Surgery Guide

Anaesthesia, Trauma and Critical Care (ATACC) Course is an international trauma course based in the United Kingdom. Accredited by two Royal Colleges and various UK emergency medical services, it teaches trauma care and trauma patient management post ATLS certification. Courses run at numerous times throughout the year for candidates drawn from all areas of medicine and trauma care.

The ATACC Faculty consists of clinicians from each medical speciality and senior members of the various emergency services. For this reason, the ATACC course is a multi-disciplinary course especially suited for all specialties and is ideal for those working within trauma, surgery, anaesthesia, emergency medicine, critical care, radiology and pre-hospital medicine. It is also appropriate for any individual in a profession allied to medicine who may encounter trauma patients as part of their daily duties (whether they be Nurses, Operating Department Practitioners [ODPs], Physician Assistants or members of the emergency services) such as Paramedics, Emergency Medical Technicians (EMTs).

The courses teach trauma management from the roadside through to critical care and, as such, include both pre-hospital and in-hospital care of trauma patients.

Numerous other courses have been developed from the ATACC course including Rescue-trauma training (RTACC), scene safety and assessment (ISAC), critical care transport (BATT), human simulation critical incident training (CISTR).

ATACC started as a new approach to trauma education but has since developed into a spectrum of courses in addition to a highly skilled trauma and rescue team providing critical care at the roadside and other difficult environments. Every member of the ATACC team is committed to operating to the highest clinical standards, to keeping the ATACC courses up-to-date and to improving trauma care worldwide.[1] [2]

It is a non-profit charitable organisation whose objective is to deliver the most up-to-date teachings in trauma management and patient care. The organisation’s primary activities are teaching medical practitioners and other emergency services personnel in the management of trauma and pre-hospital care. In addition to its educational resources, the organisation also has a highly skilled and multi-disciplinary ATACC Medical Rescue Team (ATACC MRT), comprised of practitioners from all specialities. It operates and is available for the purposes of trauma care management in the pre-hospital care environment throughout the United Kingdom on an entirely voluntary basis. There is also an ATACC Disaster Response Team (ATACC DRT) available on standby for deployment an international basis to operate throughout international disasters. The ATACC DRT, affiliated with the United Nations, has responded to many international disasters and has been involved in many international disaster response training exercises.

The aims and ethos of the ATACC organisation are to develop, educate and perform the Gold Standard of trauma and pre-hospital clinical care.

In 1940-41, ASA asked a committee of three physicians (Meyer Saklad, M.D., Emery Rovenstine, M.D., and Ivan Taylor, M.D.) to study, examine, experiment and devise a system for the collection and tabulation of statistical data in anesthesia which could be applicable under any circumstances.[1] This effort was the first by any medical specialty to stratify risk for its patients.[12] While their mission was to determine predictors for operative risk, they quickly dismissed this task as being impossible to devise. They state:

“In attempting to standardize and define what has heretofore been considered ‘Operative Risk’, it was found that the term … could not be used. It was felt that for the purposes of the anesthesia record and for any future evaluation of anesthetic agents or surgical procedures, it would be best to classify and grade the patient in relation to his physical status only.”[11]

The scale they proposed addressed the patient’s preoperative state only, not the surgical procedure or other factors that could influence surgical outcome. They hoped anesthesiologists from all parts of the country would adopt their “common terminology,” making statistical comparisons of morbidity and mortality possible by comparing outcomes to “the operative procedure and the patient’s preoperative condition”.[1][13]

They described a six-point scale, ranging from a healthy patient (class 1) to one with an extreme systemic disorder that is an imminent threat to life (class4). The first four points of their scale roughly correspond to today’s ASA classes 1-4, which were first published in 1963.[5] The original authors included two classes that encompassed emergencies which otherwise would have been coded in either the first two classes (class 5) or the second two (class 6). By the time of the 1963 publication of the present classification, two modifications were made. First, previous classes 5 and 6 were removed and a new class 5 was added for moribund patients not expected to survive 24 hours, with or without surgery. Second, separate classes for emergencies were eliminated in lieu of the “E” modifier of the other classes.[14][13] The sixth class is now used for declared brain-dead organ donors. Saklad gave examples of each class of patient in an attempt to encourage uniformity. Unfortunately, the ASA did not later describe each category with examples of patients and thus actually increased confusion.

