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PreHospital Trauma Life Support

A history of 25 years of PHTLS on the release of its sixth edition text

As the 1970s ended and the 1980s began, the Advanced Trauma Life Support course began to establish itself as the standard in physician trauma training. As a developer of the first ATLS text and courses, Norman McSwain, MD, was certain that the information in this course would be of even more value to EMS providers.

     McSwain set about finding a partner to develop and disseminate a prehospital version of ATLS. The National Association of EMTs accepted his proposal, and the American College of Surgeons agreed to provide medical oversight to the partnership. A committee was formed within NAEMT to coordinate development of the course and work out faculty training across the United States. NAEMT's PHTLS Committee later became a division of the association to accommodate the needs of the PHTLS Executive Council in coordinating PHTLS activities all over the world.

     With a team of NAEMT members working with McSwain, pilot courses were conducted regionally in the United States. Based on the experiences of those first courses, the program was formalized and regional workshops were conducted to train faculty. With publication of the PHTLS textbook in 1984, the program began to grow rapidly. By publication of the third edition, its architects had placed PHTLS on a four-year revision schedule to ensure it was consistent with changes in the ATLS content and that standards were updated.

Research Funding
PHTLS, together with NAEMT, continues to fund trauma-related research studies. Currently, three projects are ongoing, looking at improving pain management in patients with fractures and burns, supplemental support with blanket roles during rapid extrication, and evaluating the reliability and sensitivity of prehospital clinical examinations to detect pelvic fractures in blunt trauma patients.

PHTLS Sixth Edition Text
As PHTLS releases its sixth edition text and instructor resources, a half-million providers have been trained in 38 countries. The PHTLS Executive Council has created the most comprehensive text yet, with new materials that reflect the latest in educational standards and create interactive learning environments that allow participants to apply course concepts throughout the course.

     As with previous editions, the PHTLS text begins with ATLS. In this case, the ATLS seventh edition was used as a basis to develop the text, which creates consistency with the physicians trained in ATLS and the nurses taking Advanced Trauma Care for Nurses courses.

     The text is evidence-based. Position papers are included where appropriate and the text is fully referenced. Another enhancement throughout this text is the inclusion of expanded information on prolonged or extended transport. The sixth edition is divided into five divisions:

Energy and Injury
The first division includes the introduction and chapters on injury prevention and kinematics. The introduction includes a new section on reading medical literature to give providers guidance on deciphering published prehospital research. Injury prevention includes updated statistics and a new section on preventing injury in EMS providers, including information on ambulance crashes. The kinematics chapter has been significantly revised, including a section on shotgun injuries.

Assessment and Management
The second division includes chapters on the scene, the patient, airway and ventilation, and shock. The scene is an all-new chapter that looks at street survival, hazardous materials/decontamination, bloodborne diseases and crime scenes. The patient content includes a look at hemorrhage control and triage. Airway and ventilation content reflects recent research on intubation and ventilation rates and quality, and includes discussion on capnography. Shock content features expanded physiology and the latest evidence regarding hemorrhage control.

Specific Injuries
Included in the third division are head trauma, spinal trauma, thoracic trauma, abdominal trauma, musculoskeletal trauma, burn trauma, pediatric trauma, geriatric trauma, environmental injuries (including heat and cold injuries) and a chapter on other environmental injuries. The chapter on head injury was edited by a former EMT/neurosurgeon and features new material on facial trauma and soft tissue neck injuries. The spinal and thoracic trauma chapters were updated to include a section on commotio cordis. The abdominal chapter includes a section on FAST sonograms. The musculoskeletal section was extensively reorganized and includes new sections on compartment syndrome and crush injuries. The burn trauma chapter was significantly revised with sections on chemical burns and smoke inhalation. The American College of Surgeons' Committee on Trauma Pediatric Subcommittee provided input for the pediatric chapter, which discusses pediatric abuse and integrates the EMSC/NAEMSP guidelines and JUMPSTART triage. Geriatric trauma has been significantly revised, including abuse. Revision of the environmental chapter was guided by a military paramedic/physiologist. A new chapter on other types of environmental injuries looks at scuba diving emergencies, high altitude situations, lightning injuries and drowning.

