Issue: 2017 > April > editorial

How one plane crash changed the way we work

S.M. Pasha
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In 1976 Dr James K. Styner, an orthopaedic surgeon and amateur pilot, was involved in a plane crash in a dark field in Nebraska. The crash resulted in the death of his wife, leaving him with his four children, of which three were heavily injured and unconsciousness. He eventually hitchhiked with his children to a small and already closed hospital in Hebron, Nebraska. When the trauma team eventually arrived Styner noticed that the medical team was unprepared for such an emergency and the standard of care was poor and inadequate. Back at work he and his colleague Paul Collicott founded the initial advanced traumatic life support (ATLS) course. In 1980, the ATLS course was adopted by the Committee on Trauma of the American College of Surgeons and it was recommended that all trauma patients should be approached using the ABCDE assessment.

If properly implemented, ATLS can lower mortality in traumatic patients by at least 15%.1 The cornerstone of ATLS is the systematic ABCDE assessment for the early recognition and treatment of potentially life-threatening conditions. Although developed for traumatic patients, the ABCDE assessment has been increasingly implemented on emergency wards for medical emergencies in the recent years. The Dutch minister for healthcare even obliged all medical doctors in an emergency ward to attend an ABCDE course. However, evidence for the clinical benefits for the ABCDE assessment in medically ill patients is lacking. In the current issue of the journal, Olgers et al. assessed the frequency of the use of the ABCDE assessment in potentially unstable medically ill patients and determined factors influencing the choice whether or not to use the ABCDE approach.2 A fast majority of potentially unstable patients (67%) where not assessed using the ABCDE approach. However, in (potentially) unstable patients with more urgent triage codes the ABCDE assessment was performed more often and in a highly efficient manner.

The study by Olgers et al. is the first to assess the use of the ABCDE assessment in medically ill patients. Although it is a single-centre observational study with multiple limitations, this study is a great step forward. Especially in current times with overcrowded emergency wards and an ageing population, geriatric patients are becoming more and more prominent in the emergency ward. They often present without a clear complaint or in an altered mental state and unable to clarify their symptoms. These alterations can impair the accuracy of the diagnosis of the main complaint and mask potentially serious diseases. In this group of patients, a systematic approach following the ABCDE assessment could probably increase the chance of a correct and fast diagnosis.

In my opinion, a systematic routine could maybe lower the amount of misdiagnosis and subsequently prevent further harm in patients presenting to the emergency wards. Since it is fast and easy to use also young and unexperienced physicians will be able to assess a critically ill patient. However, further studies are needed. These further studies should focus on the efficacy and efficiency of the ABCDE assessment in medically ill patients. 


  1. Celso B, Tepas J, Langland-Orban B, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60:371-8. 
  2. Olgers TJ, Dijkstra RS, Drost AM, ter Maaten JC. The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study. Neth J Med. 2017;75:107-12. 
  3. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2-S23.