays'
,Skill'Sta4on'XI,E''Log'roll'Video.'
,Summary'points''1,5'
''
'
x
x
x
'
To'include'all'main'procedural'videos'e.g..'Chest'Tube'inser4on,'pericardiocentesis,'
Intraosseous'needle,''plus'some'extras.'
Voice'ac4vated'on'new'iphone'and'Just'in'4me'!''
'
The'convenience'of'a'list'of'useful'interac4ve'clinical'
tools'algor4hms'and'calculators.'
'
E.g..'GCS'tool,'Pediatric'verbal'score'and'the'
Parkland'Formula.''
' '
''',App'specic'for'
''''..the'Anaesthe4c'trainee'learning'airway'
maneuvers'
'
'''the'surgical'trainee'using'head'injury'algorithms,'
indica4ons'for'laparotomy'and'dermatomes.'
'
The'ability'to'personalise'and'dene'My'ATLS'App.''
07.05.12'
4'
'
Approved'sample'ques4ons..'
'
Many'dierent'ideas'and'huge'poten4al'to'develop'
the'app'to'assist'with..'
'
',Na4onal'and'local'running'of'courses.'
',Sharing'of'course'resources'and'user'specic'log'on.'
',Valuable'resource'of'ATLS'trainees'
',Social'media''facebook'and'TwiOer'
',Complimen4ng'e,learning''
''
''
''
'
Using'GPS'to'Find'course'near'me.'
All'registered'course'centers'pop'up'with'full'details,'
contacts'etc.'
Upcoming'courses'and''
'''availability'?'
'
Facebook'page'useful'to'generate'exposure,'
ideas,'discussion'and'feedback.'
The'role'of'the'TwiOer'feed.'
Clinical'valida4on'of'the'App'once'developed.'
''
'
'
A"randomised"control"trial"to"determine"if"use"of"iResus"applica3on"on"a"
smart"phone"improves"the"performance"of"an"advanced"life"support"
provider"in"a"simulated"medical"emergency."Journal"of"Anaesthesia"
2011,"66"pg"255@262""
'
ATLS'Resources'
Instructors'' Coordinators'
'
Ini4al'ideas'and'discussion'from'the'mee4ngs'in'San'
Francisco'have'now'become'a'solid'framework'for'
ACS'and'programmers'to'work'from.'
IT'company'made'a'great'start'with'what'is'quite'a'
mul4plalorm'IT'challenge'!'
Aiming'launch'at'the'end'of'this'year.'
A'fantas4c'project'that'will'enthuse'and'mo4vate'the'
ATLS'students'of'the'future.''
''''''''''''''''''''''
07.05.12'
5'
'
Dr"George"Brighton,"Berlin"April"28
th
"2012.'
1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,The,European,Trauma,Course,,Freddy,Lippert,
The Course Management Committee for the European Trauma Course
European Trauma Course
Learning from friends
Freddy Lippert

CEO
Emergency Medical Services
The Capital Region of Denmark
Copenhagen, Denmark

Ass. Professor Copenhagen University

l i p p e r t @ r e g i o n h . d k
Freddy Lippert
European Resuscitation Council
ERC Board / General Assembly
ERC Guidelines writing Group
European Trauma Course Organization

Agenda
History of the European Trauma Course
The organisation and societies behind
What is the European Trauma Course
The course concept and content
The future of ETC
ETC ATLS - future cooperation?
On behalf of
European Trauma Course Organisation ETCO
Karl Thies, Guttorm Bratteb (ESA)
Eric Voiglio, Mauro Zago (ESTES)
Charles Deakin, Freddy Lippert (ERC)
Marc Sabbe, Raed Arafat (EuSEM)
Carsten Lott (ECTO)
Bart Vissers (ERC management
representative)
Founding persons
Peter Driscoll
Carl Gwinnutt
Peter Goode
Carsten Lott
Mary Rose Cassar
Ivan Esposito
Giuseppe Nardi
Stefano DiBartolomeo
Rui Araujo
Ernestina Gomes
Mike Davis
Freddy Lippert
David Robinson
Michael Hpfl
Markus Roessler
Karl Thies

2
Berlin Berlin

A huge step forward
Established the
structured system
and common
language for trauma
care
New educational
approach to
teaching/learning
In the beginning

Bologna, Italy in 2002
Letter to the Editor
in Resuscitation
Do we need a European approach to
trauma care? by Karl-Christian Thies.

