World J. Surg. 22, 1192–1196, 1998WORLDJournal of

SURGERY© 1998 by the Societe

Internationale de Chirurgie

Effect of Basic Prehospital Trauma Life Support Program on Cognitive andTrauma Management Skills

Jameel Ali, M.D., M.Med.Ed.,1 Rasheed Adam, M.B., B.S.,2 David Josa, M.B., B.S.,2 Ian Pierre, M.B., B.S.,2

Henry Bedsaysie, M.B., B.S.,2 Undine West, R.N.,2 Jennifer Winn, R.N.,2 Ernest Ali, R.N.,2

Beresford Haynes, R.N.2

1Department of Surgery, University of Toronto, 100 College Street, Room 311, Toronto, Ontario M5G 1L5, Canada2University of the West Indies, Mount Hope Medical Campus, Uriah Butler Highway, Mount Hope, Republic of Trinidad and Tobago

Abstract. We tested the effectiveness of a basic prehospital trauma lifesupport (PHTLS) program by assessing cognitive performance andtrauma management skills among prehospital trauma personnel. Four-teen subjects who completed a standard PHTLS course (group I) werecompared to a matched group not completing a PHTLS program (groupII). Cognitive performance was assessed on 50-item multiple choiceexaminations, and trauma skills management was assessed with foursimulated trauma patients. Pre-PHTLS multiple choice questionnairescores were similar (45.8 6 9.4% vs. 48.8 6 8.9% for groups I and II,respectively), but the post-PHTLS scores were higher in group I (80.4 65.9%) than in group II (52.6 6 4.9%). Pre-PHTLS simulated traumapatient performance scores (standardized to a maximum total of 20 foreach station) were similar at all four stations for both groups, rangingfrom 7.9 to 10.4. The post-PHTLS scores were statistically significantlyhigher at all four stations for group I (range 16.0–19.0) compared to thosefor group II (range 8.0–11.1). The overall mean pre-PHTLS score for allfour stations was 8.3 6 2.1 for group I and 8.8 6 2.0 (NS) for group II; thegroup I post-PHTLS mean score for the four stations was 17.1 6 2.7 (p <0.05) compared to 9.1 6 2.3 for group II. Pre-PHTLS Adherence toPriority scores on a scale of 1 to 7 were similar (1.1 6 0.9 for group I and1.2 6 1.0 for group II). Post-PHTLS group I Priority scores increased to5.9 6 1.1. Group II (1.1 6 1.0) did not improve their post-PHTLS scores.The pre-PHTLS Organized Approach scores in the simulated traumapatients on a scale of 1 to 5 were 2.1 6 1.0 for group I and 1.9 6 1.2 forgroup II (NS) compared to 4.2 6 0.9 (p < 0.05) in group I and 2.0 6 0.8in group II after PHTLS. This study demonstrates improved cognitive andtrauma management skills performance among prehospital paramedicalpersonnel who complete the basic PHTLS program.

The Advanced Trauma Life Support (ATLS) program was intro-duced in Trinidad and Tobago in 1986 with the aim of improvingoutcome among trauma victims. This program has been shown toimprove trauma patient outcome within the hospital setting [1].Such improvement was related to improved cognitive and traumamanagement skills among physicians treating trauma victims inthe major trauma referral center in Trinidad and Tobago [2, 3].The skills taught through the ATLS program were shown to have

increased in frequency and effectiveness following this training [3].Subsequent data suggested, however, that survival among traumapatients had not significantly improved, even when treated byATLS-trained physicians primarily because of significant prehos-pital trauma-related mortality [4].

The Prehospital Trauma Life Support Program (PHTLS) wasintroduced in 1992 to address the need for improving prehospitaltrauma care in Trinidad and Tobago. We have demonstrated [5]that after the PHTLS program trauma patients transported byambulance had lower overall mortality for the same degree ofinjury compared to the period when no PHTLS training wasprovided for the paramedical personnel. We further demon-strated that stabilization and resuscitation techniques taught inthe PHTLS program were more frequently implemented in theprehospital setting by paramedical personnel after the PHTLSprogram [6], with the inference that the improved trauma patientoutcome was related to the increased utilization of PHTLS-taughttechniques. The present study was aimed at assessing the impactof the PHTLS program on cognitive and trauma patient manage-ment skills among paramedical personnel completing the pro-gram.

