MILITARY MEDICINE, 163, 11:747, 1998
Advanced Trauma Life Support versus Combat Trauma Life Support Courses: A Comparison of Cognitive Knowledge Decline Major Ron Ben Abraham*t Major Amir BlumenJeld* Lieutenant Colonel Michael Stein*t Lieutenant Colonel Shmuel C. Shapira**
Captain Gideon Paret*t Captain Avraham Rivkind** Brigadier General Joshua Shemer*t
This prospective study was conducted to compare cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) and Combat Trauma Life Support (CTLS) courses in Israel. The investigation was based on multiplechoice questions that tested the results of 211 ATLSand CTLS course graduates and was performed 3 to 66 months after completion of the courses. These results were then compared with the examination outcomes immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the two courses. No significant difference was found in the rate of decline in knowledge gained from the two courses after a given period. Priority for refresher courses should be set regardless of type of course previously attended by physicians.
primary trauma care skills for physicians who have had no contactwithtrauma in their daily practice but whoare assigned to combatunits in their reserve military service is mandatory. In addition to the ATLS course, a Combat Trauma Life Support (CTLS) course, whichprovides battlefield-related subjects, was developed.' Fundamentally, this is the original full ATLS course supplemented by additional topics relevant to the battlefield. This study evaluates the rate and extentofcognitive knowledge decline in graduates ofthe ATLS and CTLS courses.
Introduction
D Israelto improve on the provision ofinitialcare fortrauma vtctims.'Anational systematic approachfor trauma care orga-
Uring the last decade, a concerted effort has been made in
nization was launched. The Israeli Council for Trauma was established and assumed the leadership forimplementing planning and prioritization ofits national policy concerning trauma management." A total of six trauma centers were inaugurated across the country. Anumber ofspecialized trauma units were established using the services ofsurgeonswhohad completed a full fellowship in traumatology. Themajorfocus ofthe campaign was the improvement of trauma care education. Accumulated experience and the evaluation ofdata from both the civilian and the military sectorshas shownthat primarytrauma victim care duiing the "golden hour" in Israel needs Improvement." Introduction of the Advanced Trauma Life Support (ATLS) program by the IsraelSurgical Society and the IsraelDefense Force Medical Corps was seen as the appropriate intervention required to evoke improvement in trauma care.' The program received further recognition whenthe coursewas officially accredited bythe Scientific Council of the Israel Medical Association." In Israel, the ATLS courses are held onlyin the School of Military Medicine, l.e., under the supervision ofthe Surgeon General. TheIsraelDefense Force is essentially based on reserve units. Medical care in these units is provided by reserve military physicians. The ability of these physicians to deal with trauma victims in a competent manner is essential. Improvement of *Israel Defense Force Medical Corps. tSackler School ofMedicine, Tel Aviv University, Tel Aviv, Israel. tTrauma Unit, Department of Surgery, Hadassah Medical Center, Jerusalem, Israel. This manuscript wasreceived for review in December 1997 andwasaccepted for publication in March 1998. Reprint & Copyright ©byAssociation ofMilitary Surgeons ofU.S., 1998.
Materials and Methods Population Atotal of211physicians whohad, duringthe previous 3 to 66 months, successfully completed the ATLS or the CTLS course were randomly assigned to an examination consisting of 40 multiple-choice questionsdealing with acute trauma care. Methods Themultiple-choice examination was similarin structure and content to the writtenexaminations forthe pre-ATLS and postATLS course,and the level ofknowledge needed to complete the pre-and post-tests forthe coursewasassumedto be equtvalent, The questionswere formulated by consensus by a team of five senior traumatologists, The results of the original post-ATLS multiple-choice examinations of these 211 physicians were retrieved for comparison from the computerized data bank maintained at the School ofMilitary Medicine. Statistical Analysis
Asurvival analysistechnique was applied to analyze the rate ofcognitive knowledge decline among graduatesofthe ATLS and CTLS courses. A survival analysis curve was applied to each course. The analysis of the results was based on the difference ratio (DR), whichis the absolute difference between the post-course and decline test grades divided by the post-course test grade and expressed as a percentage. To determine how rapidly knowledge declines, weadapteda model based on survival analysis," in which the decline is measured in survival terms. The analysiswas based on 80% knowledge retention, reflecting the fact that a participant who achieved 100 points in the postcourse test would need an additional course when his or her grade declined to less than 80 points, the minimum passing grade. Using survival analysis terminology, we consider an individual to have"failed" at the timeofthe decline test ifhis or her DRwas less than 80% and to have"passed" the test ifhis or her DRwas 800/0 or higher. This is a liberal procedure, because the
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Comparison of Cognitive Knowledge Decline
DR may actually have decreased to less than 80% before the individual was retested. Thetiming forthe refresher coursewas considered appropriate when 500/0 of the examined group retained 80°A> or less oftheir immediate post-ATLS knowledge.