Resuscitation 2004:60:113-114

Letter to the Editor
There is obviously a demand for a reasonable,
commonly accepted approach and an enhanced
programme of training in trauma care in Europe.
it seems sensible to develop a European
approach to trauma resuscitation that is more
flexible, based on the best evidence available, and
which is adjustable to local conditions. We suggest
that an ERC Task Force be established in order to
create European guidelines on trauma
resuscitation.
3
The vision of the ETG
To use state-of-the-art evidence based knowledge
To be interdisciplinary and multi-specialty
To teach a team approach reflecting European
practice
To address the pre-hospital and the early hospital
period to enhance continuity of care
To meet the requirements of contemporary adult
learning
To be mainly practical
To be flexible and adaptable enough to meet the
different regional needs within Europe
To be affordable throughout Europe
Organisations behind
The European Trauma Course Organisation
The role of the ERC
Benets from logistics and network of
all the ERC courses: BLS-AED, ILS, ALS,
NLS, EPLS, GIC
Course Management System
ETC development
Two years for course planning
First pilot course in Malta in 2006
Two more pilot courses in 2007 - 2008

2006-2008
2 years of pilot courses, revisits & revisions
2006,
MALTA,
,2007,
Stavanger,
,2007,
Rome,
,2008,
MALTA,
The first official
European Trauma Course
ERC 2008 Ghent, Belgium May 2008
4
ETC Course Structure
2 day scenario/simulation based,
hands-on course
Lectures time kept to an absolute
minimum
Manual: electronic and printed
Training for individuals and teams
Different manikins and equipment
Modular to allow flexibility
ETC Course materials
Manual (paper)
Electronic version
The Course Management Committee for the European Trauma Course
Initial assessment and
resuscitation of the severely
injured patient
2. Team leadership
Command and control
Resources
The Team
The 5 second round
Problems
Less often hands
on
Coordination
Task allocation
Task performance
Interventions
Outsiders

Communication
Team members
Pre-hospital team
Patient
Other specialities
Relatives
A
B
C
D
E
Airway with cervical spine control
Breathing and ventilation
Circulation & control of hemorrhage
Dysfunction of the CNS
Exposure & environment
Primary survey & resuscitation
Assessment and test
Continuous assessment
Knowledge and skills
Team member competence
Team leader competence
No final written testing
A final scenario based examination as
team leader in a team
5
Team Leader Assessment
Test scenario on day 3
Standardised scenarios
Candidate is Team leader
Instructors are the Team
Criteria needing to be
met
From candidate to instructor
Candidates
Instructor Potential
Instructor Candidates
Generic Instructor Course and ETC-
instructor day
Instructors
The Candidates
Groups of four
Stay together during the
course
Work together as trauma
teams in workshops
Team-leader
Team-member or
Critiquer
Workshop Characteristics
Hands on
Scenario based
Small groups
Scenario training as teams
Lead instructor
Second instructor
Candidates
Vertical Management:
Individual Approach
Initial information
Additional information
Interactions
6
Horizontal management
Planning and Discussion
Team Leaders Brief
Examination findings
on role play cards
Team Briefing
ETC comments from experts