Methods

Two matched groups (14 in each group) of paramedical personnelwere compared. Group I completed a standard basic PHTLScourse, whereas group II did not. Both groups had receivedsimilar background training (in the form of St. John’s Ambulancefirst aid) and had similar educational backgrounds.

Cognitive performance was assessed through a 50-item multiplechoice question (MCQ) test prepared by experts in prehospitaltrauma care. This test was administered simultaneously to bothgroups prior to group I attending the basic PHTLS course. Oncompletion of the PHTLS course by group I, both groups againtook the MCQ test.

Four simulated trauma patient scenarios were used for testingtrauma patient resuscitation skills among the participants. Adetailed checklist identifying the specific maneuvers for each

This International Association for the Surgery of Trauma and SurgicalIntensive Care (IATSIC) article was presented at the 37th World Con-gress of Surgery International Surgical Week (ISW97), Acapulco, Mexico,August 24–30, 1997.

Correspondence to: J. Ali, M.D.

trauma scenario was constructed by a group of physicians trainedin trauma management. These items were assigned weightedscores, and physician-examiners assessed the performance of eachsubject at the four stations without knowledge of whether thesubjects had completed the PHTLS program. There were 30 to 40items with a total score of 75 to 110 points per patient station, andthe scores for each station were standardized to a maximum of 20to allow comparison. This technique allowed a detailed standard-ized objective assessment of the subjects’ performance at eachsimulated trauma patient station. The first simulated traumapatient station consisted of a patient with airway compromise andblunt torso trauma and the second a patient with problemsrelating to difficult extrication. The third station tested techniquesof immobilization with an extremity fracture; and the fourthstation tested techniques of pediatric trauma immobilization.

In addition to the trauma station scores, the examiners wererequested to rate the degree to which the student demonstratedan organized approach (Organized Approach Scores) to themanagement of the patient on a scale of 1 to 5 as well as thedegree of adherence to priority (Adherence to Priority Score) foreach station on a scale of 1 to 7. Without adding up theappropriate scores the examiners were also asked to assign agrade to each student. The grades were honors, pass, borderline,and fail. The trauma station performances were assessed after theMCQ tests were completed by both groups, with the first testing ofthe four stations being conducted prior to the PHTLS programand the second testing being done after training by the PHTLSprogram.

Repeated-measures analysis of variance was used for within-group comparisons and the unpaired t-test for between-groupcomparisons. A p value of , 0.05 was considered statisticallysignificant. Measurements are reported as means 6 standarddeviation.

Results

MCQ Scores

As demonstrated in Figure 1, the two groups had similar scores inthe MCQ test prior to the PHTLS program (group I 45.8 6 9.4%,group II 48.8 6 8.9%). Post-PHTLS scores were statisticallysignificantly higher in group I (80.4 6 5.9%) than in group II, whodid not improve their scores in the MCQ test (52.6 6 4.9%).

Trauma Patient Scores

As indicated in Table 1, groups I and II had similar scores for allfour stations prior to training by the PHTLS program. Group Isignificantly improved their scores at every station after PHTLStraining, whereas there were no significant changes in the post-PHTLS scores at all four stations for group II.

The mean overall trauma station scores for all four stations arecompared in Figure 2. These scores were similar for the twogroups before PHTLS (group I 8.3 6 2.1 vs. group II 8.8 6 2.0).Post-PHTLS overall mean trauma station scores were 17.1 6 2.7for group I (p , 0.05) and 9.1 6 2.3 for group II. Group Itherefore showed a statistically significant improvement in thetrauma station scores, but group II did not.

