Anaesthesia trauma and critical care course

The Anaesthesia Trauma and Critical Care Course (ATACC) was developed in 1997 to provide an alternative to the Advanced Trauma Life Support (ATLS) course (Royal College of Surgeons of Edinburgh, 2012), which would have the benefit of being developed around current clinical practice within the UK (Forrest et al, 2006). It was also highlighted that ATLS, although widely taught to various professionals, has a strong surgical bias that may not always be beneficial or appropriate. ATACC was designed to address this bias by developing a course which was representative of the need for early involvement from various specialists, especially those of anaesthesia (Forrest et al, 2006). A secondary, but equally important aim in the development of ATACC, was to provide an up-to-date, evidence-based course as an alternative to ATLS, which has been critiqued for lacking appropriate underpinning evidence (Luke, 2006; Southern and Sen, 2007) and lacking relevance for UK practice (Driscoll and Wardrope, 2005; Southern and Sen, 2007). The ATACC faculty have also developed and run a number of other Rescue Trauma and Critical Care (RTACC) courses (Box 1), designed for healthcare practitioners and others working in pre-hospital environments. They also offer courses in Critical Care Patient Transfer, Incident Safety Assessment and Human Simulation Critical Incident Training (ATACC, 2011).

The course itself was delivered over three days by a faculty drawn from paramedic, nurse, fire service, physician, anaesthetic and surgical specialities (Box 2). This provided an excellent opportunity to learn from specialists in their field for each aspect of the course. Instructors from the fire service for example facilitated the extrication skill station, while the instructor for the out-of-hospital trauma station was an advanced paramedic from Ireland. The three days comprise a mixture of didactic lectures, skill stations and scenarios (both indoors and out). Candidates were sent a course manual before the course commenced and were advised to read this thoroughly before the first day of the course. The course manual is a substantial work, at 262 pages long, written by a number of consultants, registrars and other practitioners. It comprehensively covers all aspects of the course and is excellent pre-reading material, providing background information on the pathophysiology of many traumatic injuries as well as easy-to-follow flowcharts for some aspects of trauma management. The manual also references numerous contemporary textbooks and articles, which makes undertaking further self directed reading an easy task. Candidates were also advised to bring their own personal protective equipment and to use this during all the practical sessions.

The skill stations covered practical procedures including intubation, undertaking surgical cricothyroidotomy and thoracostomy. These sessions were excellently taught by practitioners experienced in the skill in question and used animal tissue, which is far more realistic than the commonly used plastic manikins. Tissues included; sheep thoraces for thoracostomy and chest tube placement, and larynges for undertaking surgical airways, along with pigs' trotters for intraosseous access. The opportunities to use both the EZIO (Vidacare, 2012) and the FAST-1 (PyngMedical, 2010), on manikins and animal tissue, was especially beneficial, even more so when instructed by a practitioner thoroughly knowledgeable in the advantages and disadvantages of each system. The ATACC course also covers the use of diagnostic ultrasound and the eFAST protocol for detecting free abdominal fluid (Sonosite, 2008), which is sure to be of use to an increasing number of pre-hospital care providers in the next few years. The eFAST session was extremely well taught, and it was of great interest to see firefighters with no previous experience in ultrasonography quickly locating the kidneys, bladder and heart.

The lectures, in general, were of a very high quality and covered areas of practice such as the kinematics of trauma, damage control surgery, crush injury and mass casualty incidents. It was however, surprising that during the lecture covering burns from a CT2 in anaesthesia, candidates were advised that pre-hospital RSI for patients with large-area or facial burns should be avoided and rapid transport to hospital initiated instead. This is especially interesting as many other authorities recommend early intubation for such patients (Rice and Orgill, 2011). In contrast to this unusual teaching, the information in this session covering Jackson's Thermal Wound Theory and the Parkland Formula were extremely interesting and relevant. Another interesting paradigm observed during the course was the liberal use of arterial tourniquets in cases of crush injury. Although widely advocated for their haemostatic capabilities, the evidence for tourniquet use in crush syndrome currently appears less clear, not forming part of current consensus guidelines (Greaves et al, 2004), and it is interesting to see a national course advocating their use so authoritatively.

Current pre-hospital care providers may find some aspects of the course frustrating. This is especially likely when the aim of certain moulages was, according to members of the faculty, to present a ‘no-win’ scenario, in an effort to demonstrate the potential difficulties unique to pre-hospital care. This involved scenarios such as a shooting in a nightclub, with no police in attendance, uncooperative door staff, no lighting, loud music and aggressive revellers who assaulted candidates while they rendered aid to simulated patients. Far from using scenarios such as this to highlight the importance of scene safety and knowing when it is unsafe to enter a scene, this scenario forced the candidates to enter the dangerous environment and attempt a rapid evacuation and treatment of multiple casualties while under attack from revellers. These scenarios were certainly not for the faint-hearted, and may be daunting for practitioners with no experience of pre-hospital care. Although scenarios such as this may have a place in training for some aspects of pre-hospital care, in my opinion they are an inappropriate way to introduce the sub-specialty to in-hospital practitioners.