ATLS and the ETC should walk arm in arm
around Europe
ATLS for basic vertical management and ETC for
advanced horizontal management team training
7
The ETC builds on the principles of ATLS and allows
doctors to take knowledge and skills and use them as
part of a team. It particularly struck me watching the
team scenarios how individual components of ATLS
were all running simultaneously.
ATLS provided a valuable springboard from which the
ETC could then go on and explore more complex
issues relating to trauma care in particular training in
team management.
My hope is that the two courses will flourish along side
each other in Europe and particularly in the United
Kingdom.
Validity pressure increases as does complexity over the
two days. Appropriate content real cases without
ridiculous injuries or unreal circumstances. Team allowed
to play their own role at work rather than being forced to
play the role of someone you are not so the validity of
the team trying to work out what they are capable of as a
whole and who they need to supplement was very real.
Overall impression I thoroughly recommend this course, it
is the natural and logical progression for all StRs and
consultants and should be a mandatory course once
there are enough faculty in the UK.
Support Yes with no reservations.
Thoughts for the future
Trauma care with ETC and ATLS courses
A common goal
International guidelines on trauma care
like the ILCOR (ilcor.org)
International consensus on science
International treatment recommendations
Courses with different approaches (basic,
individual, skill training, team training,
team leader training)

SUMMARY
The European Trauma Course:
Is interdisciplinary
is team approach
is practical
is affordable
is flexible and adaptable
Uses modern adult learning methods

8
www.europeantraumacourse.com
07.05.12
1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,Sustainability,of,ATLS,courses,,Bouillon,,Woel,,Hofmann,Muenzberg,
Sustainability of ATLS courses

Bouillon, Woelfl, Hofmann,Muenzberg
Does it work? Question of the didactic

Does it help? Question of the outcome

Does it work?
Meassurment of the Sustainability on two levels:

Knowledge
Skills
Does it work?
3 Meassurment points:

1. Directly before the course
20 Questions of the Pre-Test
Moulage scenario with videotaping
2. Ending of the ATLS course
20 Question out of the Post-Test
Videotaping of the moulage scenario

3. 3 month after the course
20 Question
Moulage scenario with videotapig

Does it help?
1
ATLS%Europe,Mee.ng,Berlin,,April,2012,,The,ATLS,classica.on,of,shock,%,is,a,modica.on,necessary?,,
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Manuel,Mutschler,
The ATLS classification of shock-
is a modification necessary?
Manuel Mutschler

Department of Trauma and Orthopaedic Surgery
University Witten/ Herdecke, Cologne Merheim Medical Center
Class%I, Class%II, Class%III, Class%IV,
Blood%loss%in%%% <15% 15130% 30140% >40%
Pulse rate% <100% 1001120% 1201140% >140%
Blood pressure% Normal Normal Decreased% Decreased%
Mental status% Slightly%anxious Mildly anxious% Anxious, confused% Confused, lethargic%
Pulse,pressure,
Normal,or
increased
Decreased Decreased Decreased
Respiratory rate 14%20, 20%30, 30%40, >35,
Urine,output >30, 20%30, 5%15, Negligible,
Fluid replacement% Crystalloid% Crystalloid% Crystalloid and blood% Crystalloid and blood%
The ATLS classification of shock
Student Course Manual, 8th edition
Validation of the current ATLS classification of shock
TraumaRegister DGU

Aim of the study

> 67.000 patients included
357 affiliated hospitals in 6 European countries

TraumaRegister DGU
0
10'000
20'000
30'000
40'000
50'000
60'000
70'000
80'000
1
9
9
3

