An Algorithm for the Unknown
How James Styner faced personal tragedy and developed ATLS
On February 17, 1976, Dr. James Styner was flying his family back to their home in Lincoln, Nebraska after attending a Valentine’s Day wedding in Los Angeles. His wife Charlene had gotten up from the co-pilot’s seat to comfort their youngest child and had not yet re-buckled her seatbelt. As James dropped below the clouds to avoid a storm, he became disoriented- rather than skimming just below the clouds, he dropped towards the horizon and collided head-on with a row of trees. The plane’s wings were ripped off, the fuel tanks emptied, and the family- James, Charlene, and their four children- came crashing down.
Charlene, still unbuckled, was ejected through the window and died instantly. James and his children, buckled to their seats, were injured. But James was an orthopedic trauma surgeon, and he knew the immediate dangers the family faced. Putting aside his own pain and fear, his first concern was fire. He managed to drag his children away from the plane and into the dark Nebraska night before searching the forest for his wife. He found her- dead- about 300 feet from the aircraft. And then he began to wait. His three younger children were in and out of consciousness; his oldest couldn’t move his right arm, and he himself had facial fractures that left him nearly blind. With the fear of fire resolved, the fear of hypothermia and head injury came to the forefront.
As the minutes became hours, Styner decided that help wasn’t coming. At around 2 in the morning, he left Christopher, his oldest, to watch the other three children and slowly walked towards the road. Bloody and staggering, looking in the dark night like something out of a horror movie, he began trying to flag down a passing car or truck. Incredibly, the third vehicle to pass him stopped. With the driver’s help, he loaded his children into the car and they drove to the town’s hospital.
As they pulled up to the hospital, James exhaled in relief- gratitude washing over him for the proximity to help. He was quickly disillusioned. They had crashed down in Hebron, Nebraska, a town of less than 2000 people. The hospital was not just small: it was closed. The night nurse who opened the door initially refused them entrance, citing protocol that demanded a doctor be present for any admission. Finally, the town’s two general practitioners were roused and arrived, and the family was taken in for treatment. Things did not improve once inside.
The hospital’s staff were clearly inexperienced with trauma and overwhelmed by the arrival of five bleeding, concussed patients. Their assessment and treatment of the family was haphazard and without method. James would later recall with particular clarity watching a physician carry his 8-year-old son to the x-ray area in a cradle carry- an arm under his knees and shoulders, the child’s head dangling with no thought to a potential neck injury.
James Styner knew what excellent trauma care looked like. He was horrified by the contrast to what he saw his children receiving. He began frantically calling his partners, working to arrange emergency transportation to his own hospital- barring the Hebron providers from any further contact with his children as they waited. Finally, a helicopter was arranged, and the five Styners arrived at Lincoln General Hospital. A team of emergency personnel stood waiting for them, and immediately sprung into action. Styner, finally able to hand over the care of his children and receive much-needed treatment himself, recalled the feeling of “coming out of a hostile dark hell into civilization.”
The family was eventually discharged, and they spent the next year recovering physically and emotionally. They grieved the loss of Charlene. Their wounds slowly healed. But Styner found himself unable to move past the accident- focusing not on the losses, or even the plane crash itself, but the horror he felt when he realized that the hospital did not know how to help his family.
When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed.
James Styner, ATLS Manual
Defining the Problem
It would have been easy to focus on who messed up. Styner himself was flying the plane, and then, to arrive at a hospital where a nurse barred entry, and a physician ignored basic principles of care, leaves a great deal of room for blame. Styner had a different perspective. He was familiar with the trauma bays of Lincoln, a large city with busy hospitals that might see a dozen traumas on an average night. He also understood the urgency of trauma: what is known as “the golden hour.” Half of all trauma deaths occur within 60 minutes of the initial injury. His own family had survived the golden hour, but what if they had a more urgent problem? Patients injured far from a metropolitan center did not always have the luxury of time to wait for a transfer. How could a rural physician, who saw a major trauma only once or twice in their career, or a small town hit by a natural disaster, respond to the unexpected with competence? What they needed, Styner realized, was a method. A protocol or an algorithm for how to approach these situations.
