- APA Styner, James K. MD The Birth of Advanced Trauma Life Support, Journal of Trauma Nursing: April-June 2006 - Volume 13 - Issue 2 - p 41-44
- ATLS student course manual, The American College of Surgeons, 10 ed.
Medical History: The tragedy that gave birth to ATLS
Dr. James Styner transformed trauma care after a 1976 plane crash, creating the ATLS protocol (now a global benchmark) to standardize emergency treatment.
The man who changed the approach to trauma
In 2025, in any hospital, a trauma is received by staff specifically trained in its treatment. They all know what they have to do and act in complete unison, coordinated by a Team Leader, according to a codified treatment pathway called ATLS (Advaced Trauma Life Support).
This pathway, based on repeated, schematic and simple assessments of specific signs and symptoms and the immediate recognition and treatment of life-threatening complications, makes it possible to standardise the response to trauma, to frame the patient from the ground up by getting ‘the right patient in the right hospital, in the right time', to optimise response resources (think, for example, of those who are faced with deciding whether, or not, to fly a helicopter, or deciding when, and if, to have a CT scan or go straight to the operating room) and, ultimately, to optimise patient outcomes.
But how did it come about? This is the story of Dr. James Styner and how his personal story changed the approach to trauma.
The plane crash
To fully understand the course of events, we must take a leap in space and time. We are in Nebraska (USA), a state that covers 200,520 square kilometres with, at the time, 1,490,000 inhabitants (a population density of about 7 inhabitants per square kilometre), in the territory of the ‘great plains’, with kilometres and kilometres of pastureland, very few densely populated cities and vast areas of... nothing.
The year is 1976. Miloš Forman's ‘Someone Flew Over the Cuckoo's Nest’ wins the Oscar for best film, the Eagles, Bob Dylan, Queen are playing. Car of the year is the SIMCA 1307-1308 and the mobile phone is still little more than a prototype. The pre-hospital rescue system (we are talking about the USA, but even in Europe it was practically the same) was still essentially based on non-centralised voluntary work, carried out by untrained personnel, with makeshift vehicles, almost always civilian: in some cases the undertakers' cars were even used, the only ones actually adaptable to a stretcher.
The protagonist of this story is Dr James Styner, a trauma surgeon practising in Lincoln, Nebraska.
One February afternoon, Dr. Styner, who is also a pilot, boards his plane with his family (wife and four children) to return to Lincoln, Nebraska, after a trip to California.
The pilot already has five hours of flying behind him, is tired, has stopped for refuelling, but has decided to take off again quickly because of a storm, which he wants to leave behind.
At 6pm, flying over Nebraska, he encounters a layer of low clouds. He is tired, it is dark and he has no instrument rating, but he cannot turn back because of the storm. He then decides to lower his altitude in an attempt to get out of the clouds, and it's a close call: he loses too much altitude, becomes disoriented, crashes into a row of trees and then into the ground.
Credits: American College of Surgeons
His wife, Charlene, is hit in the head by a piece of an engine and dies instantly. Of the four children, only the eldest, 10-year-old Chris, remains conscious, suffering a fractured arm, while the other three (Randal, 8, Richard, 7, and Kimberly, 3) suffer severe head injuries and lose consciousness. Styner himself suffers chest trauma and a fractured eye socket.
Terrified, blind in one eye and in pain, but alive, Styner has only one thought: his family. With the help of his eldest son, he extricates his three unconscious children from the wreckage of the plane, pulling them away from what he perceives as the first, great danger: fire. He finds his wife about 100 metres away from the plane, but realises immediately that there is nothing more he can do for her.
Realising that fire will not be a problem, and that his children, although unconscious, have no visible external haemorrhages, Styner identifies a new potential danger in hypothermia (the temperature was in fact below zero). He gathers as much clothing as he can from their suitcases, creates a nest where he places the children and sets off with them to wait for help (the plane had a tracking system and the alarm had been raised). Help will arrive too late.
Eight hours after impact, the clouds have cleared and the full moon allows a glimpse of a road not far away. Styner decides to go for help himself. He leaves his eldest son with his brothers, telling them not to go looking for him and not to move under any circumstances, and heads for the road.
To two travellers, named Rick and David, a screaming man, covered in blood, appears in the middle of the road at two in the morning. Fortunately, ‘Criminal Minds’ and other TV series that strongly advise against this will not be written until 20 years later, and the two decide to stop and help. They load Styner and the kids into the car (yes... 7 people, 5 of whom were paediatric injuries, in a 1970s car) and head to the nearest hospital. What seemed like the end of a terrible nightmare was only the beginning.
Trauma management before ATLS
The hospital, to begin with, had an emergency room, but it was closed. The nurse on duty, visibly agitated and without the slightest idea what she should do, calls the two doctors (two ‘general practitioners’) on call. Doctors Pembry and Bunting rush to the hospital, but they, too, are disoriented and act in a confused manner. One of the children, Richard, becomes agitated because of the head injury. He is picked up and taken to Radiology, where a cranial X-ray is taken (the first CT scans were not installed until 1974, and certainly not in rural Nebraska). The doctor returns, joyfully announcing that there are no fractures. The question of immobilising the spine, of investigating fractures of the spine, does not occur to him, because he simply DID NOT KNOW that he should have done it.
Styner at this point has had enough and decides to take matters into his own hands: he calls his friend and colleague Bruce Miller, asking for immediate help to reach the hospital in Lincoln.
The Lincoln Air National Guard sends a transport helicopter for what is the first civilian rescue operation in the area. The medical team consists of Dr Pembry (the hospital's GP) and a nurse. At 8 a.m., 14 hours after the trauma, Dr Styner and his sons reach the hospital in Lincoln, where his friend Bruce Miller and a team of surgeons await them. Styner and all his children survive the accident.
Styner is not just a citizen, he is a doctor, a trauma surgeon, and he decides to move beyond what could have ended up as the worst mishap of his life and asks himself the fateful question ‘when I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed’ which translated as ‘if the care I can provide, without means, at the scene, is better than the care I received at the hospital, the system that produced this is wrong, and it has to be changed’.
The birth of the ATLS
And Styner, who is indeed a trauma surgeon, a man of action and not of words, decides to change the system.
He involves the director of Lincoln's emergency department, Ron Craig, a vascular surgeon, Paul (Skip) Collicott, and a nurse, Jodie Bechtel, and they decide to build on the work of Steve Carvith, who in those years had invented the ACLS, devising and promoting a similar protocol (schematic, by points, based on a few fundamental parameters) for trauma, calling it ATLS. Nothing new, no innovative technique: the greatness of this project lies in its simplicity, in bringing order to the chaos of things to be done and people who have to do them, standardising the treatment especially of what is the first, fundamental hour after the event (the ‘golden hour’).
The first alumni of the ATLS were rural Nebraska doctors in 1978. It was a success. The following year, the American College of Surgeons Committee on Trauma adopted the project, and the course, modernised and revised in the light of new scientific and technological discoveries (think of CT at first, and in more recent years of the development of FAST and ultrasound scanners as big as laptops), still represents a milestone for anyone working with trauma.