THE BIRTH OF ATLS   by the founder of ATLS James K. Styner
Chapt XXIV;XXV from THE PREHOSPITAL TRAUMA LIFE SUPPORT Manual,
Author James K. Styner, MD, FACS
Retired Orthopedic Surgeon
Copyright Elsevier

As happens so often in life, a personal experience brought
about the changes in emergency care that resulted in
the birth of the ATLS course. My own personal part in the
role of ATLS started 29 years ago when a plane crashed in
a rural area of Nebraska. The ATLS course was born out of
that mangled mass of metal, the injured, and the dead.
This is what I remember.

On February 17, 1976, my family left Los Angeles to
return to Lincoln, Nebraska, after a wedding.
I flew a 6-seat Beach Barron twin-engine plane. My wife,
Charlene, sat in the copilot’s seat. Our eldest son, Christopher,
age 10, sat behind me facing the oxygen bottle that was strapped
to the back of the pilot’s seat. Kimberly, his 3-year-old sister, sat
on his lap, strapped in with the lap seat belt around both
of them. The two middle boys sat next to the rear luggage
door; 7-year-old Randy was on the right, with 8-year-old
Richard beside him. The temperature was 29° F (–1.66° C)
that night.
Five hours into the flight (6:00 PM), trying to stay below
a layer of clouds, I became disoriented and lost altitude.
We flew into a row of trees at 163 miles per hour (311 km/
hour). The wings of the plane were ripped off, the fuel
tanks emptied, and a large hole was torn in the right side of
the aircraft. We dropped into a thicket that cushioned the
landing and then rocketed us onto a fi eld. A piece of the
propeller came through my pilot’s window, missed me, and
hit Charlene’s head. She died instantly. At impact, Charlene
was ejected. The plane traveled another 294 feet (89.6
meters), rotating 180 degrees, but it stayed upright.
What seemed like an eternity actually took 21/2 seconds.
There was a tremendous noise. I waited to die. Then I
remember silence.
My face had hit the dash. I sustained fractured ribs over
the spleen. My forehead and face were lacerated. My left eye
was closed, and I had diffi culty seeing out of the right one.
The right zygomatic arch had an open fracture. I had a frozen
shoulder from a fall 2 months earlier. Kimberly’s head hit
the oxygen bottle. She sustained a blow-out fracture of the
orbit and a forehead laceration. Richard had lacerations
to his forehead and the right supraorbital nerve. He and
Kimberly were unconscious for 7 days. Chris crashed into
Kimberly’s back and was spared a head injury but had a
fractured right forearm and a severe laceration of the dorsum
of the right hand. Randy sustained an open depressed skull
fracture. His right leg came out of the luggage door and was
impaled at the knee by a piece of metal, under the aircraft.
He remained in a coma for 3 days.

I don’t know how long I sat after the world became silent.
The fi rst thing I thought was fi re, and I exited through the
opening, running straight into barbed wire that entangled
the aircraft. This got my attention. Then I realized the kids
are still in the plane! I saw Randy and started to pull him
free when I realized he was pinned under the fuselage.
Chris passed Kim to me. I set her away from the aircraft and
removed Richard next. Chris was able to extract himself.
I returned to Randy and used my hands to dig his leg out.
I don’t know how hard the ground was, but there were no
marks on my hands. His leg fell off the impalement, and I
waited for the bleeding that never started.
Once we all were away from the aircraft and fire was
not a problem, I realized the potential for hypothermia.
We gathered clothing from scattered suitcases, and made a bed
in the back compartment where I placed the kids and piled
more clothes over them. Chris and I sat in the front and
waited, but help never came. The overcast from earlier in
the evening dissipated into a clear night sky with a near-full
moon. I went looking for my wife and found her on the third
try. I checked her, and confirmed she was gone. I would go
back three more times to be sure she was really gone.
We could see a road some distance away from the plane.
After waiting until approximately 2:00 AM, I decided to go for
help. I instructed Chris to stay with the children. I walked
5/8 of a mile along a dirt road to a highway and fl agged down
a car after two trucks didn’t stop. The occupants’ names
were Rick and David. I told them what had happened, and
we drove to the accident site and loaded the kids in the car.