The idea was not entirely novel. Another Nebraska surgeon, Steve Carveth, had only recently developed the protocols and algorithms known as “ACLS” – Advanced Cardiovascular Life Support. ACLS helped physicians move quickly when faced with a heart attack. Similar algorithms were being increasingly used for the treatment of a variety of chronic and acute illnesses— from medication choice in asthma, to diagnosis and treatment of stroke. But these algorithms focused on one specific disease or disorder. The same markers, the same diagnostic criteria and tests, the same treatments. Could it be possible to build a protocol for trauma? Trauma is as wide as the world. It’s a plane crash and a gunshot to the abdomen; a laceration and a lost limb; it’s a trip-and-fall and a three-car pile-up. How do you build an algorithm for the unknown?
The Birth of ATLS
Styner put together a team of experienced nurses and physicians. They analyzed how they themselves responded when a trauma arrived; the protocols and practices they followed but had not yet codified. The things that were normal and natural for busy trauma centers, but unknown to the rural physician.
In some ways, they created nothing new. The team was not trying to develop a new diagnostic test or a more effective treatment. Their focus was on ensuring that every patient, at every hospital, received the best treatment already available. What they created was an approach. An algorithm.
Today, when a trauma patient arrives at the hospital, regardless of their injury, they are met by a team poised and ready. Because today, every member of that team is most likely trained in Advanced Trauma Life Support. Which means that regardless of injury, every patient who rolls into an emergency room after an accident is met with the A, B, C’s.
Let me take you to the trauma bay for a moment. Imagine that you’ve just survived a car accident, and the ambulance has transported you to the nearest hospital. As you’re rolled into the trauma bay, you’re met with a team who slides you from the stretcher onto a hospital bed. There’s a person at the head of your bed, whose face looks down at yours.
“What’s your name, sir?”
That’s “A” – for airway. It’s not really a polite inquiry; they want to know if you’re able to speak. If you answer (“My name is Joe!”), your airway is clear. A gurgle, choke, or silence in response means that your airway may be compromised- and nothing else matters until the problem is resolved. Nothing else matters because a blocked airway means no oxygen is getting to the brain, the heart, the kidneys, the gut. The patient is minutes away from permanent brain damage. The airway is cleared, or nothing else happens. “A” is always first.
But now that you’re speaking, a stethoscope is brought to your chest- rise and fall, rise and fall. Are there breath sounds on both sides? This is “B” – breathing. Are the lungs expanding? If not, the team stops until the problem is identified and resolved. At which point they move on to “C” – circulation. What’s Joe’s heart rate? His blood pressure? Does he have a pulse? If there’s a pulse in the carotid artery at the side of the neck, that’s good; if there’s a pulse in the radial artery in the wrist, even better. A pulse all the way down in the dorsalis pedis artery, on the top of the foot? Better still- the heart is strong enough and full enough to get blood as far away as it needs to go.
A, B, C comes first because these are the things that kill trauma patients in the golden hour. It might seem obvious: if someone isn’t breathing, their broken leg is unimportant. But when Joe arrives with his thigh bone protruding at a grotesque angle through his skin, it is very hard to realize that there could be a problem that is more urgent but less apparent.
The physician or team who responds to a trauma prepares for everything, expects anything. What Styner and his team created was a mental model; a process; a path. A rhythm that keeps everyone in the room dancing to the same beat, and prevents them from missing the potentially lethal injury in the face of the more immediately obvious.
Airway. Breathing. Circulation.
An algorithm for the unknown.
The Impact
The American College of Surgeons adopted the ATLS protocol (originally called “the Nebraska protocol”) soon after its development. It was expanded upon, reviewed, and taught- first in Nebraska, then throughout the United States, and now, around the world. Researchers have found that preventable trauma deaths are cut roughly in half after hospital or city-wide ATLS training, with the biggest impact in the hospitals for whom the protocol was developed: rural centers, small hospitals, and developing nations.[1][2][3]
Change is often slow, and not every innovator receives recognition in their own time. Even fewer see the impact of their work fully realized. Styner is one of these few. Before his death in 2024, more than 1 million physicians in 86 countries were trained in ATLS. It has become not just the standard of care for trauma, but a language in its own right, connecting trauma providers across cultures and communities. Styner saw the power of that language first-hand when he joined a medical mission to Peru. Two Peruvian marines were injured in a gunfight and rushed to a small field hospital. The local team and their patients spoke only Spanish. The visiting American doctors spoke only English. But “the common thread was the ATLS ‘language’ that was used by both groups,” and the result was a team working in concert: coordinated, organized, efficient, and effective.
Styner had transformed his personal tragedy into a systems-based solution. And the results are visible around the world.