While anesthesia providers use this scale to indicate the patient’s overall physical health or “sickness” preoperatively, it is regarded by hospitals, law firms, accrediting boards and other health care groups as a scale to predict risk,[10] and thus decide if a patient should have – or should have had – an operation.[11] To predict operative risk, age and obesity of the patient, the nature and severity of the operative procedure, selection of anesthetic techniques, the competency of the surgical team (surgeon, anesthesia providers and assisting staff), duration of surgery or anesthesia, availability of equipment, medicine, blood, implants and especially the level of post-operative care etc. are often far more important than simple ASA score.

These definitions appear in each annual edition of the ASA Relative Value Guide. There is no additional information that can be helpful to further define these categories.[3] It is logical to expect a missing category between ASA 2 and ASA 3 for a systemic disease which is neither mild nor severe, but is of moderate nature. It is also not clear what will be the ASA score of a patient who is suffering simultaneously from two, three or more systemic diseases (which might be of different severity).

Different authors give different versions of this ASA definition.[4] It is because this classification is vague and far from perfect. Many authors try to explain it on the basis of ‘functional limitation’ or ‘anxiety’ of patient which are not mentioned in the actual definition. Often different anesthesia providers assign different scores to the same patient.[5][6][7][8]. The word ’systemic’ in this classification creates a lot of confusion. For example, heart attack (myocardial infarction), though grave, is a ‘local’ disease and is not a ’systemic’ disease, so a patient with recent (or old) heart attack, in the absence of any other systemic disease, does not truly fit in any category of the ASA classification, yet has poor post-surgery survival rates. Similarly cirrhosis of the liver, COPD, severe asthma, peri-nephric abscess, badly infected wounds, intestinal perforation, skull fracture etc. are not systemic diseases. These, and other severe heart, liver, lung, intestinal or kidney diseases, although they greatly affect physical status of patient and risk for poor outcomes, cannot be labelled as “systemic disease” (which means a generalized disorder of the whole body like hypertension or diabetes mellitus). Local diseases can also change physical status but has not been mentioned in ASA classification.

This scoring system assumes that age of the patient has no relation to physical fitness, which is not true. Neonates and the elderly, even in the absence of any systemic disease, tolerate otherwise similar anesthetics poorly in comparison to young adults. Similarly this classification ignores patients with malignancy (cancer). This scoring system could not be improved to a more elaborated and scientific form, probably because it is often used for price reimbursement.

Although more complex scoring systems like APACHE II exists [1] they are time-consuming to calculate, and do not have the same utility for ease of communication between surgeons, anesthetists, and insurers.

Some anesthetists now propose that like an ‘E’ modifier for emergency, a ‘P’ modifier for pregnancy should be added to the ASA score.[9]

ASA stands for American Society of Anesthesiologists. In 1963 the ASA adopted a five category physical status classification system for assessing a patient before surgery. A sixth category was later added. These are:
A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund patient who is not expected to survive with or without the operation.
A declared brain-dead patient whose organs are being removed for donor purposes.

If the surgery is an emergency, the physical status score is followed by “E” (for emergency) for example “3E”. Category 5 is usually an emergency and is therefore usually “5E”. The category “6E” does not exist and is simply recorded as category “6″, as all organ retrieval in brain-dead patients are done urgently. The original definition of emergency in 1940, when ASA classification was first designed, was “a surgical procedure which, in the surgeon’s opinion, should be performed without delay.”[1] This gives an opportunity for a surgeon to manipulate the schedule of elective surgery cases for personal convenience. An emergency is therefore now defined as existing when delay in treatment would significantly increase the threat to the patient’s life or body part.[2] With this definition, severe pain due to broken bones, ureteric stone or parturition (giving birth) is not an emergency.

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