1
9
9
4

1
9
9
5

1
9
9
6

1
9
9
7

1
9
9
8

1
9
9
9

2
0
0
0

2
0
0
1

2
0
0
2

2
0
0
3

2
0
0
4

2
0
0
5

2
0
0
6

2
0
0
7

2
0
0
8

2
0
0
9

2
0
1
0

Inclusion criteria:
2002-2010
Age 16
primary admission to an affiliated hospital
Study population:
36.504 patients
Mean ISS 16 in all subgroups
> 90% blunt trauma
Study design
Blood%loss%in%%% <15% 15130% 30140% >40%
Pulse,rate <100, 100%120, 120%140, >140,
Blood,pressure, 110, 100, < 100, < 90,
Mental,status GCS,15 GCS,15, GCS,12%14, GCS,< 12
Definition of variables
Blood%loss%in%%% <15% 15130% 30140% >40%
Pulse,rate <100, 100%120, 120%140, >140,
Blood,pressure, Normal, Normal, Decreased Decreased
Mental,status Slightly anxious Mildly anxious, Anxious,,confused Confused, lethargic
2
9,3 %
90,7 %
classified by ATLS
not classified by ATLS
91 %
5 %
<1 %
3 %
ATLS class l
ATLS class ll
ATLS class lll
ATLS class lV
Combination of HR, SBP, GCS
> 90% of all trauma patients are not classified adequately
Recently in our ER
Pat., male, 35 years; car accident
HR 122/min, SBP 110 mmHg, GCS 9
Blood%loss%in%%% <15% 15130% 30140% >40%
Pulse,rate <100, 100%120, 120%140, >140,
Blood,pressure, Normal, Normal, Decreased Decreased
Mental,status Slightly anxious Mildly anxious, Anxious,,confused Confused, lethargic

N = 32.458
,, ,, ,, ,,
, < 100 100-119 120-139 140
SBP at,ER,(mean) 126.45 125.47 116.36 108.95
GCS,at,ER,(mean) 9.27 8.98 7.51 6.36
GCS,prehospital,,(mean) 11.56 11.38 10.27 9.17
Heart rate
ATLS < 100 100-119 120-139 140
SBP , Normal, Normal, Decreased, Decreased,
Mental,status Slightly anxious Mildly anxious Anxious/confused, Confused/lethargic,
Systolic blood pressure
N,=,33.135
110 100-109 90-99 < 90
HR,at,ER,(mean) , 87.87 89.14 92.78 91.01
GCS,at,ER,(mean) 9.92 7.17 6.24 4.74
ATLS 110 100-109 90-99 < 90
HR, <100 100%120 120%140 >140
Mental,status Slightly anxious Mildly anxious Anxious/confused, Confused/lethargic,
Glasgow Coma Scale
No tachycardia in any group (88-89 bpm in all groups)
Moderate hypotension (SBP 117 mmHg) in patients
with a GCS < 12
Summary
< 10 % could be classified according to ATLS
Lowered SBP increased heart rate
GCS lower through groups I-IV
3
TARN registry TARN registry
Guly 2010, Resuscitation
Heart Rate:
Association between reduced SBP and tachycardia: 128mmHg (HR<100) vs.114 mmHg (HR>140)
No relevant changes in RR and GCS (15 vs. 14)
Systolic Blood Pressure:
No relevant tachycardia observed (83 vs. 88 beats/min)
RR unaltered
Respiratory rate:
No hypotension in any group
Moderate tachycardia (HR >100 bpm/min) in patients with a RR > 30
Limitations of the studies
Retrospective analysis
Pulse pressure, urinary output were left out
Need for translation
What do vital signs tell us?
Heart Rate
Poor correlation between hypotension and tachycardia: Victorino 2003, J Am Coll Surg
neither specific nor sensitive in determing the need for emergent intervention, severe injury or transfusion
of pRBC: Brasel 2007, J of Trauma
Relative bradycardia (SBP 90 mmHg; HR 90 bpm) in 44% of all patients: increased mortality, occurs
in older patients: Ley 2009, J of Trauma
What do vital signs tell us?
Systolic Blood Pressure
Late marker of shock, compensated phase of shock
110 mmHg as a cut-off point for increased mortality: Husler 2012, Resuscitation
Dependent on initial treatment (fluids, vasopressors)
Glasgow Coma Scale
Predictor for mortality, outcome
Prehospital intubation, isolated head injuries

do we need a modified classification?
Yes

Based on a parameter which fulfills:
- Fast assessment
- Identifying patients at risk (transfusion, injury severity)

