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Trauma training for a thousand doctors

Physicians of Estonia to apply first aid ABC from friends in USA

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PHOTO: Corbis/Scanpix

Trauma surgeon and scientist Peep Talving (48), after a lengthy practice abroad, is introducing homeland to its biggest post-diploma course ever – aimed at equipping a thousand local doctors with American trauma training, over the years.

In nine months time, presumably in the Estonian National Defence College in Tartu, doctors will be attending the first aid training ATLS – Advanced Trauma Life Support. Mr Talving, having worked for six years in the trauma surgeons’ group of the hospital at University Los Angeles County and South-Carolina – a leading medical institute in USA – and, before that, residing in Sweden for two decades, has this past year been busy bringing the complementary training program into Estonia.

The memorandum of understanding signed last Thursday in Tartu serves to signify the course may indeed reach Estonia.

«No doubt this is the best international medical study programme,» assured ATLS Europe head podiatrist Andrew R. Baker, in Tallinn.

While working in Sweden, Mr Talving studied to become an ATLS instructor and was for years director of training at Karolinska University hospital. «He realised, obviously, the importance of the programme and applied for Estonia to join,» said Mr Baker.

Life saving procedures

According to Mr Talving, several countries have used the army’s money for launching ATLS. In Estonia, the Defence Forces will primarily be involved by providing classrooms and means.

«As we know, Defence Forces’ doctors use the very ATLS principles on the battle field. Pursuant to Estonian law, all civilian doctors automatically turn into military doctors in a war situation. This means: in crisis situations we would now speak the same language,» said Mr Talving.

«Estonia belongs to several international associations – NATO, the European Union. By that, communication will become very easy,» added Mr Baker.

Developed by American College of Surgeons in the 1970ies, ATLS is a study programme for medical workers dealing with trauma. The training is aimed at reducing death toll among patients and complications after severe injuries.

«The course is centred on providing the best treatment for severely injured person during the first couple of hours. These are live-saving procedures which are often very simple once one knows them and applies them at the right moment and in the right order,» explained Mr Baker.

According to Mr Talving, Estonian doctors have definitely heard of ATLS, being aware of what it implies.

«They are aware of the ABCDE-principles, but when this has not been systematically taught and continuously repeated in practice, in difficult situations the priorities tend to get blurred a bit,» said the surgeon. «Sometimes it fails to occur to the doctors that if something goes wrong they need to go back to the beginning and do it all over again, step by step, till the indicators start to improve with the patient.»

Mr Baker and Mr Talving said medical workers often get confused when seeing a patient who has lost a lot of blood. «The course teaches that even when providing medical help alone, a doctor may never get distracted from the priorities. «A» needs immediate intervention as with airways not open the patient will be dead within minutes – but you have a lot of time to deal with blood supply,» they explained with passion.

Mentality change

As noted by Mr Talving, there are several ways actually to treat a trauma patient. «For instance, doctors have various ways of thinking on how to ensure air passage. ATLS teaches the one and safe, science-based approach,» said the doctor.

The training also teaches treatment of patients with multiple traumas, and the principles of treating mass injuries where fast cooperation of several medical specialists is of vital importance.

«The greatest mentality change that occurs with the training is that the doctors will no longer be searching for the diagnosis to begin with. Medical studies are based on determining the diagnosis. With trauma, the actual diagnosis is not important as a rule. You seek for and find the problem that may kill the patient, and you fix it fast,» deliberated Mr Baker.

As shown by professional literature, ATLS does raise the chances for survival, while this is still difficult to assess scientifically. «In any case, ATLS does greatly boost the doctors’ confidence and they function better in stress situations,» noted Mr Baker.

It is hoped the first practical training in Estonia will take place in nine months’ time. After three months, 16 doctors selected from our hospitals will probably meet in England. Having passed the instructors’ training, these will become ATLS instructors who will be training other colleagues.

«Having 16 instructors in Estonia and doing three courses every year, we will be training 50 doctors a year. Thus, in ten years we’ll have some 500 doctors,» said Mr Talving and noted that to reach the aim of a 1,000 doctors it would take a long time indeed – considering the current resources.