I cannot recall how we assembled seven people in the car
or how much protection we gave their necks.
I felt no pain while I was digging out my son’s leg and
lifting the kids. After help arrived, I was unable to lift
because of chest and shoulder pain. I don’t recall any facial
pain either. Adrenaline is amazing.
At the crash site, I had to worry about fi re and hypothermia.
The wounds were possible bleeding problems.
We protected the children’s necks as best we could. I did
most of the lifting because of Chris’s fractured arm. He acted
as my eyes. Without him the task would have been nearly
impossible. We splinted his arm, I said goodbye to my wife,
and we drove to Hebron Hospital, a few miles south of the
crash site.
We arrived as a motley crew and approached the locked
emergency room door of this rural hospital. We knocked
and the night nurse opened the door. We explained our
predicament and asked if we could get the kids inside. She
told us that we would have to wait until the doctors arrived.
I cannot remember our response, but we got in. A little later
Drs. Pembry and Bunting, the two general practitioners in
this small farming community, arrived. I remember standing
at a mirror picking dried blood off my face and trying to
help. Richard was becoming agitated. A doctor picked him
up by the shoulders and the knees and took him into the
x-ray room. Picture the motion of his head and neck with this
maneuver. Later he returned with Richard and announced
there was no skull fracture. The cervical spine had not been
considered. He then began suturing the laceration. An IV
was placed in Richard and he was given Valium. I don’t
remember anyone else receiving IVs. I called my partner,
Bruce Miller, and told him what had happened and that we
would get to Lincoln as soon as we could; he notified the
hospital.
The doctors and staff in Hebron had little or no preparation
for this type of situation. There was an obvious lack of
training for triage and proper treatment.
A sheriff’s department helicopter piloted by Larry
Russell was assigned to the search (12:00 AM). An aircraft
called Looking Glass came from South Dakota, picked up
our emergency locator beacon, and directed the helicopter
to the crash site. He landed about half an hour after we had
vacated the scene and proceeded to the hospital after being
notifi ed of our arrival.
The civil air patrol was now also searching for us. They
arrived at the crash site hours later. The FAA rule at that
time was that all airports had to be checked fi rst, then a
search and rescue could begin, which took about 6 hours!
The helicopter pilot assessed the situation and suggested
we ask the Lincoln Air National Guard for transport. They
arrived with a transport helicopter and we were loaded for
the 110-mile fl ight to Lincoln. There was a crew of three,
Dr. Pembry, a nurse, and the fi ve of us. Rick and David
disappeared, and I never saw them again. We departed, and
I noted that Richard’s IV had been discontinued.
This was the fi rst air evacuation by the National Guard.
The CAP (civil air patrol) from its formation in the 1950s to
1976 responded to its fi rst crash that had survivors.
We landed at Lincoln Airport and an ambulance
transported us to Lincoln General Hospital. The emergency
department and the operating rooms were ready for us. We
arrived at 8:00 AM, 14 hours after the crash. Waiting for us
were the emergency doctor, Ron Craig, my partner, Bruce
Miller, and a plastic surgeon, Larry Ruth. This experience
was like coming out of a hostile dark hell into civilization.
So ended the longest night of my life.

ATLS Is Born
For the next year or so we tried to heal our physical and
emotional scars.
Folks got tired of my criticism of the treatment we
received before our arrival in Lincoln. I wasn’t complaining
about care at any particular facility, but the general lack of
a delivery system to treat the acute trauma patient in the
rural setting. The statement, “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,”
emphasizes this observation. Simply, you have to train them
before you can blame them. Ron Craig and I started talking
about how to prevent a recurrence of my experience. He
probably said something like, “Quit your griping and put
your money where your mouth is.” We decided we wanted to
educate rural physicians in a systematic way to treat trauma
patients, so we connected with Jodie Bechtel (now Upright),
a nurse with the Lincoln Area Mobile heart team, now a
paramedic group. The three of us decided to do a training
course for Nebraska. Jodie had worked with Steve Carvith
(also from Lincoln) when he created the ACLS course. We
decided to use a similar format and call it ATLS.
A syllabus was created and organized into a logical
approach to trauma. Eventually we got the idea of seeing
and fi xing a problem before attacking the next one, rather
than looking at every system involved and then going
back to treat. Among those who joined was a Mobile heart
team nurse with unending energy, Irvene Hughes, who
is now the ATLS program manager. Paul (Skip) Collicott,
a peripheral vascular surgeon, was also with us from the
beginning. He had the political know-how and took the
lead. Several doctors joined our efforts, and we each wrote
chapters in our specialties for the syllabus. The ABCs of
trauma were developed to prioritize the order of assessment
and treatment. The prototype was field tested in Auburn,
Nebraska, in 1978 with the help of many. Skip presented
the course to the University of Nebraska, who helped with
the surgical skill lab using live, anesthetized dogs. Skip got
the American College of Surgeons Committee on Trauma
involved. We presented the finished course to the College’s
13 regions. It was arborized in each region.

Since that first course in Auburn, 28 years have passed
and ATLS keeps spreading and growing. What was originally
intended as a course for rural Nebraska became a course for
the whole world in all types of trauma settings—500,000
students have trained in 46 countries with 25,000 courses,
and 24,000 trained physicians graduate each year. We’re
defi nitely on a roll! Everyone involved with the trauma
victim speaks the same ATLS “language.” This ability to
communicate and anticipate at all levels decreases morbidity
and mortality in that precious “golden hour.”

ATLS Today
Compared with the recent tsunami, 9-11 at the twin
towers in New York, the Gulf Coast hurricanes, and other
natural and manmade disasters over the past 20 years, our
experience was minor. Our hope is that the ATLS family
has played a part in sa ving lives since that night so many
years ago when my own family’s lives were in peril.
People often wonder or ask about how we have fared
since the crash. The kids have all done well. Kim graduated
with a degree in psychology from college, then went on
to get a master’s in human resources, and now heads that
department in a small company. Chris started college, but
never finished. He and his wife work in real estate and are
doing well. Randy graduated with a degree in biological
science and works for Orange County, California, in waste
management. Richard has a master’s degree in education
from Brown University and teaches computers, biological
science, and astronomy at San Leandro High School south
of Oakland, California.

James K. Styner, MD, FACS
Retired Orthopedic Surgeon