4
Base Deficit
BD: a physiological marker of hypoperfusion/shock
In times of POCT: easy and fast assessment
Correlates with transfusion requirements, mortality and injury severity also in young and adult trauma
populations
Four classes of worsening BD
Class 1 : -2 mmol/l normal
Class 2: < -2 to -6 mmol/l mild
Class 3: < -6 to <-10 mmol/l moderate
Class 4: -10 mmol/l severe
Davis 1996, J of Trauma
Davis 1998, J of Trauma
Rixen 2001, Shock
Rixen 2005, Crit Care
Jung 2009, J of Trauma

Inclusion criteria
TraumaRegister DGU
16.305 patients between 2002-2010
Age 16
primary admission
BD between +4 mmol/l to -20 mmol/l
Therapy

BD
-2.0
BD
-2.1 to -6.0
BD
<-6.0 to <-10
BD
< -10
pRBC transfusions/units 1.2 (3.5) 2.9 (5.6) 5.7 (8.8) 10.5 (13.9)
all blood products/units 1.5 (5.9) 4.5 (11.3) 10.3 (18.1) 20.3 (27.2)
IV fluds at ED 1701 (1902) 2454 (2710) 2941 (2535) 3230 (2705)
Vasopressors at ED (%) 15.9 30.8 49.0 72.7
p <0.001 meanSD
A BD-based classification

Worsening BD is associated with:
Rising mortality, LOS, ICU days, sepsis, MOF
Increase of injury severity reflected by ISS, NISS, RISC
Decrease of Hb, platelets, Quicks value
Vital signs

BD
-2.0
BD
-2.1 to -6.0
BD
< -6.0 to <-10
BD
< -10
SBP at ED 132.6 (26.3) 124.6 (28.0) 112.7 (30.7) 94.8 (40.4)
HR at ED 86.3 (17.8) 89.8 (20.3) 95.9 (22.5) 97.2 (32.4)
GCS at ED 10.3 (5.4) 7.8 (5.5) 6.1 (4.9) 4.7 (3.8)
p <0.001 meanSD
Comparison of BD vs. ATLS
Mass transfusion
Percent of patients receiving 1 blood unit
Mortality
Definition of ATLS by the worst category
5
Mass transfusion (10 blood units)
0%
10%
20%
30%
40%
50%
60%
l ll lll lV
ATLS
BD
A
M
a
s
s
tr
a
n
s
fu
s
io
n
(
%
)
***
***
***
*** p<0.001
1 blood unit
0%
10%
20%
30%
40%
50%
60%
70%
80%
l ll lll lV
ATLS
BD
B
P
a
t. r
e
c
e
iv
e
d

1
b
lo
o
d
u
n
it (
%
)
***
***
***
*** p<0.001
Mortality rates (%)
0%
10%
20%
30%
40%
50%
60%
l ll lll lV
ATLS
BD
C
M
o
r
ta
litiy
(
%
)
***
***
***
***
*** p<0.001
A BD-based shock classification?

BD and/or lactate can be useful in determing the
presence and severity of shock. Serial measurement of
these parameters can be used to monitor the response
to therapy.
Student Course Manual, 8th edition
A BD-based shock classification?
Shock , normal, mild moderate severe,
BD%at%
admission%,
12, <12to%16, <16%to%110, 110,
Blood,transfusion, watch, consider act
Be,prepared,for mass
transfusion,
Summary
The ATLS classification - a good teaching tool,
but it seems not to reflect clinical reality appropriately
Modified classification of shock
teaching tool
Evidence based
BD as a physiological marker of shock
Dilemma: POCT in every ED or can we redefine a new combination of vitals?

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ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

ATLS%Europe,Mee.ng,Berlin,,April,2012,,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

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