Organized Approach Scores

The organized approach scores are summarized in Figure 3. Of amaximum score of 5, the pre-PHTLS organized approach scoreswere similar for group I (2.1 6 1.0) and group II (1.9 6 1.2).Post-PHTLS scores improved significantly to 4.2 6 0.9 in group I,whereas group II (2.0 6 0.8) did not evidence improvement oftheir organized approach scores compared to their pre-PHTLSscores.

Adherence to Priority Scores

As demonstrated in Figure 4, pre-PHTLS adherence to priorityscores on a scale of 1 to 7 were similar in group I (1.1 6 0.9) and

Fig. 1. MCQ scores. Group I showed significant improvement in MCQscores after the PHTLS program, whereas group II did not improve theirscores. Group I: PHTLS; group II: no PHTLS.

Fig. 2. Overall trauma station scores for all four stations were similarprior to the PHTLS program for both groups. The PHTLS group (groupI) had an overall statistically significant improvement in mean score,whereas group II (no PHTLS) showed no such improvement.

Table 1. Individual trauma patient station scores.

Group 1 2 3 4

Pre-PHTLSI 8.5 6 2.0 9.0 6 1.0 9.2 6 1.8 9.0 6 1.7II 7.9 6 1.9 8.8 6 1.2 10.4 6 1.6 9.2 6 2.0

Post-PHTLSI 16.0 6 2.4* 16.0 6 2.8* 17.5 6 1.6* 18.0 6 1.8*II 8.0 6 1.8 8.2 6 2.0 11.1 6 2.0 11.0 6 2.1

The PHTLS group improved their trauma patient station scores at allfour stations after the PHTLS course.

*p , 0.05 compared to other groups and pre-PHTLS scores.

Ali et al.: PHTLS Effect on Trauma Skills 1193

group II (1.2 6 1.0). Post-PHTLS scores for group I increasedsignificantly to 5.9 6 1.1 (p , 0.05), whereas those for group II didnot improve (1.1 6 1.0).

Pass Status

The pass status as assigned by the examiners is summarized inTable 2. As indicated, there was a high failure rate in both groups,with 13 of the 14 participants failing in group I and 12 of 14 failingin group II. None of the 14 participants was given a clear passstatus prior to the PHTLS program. After PHTLS training therewere four honors passes, nine clear passes, one borderline pass,and no fails for the group I subjects. In group II, without PHTLStraining, 11 of the 14 were assigned a fail status, with 3 beingawarded a borderline pass.

Discussion and Conclusions

Since its inception between 1983 and 1984 as a pilot project in thestates of Iowa, Connecticut, and Louisiana [7], the PHTLSprogram has become nationally and internationally promulgatedin the same fashion as the ATLS program [8]. The PHTLSprogram was established to prevent trauma deaths by improvingtraining in prehospital trauma care [9]. The course consists of aseries of lectures and skill stations conducted over a 2-day period(18 hours). The topics presented are similar to those of the ATLS

program, consisting of sessions on the kinematics of trauma,airway management, shock and fluid replacement, spinal trauma,pediatric trauma, thoracic trauma, abdominal trauma, traumaduring pregnancy, head trauma, extremity trauma, thermaltrauma, and essentials in prehospital trauma care. The skillstations, where hands-on demonstration and practice are com-bined, consist of assessment of multiple trauma victims, airwaymanagement, spinal immobilization, rapid extrication, and pedi-atric assessment/immobilization. The course ends with a writtenexamination, tests of prehospital practical skills, and assessmentand management of trauma victims in the prehospital setting. Theprerequisites for acceptance into the course is training at the levelof an emergency medical technician, basic (EMT-BASIC). Incenters outside the United States and on an international basis theprerequisites for the basic PHTLS program are less rigid, allowingpersonnel with lesser training (e.g., St. John’s Ambulance train-ing) to enroll in the program. We have demonstrated that in adeveloping country such as Trinidad and Tobago the aim of thePHTLS program of decreasing mortality can be achieved [5].However, it may be argued that over the period of our previousstudy other interventions may have affected trauma patient out-come following the PHTLS program. All efforts were taken tocontrol for such interventions, and our study seemed to demon-strate a significant impact of PHTLS training on patient outcome.