Results The values indicated are means ± SD for all items. The age rangeofthe participating physicians was 30 to 47 years (mean, 39 ± 6.2 years). A total of 138 physicians participated in the ATLS courses. The CTLS courses were attended by 73 physicians. Byexamining the decline ratiosaccording to the different time intervals, the knowledge decline pattern with timewas investigated. Theresults ofa survival analysis performed to define the probability of retaining 80% of the post-ATLS or post-CTLS scores is presented in Figure 1. The Kaplan-Meier estimator of survival is given. No significant difference (p = 0.9) was found between the survival curves ofthe two courses. The knowledge retention global curve shows that 50% of the physicians retained 80°A> oftheir knowledge after 192weeks (95% confidence interval, 170.3-199.7).
Discussion Decline ofknowledge among participantsin different typesof emergency medicine courseshas already been described. 7,8 The results ofour studyshowthat an approximately lineardecline of cognitive knowledge exists over time. However, the decline pattern does not change according to the typeofcourse. Thefact that CTLS participants had the same decline rate as ATLS graduates is enigmatic. The CTLS curriculum is basically
the complete unchanged ATLS courseofthe American College of Surgeons? ameliorated bylecturesand practicum to consolidate the essentially civilian emergency room-oriented ATLS doctrine and the somewhat different military tasks ofthe medical officer. 4 Enhanced by simulation exercises, the CTLS course was specially designed to improve the ability of the physician to diagnoseand treat trauma victims in field conditions. Blumenfeld et ale I ° analyzed written test scores of physicians who took the CTLS course and compared them with scores achieved in the ATLS courseand found that statistically betterresults appeared among graduates ofthe CTLS course. These resultswere attributedto the comprehensiveness ofthe CTLS curriculum, which provided those dealing with combat trauma with an increased foundation of knowledge. Although the durationofthe CTLS courseis 4 days, compared with2 days for the original ATLS course, its schedule is dense and a heavy burden is placed on the participants to absorb extensive material in a relatively short time. This mayexplain the reduction of knowledge that occurs in the period immediately after the course; other reports have stated that cognitive knowledge decline can occur as early as 3 months after the completion of training. II The CTLS course is richer than the ATLS course, so more knowledge may be lost by graduates in the immediate post-course period, afterwhich a certainstate ofequilibrium is achieved depending on further experience in trauma care. Otherexplanations forthe initial decline ofknowledge among those who completed the CTLS course may lie in the environmentin which the courseswere held. Because thesecoursesare given as part of the training of the medical officer, a stressful milieu of military restrictions may interfere with participant achievement. Nevertheless, our work dealt with cognitive achievement analysis. Recently, it was demonstrated that al-
0.9 0.8 0.7 0.6
Probability
0.5 0.4 0.3
0.2 0.1 o~-------+-------t----------jf--------+--------r--
o
50
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Weeks Fig. 1. Decline in knowledge: survival distribution function.
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Compartson ofCognitive Knowledge Decline though a significant decrease in knowledge and skills occurs, commencing 2 years after completion ofthe ATLS course. participants did not demonstrate a difference in adherence to trauma priorities between the immediate post-course period and 6 months thereafter." Because continuous education and knowledge update is highly desirable. we conclude that prioritiesfor refresher courses for physicians shouldbe set regardless ofwhether they have participated in the ATLS or CTLS course. Further studies are required to determine whether trauma management skill acquisition differs between graduates ofthe ATLS and CTLS courses immediately after completion of the course or as a function oftime from graduation.
References 1. Shemer J. Shaplra sc: EstabUshing of a nation-wide trauma system in Israel. Harefuah 1995; 129: 526-8. 2. Marganit B. Rlvklnd A. Mackenzie EJ : National systemic approach for trauma services organization : a method for improving treatment for the wounded . Harefuah 1990; 119: 18-23.
749 3. Shaplra SC. Rlvkind A. Cahana A: Advanced and not abused trauma life support in Israel 1994. Harefuah 1994; 127: 421-3 . 4. KlugerY. Rlvklnd A. Donchin Y. Notzer N. Shushan A. Danon Y: A novel approach to military combat trauma education. J Trauma 1991; 31: 564-9. 5. Shemer J: ATLScourse in the development of trauma care in Israel. Harefuah 1995; 128: 697-8. 6. Cox DR, Oakes D (eds): Analysis of Survtval Data . London. Chapman & Hall, 1984. 7. Gass DA.Curry L: Physicians' and nurses' retention of knowledge and skill after training in cardiopulmonary resuscitation. Can Med Assoc J 1983; 128: 550-1. 8. Stross JK: MaIntaining competency in advanced cardiac life support skills . JAMA 1983: 249:3339-41 . 9. Committee on Trauma: Advanced Trauma Life Support Course Instructor Manual . Chicago. Amertcan College of Surgeons. 1993. 10. Blumenfeld A. Kluger Y. Ben Abraham R. Rlvkind A: Combat trauma life support training: the impact of enhanced simulations on final student scores . Millt Med 1997: 162: 463-6. II. Abendeheim DR.Willenkin RL: Retention of basic CPR skills in medical students. Circulation 1980: 62: 124. 12. AUJ. Cohen RA. Adam T, GanaJ. Pierre E. AU H. Bedaysle V, WInnJ: Attrttionof cognitive and trauma management skills after the Advanced Trauma LifeSupport (ATLSl course. J Trauma 1996; 40: 860-6.
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