Systems and Summary
"Golden principles" summarizes the text. The chapter on EMS systems was significantly revised and includes the components of EMS systems, trauma systems and levels of trauma centers, along with sections on ground transportation, including a look at lights and sirens. Appropriate use of aeromedical transport is also presented.

Special Considerations
Special considerations includes chapters on disaster management, weapons of mass destruction, civilian tactical EMS and wilderness trauma care. Disaster management is a new chapter focusing on mass casualty incident management, incident command, medical response, public health response, the threat of terrorism, decontamination and psychological response. Weapons of mass destruction is a new chapter focusing on PPE and explosive, incendiary, chemical, biological and radiological agents. The new civilian tactical EMS chapter looks at TEMS and protective medicine, zones of care, the differences between TEMS and EMS and medical counterterrorism operations. Wilderness trauma care, another new chapter, looks at the wilderness context of EMS, risk vs. benefit decision-making, wound management, dislocations, CPR in the backcountry, and bites and stings.

Military PHTLSz
The sixth edition military text was completely reconstructed. It begins with a preface and introduction and moves into combat field care, tactical field care, CASEVAC and triage in tactical combat casualty care. Blast injuries, medical operations in urban injuries, MEDIVAC and military medical ethics are also discussed.

Sixth Edition Rollout
The rollout of the sixth edition will occur at EMS EXPO in Las Vegas, NV, Tuesday, September 26. During the eight-hour rollout, PHTLS faculty from all over the world will be introduced to the new text, instructor materials and the new course structure. The following day, the PHTLS faculty will be brought together for the NAEMT PHTLS Division meeting. The updated policies and procedures, which can be viewed on the PHTLS website at www.phtls.org, will be discussed, as well as PHTLS activities past, present and future. PHTLS state and country coordinators will also give reports and participate in group discussions. Also during the meeting, PHTLS appreciation awards will be distributed. At 3 p.m. on September 27, Dr. James K. Styner will deliver the Scott Frame Memorial lecture, titled The Birth of ATLS, recounting his personal tragedy that gave rise to the development of ATLS and subsequently PHTLS and ATCN. For more information, visit www.emsexpo2006.com.

PHTLS Around the World
In 1985, the first international courses were conducted in Mexico, England, Ireland and Israel. As PHTLS faculty spread out across the country, the international community became increasingly involved in the growth of the program. The international community of PHTLS and the year their programs began includes:

  • Canada, Trinidad and Tobago and Barbados in 1988
  • Argentina, Israel and Colombia in 1995
  • Chile and Brazil in 1996
  • Italy, Holland and Sweden in 1997
  • Greece and Australia in 1998
  • Hong Kong, China and Panama in 1999
  • Saudi Arabia, Norway and Switzerland in 2000
  • Bolivia, New Zealand and Venezuela in 2001
  • Denmark, Uruguay and Peru in 2002
  • France and Portugal in 2003
  • Scotland and Spain (see photo above) in 2004
  • Grenada in 2005
  • United Arab Emirates and Luxembourg in 2006.

      Programs have also been developed in Eastern Europe through demonstration courses in Bulgaria and Macedonia, and there are plans in place to bring the course onto the African continent in the near future. To date, PHTLS has conducted courses in 38 countries.

Will Chapleau, EMT-P, RN, TNS, has been a paramedic for 30 years and a trauma nurse specialist for 17 years. Currently, he is chief of the Chicago Heights Fire Department and is on the board of directors of the National Association of EMTs, the National Association of EMS Educators and the Society of Trauma Nurses. He has published numerous texts and journal articles and has lectured all over North and South America, Europe and Asia.