The present study allowed a more controlled environment fortesting the effectiveness of the PHTLS program on cognitive skillsand management of trauma patients. The technique of simulatedpatient scenarios has been shown to be an effective, reliable, validtool for testing clinical skills in an objective manner by allowingthe clinical skills of the students to be observed and assessed in amore precise manner than in the real clinical situation when suchtesting is impractical [10–14]. Cognitive skills acquisition wastested simply by the subjects’ performance on an MCQ examina-tion, which is a standardized and recognized form of assessment.The clinical skills performance was assessed using reliable simu-lated patient scenarios. Using these two techniques our studydemonstrates clearly that the PHTLS program improves theperformance of prehospital personnel in patient trauma manage-ment skills. Our study also demonstrates that the knowledge ofprehospital trauma care is improved significantly after the PHTLSprogram as judged by MCQ testing. The improvement in traumapatient management was assessed by overall care of the simulatedpatient and the degree to which the subjects adhered to estab-lished priorities in, and an overall acceptable organized approachto, management of trauma patients. This study, in conjunctionwith our previous studies on the effect of the PHTLS program on

Table 2. Pass status (trauma station).

Group

No. of subjects

Honors Pass Borderline Fail

Pre-PHTLSI 0 0 1 13II 0 0 2 12

Post-PHTLSI 4 9 1 0II 0 0 3 11

None of the subjects was assigned a clear pass prior to the PHTLSprogram. Of the 14 subjects taking the PHTLS course, 13 had a clear passor honors, whereas the control group did not have any clear passes.

Fig. 3. Organized approach scores improved significantly after thePHTLS program in group I, whereas group II (no PHTLS) showed nochange in organized approach scores.

Fig. 4. Adherence to priority scores improved significantly in the PHTLSgroup (group I), whereas in group II (no PHTLS) there was no change.

1194 World J. Surg. Vol. 22, No. 12, December 1998

trauma patient outcome, suggests that this course is an effectivetool for preparing paramedical personnel in the concepts ofprehospital trauma patient care.

Resume

Nous avons teste l’efficacite du programme «PHTLS» pourevaluer les performances cognitives et la qualite de la prise encharge par le personnel soignant, des blesses avant leur hospital-isation. Methodes: Un groupe de 14 candidats qui ont completeun course standard «PHTLS» (groupe I) a ete compare a ungroupe de personnes apparie mais n’ayant pas eu cet enseigne-ment (groupe II). Les performances cognitives ont ete evalueespar un examen a choix multiple (ECM) (50 items) alors quel’evaluation de la qualite de la prise en charge a ete basee sur lapratique sur quatre simulations de traumatise. Resultats: Lesscores ECM pre-cours PHTLS etaient similaires pour les deuxgroupes I et II, respectivement, de 45.8 6 9.4 et de 48.8 6 8.9%mais les scores post-cours ont ete meilleurs dans le groupe I(80.4 6 5.9%) compares a ceux du groupe II (52.6 6 4.9%). Lesscores de performance de la prise en charge pre-PHTLS (stan-dardises a un maximum de 20 pour chaque «blesse» simule)etaient similaires pour les quatre situations de blesse dans chaquegroupe allant de 7.9 a 10.4. Les scores post-PHTLS etaientstatistiquement plus eleves dans les quatre stations de travail dugroupe I (extremes de 16.0 a 19.0) compares au groupe II(extremes 8.0 a 11.1). Le score moyen global pre-PHTLS pour lesquatre simulations de blesse etait de 8.3 6 2.1 pour le groupe I etde 8.8 6 2.0 (difference non-significative) pour le groupe II, alorsque le score moyen du score moyen post-PHTLS pour les quatresimulations du group I etait de 17.1 6 2.7 (p , .05) compare auscore de 9.1 6 2.3 pour le groupe II. Les scores pre-PHTLS del’examen concernant l’adherence aux priorites (Adherence toPriority score), etales sur une echelle de 1 a 7, etaient similaires(1.1 6 0.9 pour le groupe I et 1.2 6 1.0 pour le groupe II). Cesscores ont augmente a 5.9 6 1.1 dans le groupe I alors qu’ils n’ontpas change dans le groupe II (1.1 6 1.0). Les scores pre-PHTLSsur l’organisation de l’approache des soins (Organized Approachscore) chez le traumatise simule, allant de 1 a 5, etaient de 2.1 61.0 pour le groupe I et de 1.9 6 1.2 pour le groupe II (NS). Cesscores etaient de 4.2 6 0.9 (p , 0.05) pour le groupe I et de 2.0 60.8 pour le groupe II en post-PHTLS. Conclusions: Cette etudedemontre une amelioration des performances cognitives et de laqualite de la prise en charge des blesses parmi le personnelparamedical qui ont complete une formation PHTLS de base.