«We will start the training with emergency medicine doctors at Estonian trauma centres, as well with surgeons, anaesthesiologists and other specialists and residents who are the first to see a trauma patient,» explained Mr Talving. After that, doctors in small hospitals will be involved in the training.

Well equipped hospitals

American College of Surgeons never issues licences to universities, hospitals or armies; rather, the partner needs to be a specialist organisation – in Estonia’s case, it’s Estonian Association of Surgeons. During a lengthy process, it is assessed if the host country is capable of conducting the further trainings on its own.

«The conditions available in the Tartu University Hospital are excellent. The amount of doctors who desire to participate is fantastic,» said Mr Baker, having visited the hospital.

«Beholding the North Estonian Regional Hospital’s new wing, it is very modern – ultrasound machines everywhere, computer tomographs everywhere, magnetic cameras. All kinds of things can be done. But what is completely missing is post-diploma training for doctors dealing with trauma patients,» said Mr Talving.

To launch the courses will cost about €100,000, €70,000 of which was provided by social ministry. The rest will be provided by Tartu University Hospital and North Estonian Regional Hospital.

«As a result of the training, doctors will receive an internationally accepted certificate which will definitely raise the level of our healthcare,» said social ministry press representative Armo Vask.

Traumas killing the youth

According to North-Estonian Regional Hospital chief-doctor/adviser on emergency medicine Peep Talving, there is a tendency to view trauma patients in a bad light, but this is not supposed to be – trauma is a surgical sickness, often claiming the lives of young people.

«In Estonia, trauma has had a bit of a bad taste to it – like these are the drunk down-and-outs who now also have a trauma on top of it all. But we all do various things in life which may lead to injury. Therefore, we must view all members of the society the same and treat them right,» said Mr Talving.

With people aged 1–45, trauma is the topmost cause of death. «The young drive the fast machines, climb the heights and take risks. If these injured young people are brought back to health, with proper treatment, this is of great value to the people and to the economy,» noted the surgeon.

As admitted by Mr Talving, Estonia is a relatively safe environment, but has an endangering amount of trauma deaths according to Eurostat data.

«Recently, we did a survey of trauma cases in the major hospitals, in 2013, and we discovered 256 cases of severe injuries. Of these cases, penetrating traumas i.e. knife and bullet injuries only amounted to 5.1 percent – which is very low as compared to the rest of the world. In 94.5 of the cases, it was blunt traumas,» said the surgeon.

Even so, blunt trauma brings very many injuries and, according to Mr Talving, multiple injuries need well-structured treatment. Quality of trauma treatment can be raised by validated training like ATLS – so far lacking in Estonia.

What is ATLS?


•    ATLS is an accredited course for doctors dealing with trauma patients, developed by American College of Surgeons trauma committee.

•    First aid is provided based on firmly structured vertical algorithm of ABCDE. «A» means airway maintenance with cervical spine protection, «B» is ensuring breathing and ventilation, «C» is circulation with haemorrhage control, «D» means disability/neurologic assessment, and «E» is exposure and environmental control.

•    ABCDE operates according to a strict structure: if «B» does not work, one may not take «C» first, nor jump from «B» to «D» etc. Once the initial algorithm is passed, the patient may be further examined.


•    The ATLS course was created by an American orthopaedic surgeon James K. Styner after a tragic airplane accident in 1976, as he crashed in his private plane in the wastelands of Nebraska. His wife Charlene died in an instant; three of the four children were critically injured.

•    There on the field, Mr Styner performed the initial triage on the children. Then he stopped a car which transported him to the nearest hospital. As they arrived, the county hospital was closed. As it was opened and the local doctor summoned, Mr Styner, saw the fist aid provided was neither sufficient nor fitting. Mistakes were made every step of the way.

•    After the incident, Mr Styner announced: «If, with limited resources, I could provide better first aid than my children received in the largest regional hospital, there is something the matter with the system and it needs correction.»

Source: Postgraduate Medical Journal, Andrew R. Baker

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