Columns, Trauma


I have already made my feelings on merit badge medicine known [see We Don t Need No Stinkin Badges! ]. These courses are OK for continuing education but should never be required as a condition of employment or certification. However, I would like to turn our attention to the phenomena of Basic Trauma Life Support (BTLS) and Prehospital Trauma Life Support (PHTLS). These two courses are among the most popular merit badge courses in EMS. But there seems to be some redundancy between the two, and wherever there is redundancy, there is increased cost.

The history, as I remember it, was that BTLS was developed by John Emory Campbell, MD, and the Alabama Chapter of the American College of Emergency Physicians (ACEP). The book, now in its 5th edition, bears a 25th Anniversary Edition label and has been continuously published by Brady. BTLS has an international organization and a board of directors, comprising primarily physicians, of which Dr. Campbell remains the president.

The history of PHTLS is somewhat similar. In 1981, the National Association of Emergency Medical Technicians (NAEMT) asked Norman McSwain Jr., MD, to develop an ATLS course for non-physicians that would be loosely based on the American College of Surgeons Advanced Trauma Life Support (ATLS) course. A committee was appointed, and the first courses were conducted in 1983. The textbook, originally published by Emergency Training International (ETI) and later by Mosby, is also in its 5th edition. PHTLS remains under the aegis of the NAEMT, and Dr. McSwain remains its medical director. (Publisher s note: Mosby and Jems are both imprints of Elsevier Inc.)

Although most states accept either certification, considerable allegiance and loyalty to each course is evident among providers. I have some friends who swear by BTLS while others prefer PHTLS. I actually saw a fairly heated argument in a tavern in Phoenix many years ago about whether the BTLS term Kinetics of Trauma was right or whether the PHTLS term Kinematics of Trauma was correct. Both men had admittedly had too much to drink, but the argument was interesting. The two organizations seem as juxtaposed to each other as you would see in any political party. The information provided by the courses has typically been similar. So why two courses? Why two textbooks? Why two organizations? Why two sets of instructor manuals? Why two sets of PowerPoint slides? Why can t there be just one course?

I understand that this is a capitalistic society and competition is good. I understand that PHTLS is a major source of income for the NAEMT and BTLS is a source of income for Alabama ACEP. Both publishers must be making money from the textbooks, or they wouldn t continue to revise and publish them.

But here is the problem. As these courses have independently evolved, they have taken slightly different directions. Because of this, treatments have started to vary. Also, these courses have not adequately reacted to changes in the medical literature. This divergence is now becoming a problem for students. I recently had a young paramedic ask about the appropriate target blood pressure for trauma patients. BTLS says the systolic pressure should be between 90 and 100 mmHg, but PHTLS says it should be between 80 and 90 mmHg. Although I think PHTLS is more correct, that doesn t help the student, especially when they take a re-certification exam in their state. EMTs and paramedics, especially those new to the profession, need to know the standards and they will then strive to achieve them. If they are unsure of the standards, they are then unsure in their care.

Other problems exist in these courses. Extensive material on MAST remains despite the fact that the preponderance of the medical literature says these are nothing but an inflatable splint and play no role in shock management. Another example is the algorithms for spinal immobilization. PHTLS primarily follows the NEXUS criteria and BTLS follows the Maine Protocol. Both are accurate but are different in their process. Again, this causes confusion in our industry.

Although I ll be declared a heretic (again), I think it s time we have the two entities sit down and do one of two things: Combine the courses and the organizations. (Reduction of this redundancy will save money and allow the course to be offered to more people at a lesser cost.) Or have a consensus conference with each publisher and their experts represented to ensure that both programs are conveying the same information to EMS students.

I would like to see everything become evidence-based, as we are seeing with the American Heart Association and the Brain Trauma Foundation. Each organization should then suggest standards, guidelines or treatment options on the basis of the level of scientific evidence supporting each.