Resumen

Se estudio la efectividad del Programa Basico de AtencionPrehospitalaria de Soporte Vital en el Trauma (Basic PrehospitalTrauma Life Support Program, PHTLS) mediante la evaluaciondel conocimiento y de las habilidades practicas del personal deatencion prehospitalaria de trauma. Metodos: Se comparo ungrupo de 14 personas que habıa completado el programa PHTLS(Grupo I) con uno de igual numero que no lo habıa hecho (GrupoII). El conocimiento se evaluo por medio de examenes consis-tentes en 50 preguntas con respuesta de escogencia multiple, y delas habilidades mediante el manejo de cuatro pacientes simulados(cuatro estaciones). Resultados: Los puntajes pre-PHTLS en losexamenes de respuestas de escogencia multiple (ERM) fueron

similares (45.8 6 9.4 vs. 48.8 6 8.9% para los grupos I y II,respectivamente), pero los puntajes post-PHTLS fueron mas altosen el Grupo I (80.4 6 5.9%) que en el Grupo II (52.6 6 4.9%).Los puntajes pre-PHTLS del manejo de pacientes simulados(estandarizados a un total maximo de 20 para cada estacion)aparecieron similares en las cuatro estaciones en ambos grupos,con un rango de 7.9 a 10.4. Los puntajes post-PHTLS resultaronestadısticamente mas altos en las cuatro estaciones en el Grupo I(rango de 16.0 a 19.0) en comparacion con el Grupo II (rango8.0 a 11.1). El puntaje global promedio pre-PHTLS para lascuatro estaciones fue 8.3 6 2.1 en el Grupo I y 8.8 6 2.0 (NS) enel Grupo II, en tanto que el puntaje promedio post-PHTLS paralas cuatro estaciones fue 17.1 6 2.7 (p , 0.5) en comparacion con9.1 6 2.3 para el Grupo II. Los puntajes en cuanto a obedienciade prioridad en una escala de 1 a 7 fueron similares (1.1 6 0.9para el Grupo I y 1.2 6 1.0 para el Grupo II). Los puntajes encuanto a obediencia de prioridad Post-PHTLS en el Grupo Iascendieron a 5.9 6 1.1, en tanto que no mejoraron en el GrupoII (1.1 6 1.0). Los puntajes en cuanto a enfoque organizadoPre-PHTLS en los pacientes simulados, en una escala de 1 a 5,fueron 2.1 6 1.0 en el Grupo I y 1.9 6 1.2 en Grupo II (NS), encomparacion con 4.2 6 0.9 (p , 0.5) en el Grupo I y 2.0 6 0.8 enel Grupo II post-PHTLS. Conclusiones: El presente estudiodemuestra superacion en cuanto a conocimientos y habilidadespracticas del personal paramedico prehospitalario que ha comple-tado el programa PHTLS.

Acknowledgments

The authors acknowledge the kind assistance and cooperation ofthe medical and paramedical staff of the Eric Williams MedicalSciences Complex, Mount Hope Medical Campus, University ofthe West Indies Faculty of Medicine.

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