The COT at 100: A Legacy of Improved Care for the Injured Patient

In 1922, there was no organized approach to the care of injured patients—no injury prevention campaigns, no prehospital care, no trauma centers, no blood banks, no trauma registries or quality improvement (QI) programs, no uniform trauma education, no providers dedicated to emergency medicine or trauma surgery, and no coordination of disaster response. None of the components of what we consider a trauma system today existed. Recognizing the need to improve injury care, the American College of Surgeons (ACS) Board of Regents established the Committee on Fractures (COF), which evolved into the Committee on Trauma (COT), which has worked tirelessly to transform trauma care over the past 100 years.

Committee on Fractures Formed

Charles L. Scudder, MD, FACS, was a general surgeon at Massachusetts General Hospital (MGH), Boston, and a prolific writer on an array of surgical topics. He took a special interest in the care of the injured patient and the management of fractures, becoming an authority on the topic with the 1900 publication of The Treatment of Fractures. Dr. Scudder was appointed to the American Surgical Association Committee on Fractures in 1914, and in 1922 he organized a conference of 26 prominent surgeons at MGH to develop a standardized approach to the treatment of fractures.

Hence, when the ACS Board of Regents formed the COF in 1922, Dr. Scudder was the natural choice for committee chair. In total, 18 members were appointed to the initial COF from the US and Canada, with each committee member charged with establishing a local committee to promulgate the work of the COF, thus establishing the regional committee structure. The initial focus of the COF included first aid treatment and transportation of the injured, the appropriate equipment for ambulances and hospital receiving wards, and the curriculum for medical students. Some of the early subcommittees of the COF included Steel Bone Plates and Screws, The Use of the Fluoroscope, Motion Picture Film on the Treatment of Fractures, Editorial, Fracture Service Organization, Medical Education of Undergraduates, Ambulance Equipment, Physical Therapy, Rehabilitation, American Railway Association Liaisons, and the Regional Committees.

In 1929, Dr. Scudder gave the first Fracture Oration at the ACS Clinical Congress, which became an annual tradition, now formally known as the Scudder Oration on Trauma. The COF published a special issue of the ACS Bulletin, “The Principles and Outline of Fracture Treatment,” in March 1931. Dr. Scudder served as the Chair of the original COF until he retired in 1933. Frederic W. Bancroft, MD, FACS, was his successor, but Dr. Scudder remained involved in the work of the Regional Committees through 1947.

In parallel to the work of the COF, the ACS also appointed a Board of Industrial Medicine and Traumatic Surgery in 1926, chaired by Frederick A. Besley, MD, FACS. This group was charged with improving the care of the ill and injured in industry and eliminating industrial health hazards. They developed a minimum standard for medical service in industry and surveyed industrial establishments, issuing certificates of approval to those businesses that met the standards. By 1937, at least 1,657 surveys had been completed, and approximately 50% earned a certificate of approval. This work led to substantial improvements in the care of individuals injured in industry and supported injury prevention efforts in the workplace.

In 1939, the Board on Industrial Medicine and Traumatic Surgery merged with the COF to form the Committee on Fractures and Other Trauma, with Robert H. Kennedy, MD, FACS, as its Chair. In 1949, the Board of Regents voted to officially change the name of the Committee on Fractures and Other Trauma to the Committee on Trauma.

The Structure and Growth of the COT

Regional Committees

As noted, the original COF included 18 members who were given the charge from Dr. Scudder to form a local committee in their home area. The number of local committees continued to grow. By 1947, the COF had 87 local committees and more than 1,800 members. To manage this growth, the committee divided the US and Canada into 13 sections and established new Section Chief roles. By 1960, the COT had 242 state, provincial, and local committees with more than 3,000 members. In 1972, there were 66 state/provincial committees and 341 local committees, with an estimated 3,400 total participants.

The regional committees have been critical to the COT’s promulgation of programs. In his review for the 50th anniversary of the COT, Oscar P. Hampton Jr., MD, FACS, wrote, “Until about 1960, trauma committees constituted the only physician groups striving to improve emergency ambulance service. Regardless, regional committees worked diligently and undoubtably achieved improvement in their respective localities.”

In the 1950s and 1960s, the regional committees worked with the COT Field Program to survey and implement standards for emergency departments. They supported mass casualty training and civil defense preparations and began to focus on injury prevention by supporting efforts to improve motor vehicle safety and advocating for the use of seat belts. In partnership with the National Safety Council, the regional committees were instrumental in executing the States Program for Motor Vehicle Safety.

In the 1970s and 1980s, the regional committees played a significant role in the implementation and growth of trauma center verification, collecting data for the Major Trauma Outcome Study, and in the widespread adoption of the Advanced Trauma Life Support^® (ATLS^®) and Prehospital Trauma Life Support (PHTLS) courses. In the 1990s, the regional committees advanced the development of trauma systems that required new state legislation.

Global interest in the activities of the COT was evident in 1955, when the College received a request to translate The Management of Fractures and Soft Tissue Injuries into Spanish. Discussion of forming regional committees outside of the US and Canada began in 1970, and was supported by the subsequent widespread promulgation of the ATLS program.

In 1987, Latin America became the 14th Region of the COT, and committees were formed in Argentina, Mexico, Colombia, Brazil, and Chile. Region 14 was briefly renamed the International Committee on Trauma in 1995. By 2007, three international regions had been established including Region 14, which encompassed all of Latin/South America, and Region 15, composed of Europe, the Middle East, and Africa, as well as Region 16 for Australasia. In 2012, Region 17 was formed for the growing programs in the Middle East and North Africa.

The ACS COT Regional Committees on Trauma continue to play an integral and active role in the COT, with the COT Vice-Chair serving a dual role as Chair of the Regional Committees.

Central/National Committee

Both the terms “central” and “national” have been used interchangeably over the years to distinguish the original appointed committee from the regional committee structure. By 1972, the central/national committee had 41 active members, along with a variable number of senior members. In 2002, the ACS Board of Regents eliminated the senior member category, and, as a result, the active membership continued expanding to manage the COT’s increasing activities and embrace additional specialties.

As the COT has grown and medicine has become further specialized, the committee’s leadership sought to embrace surgeons from all specialties that support the care of injured patients. As of 2020, the COT had 100 central members, including 61 general surgeons, eight burn surgeons, eight neurosurgeons, eight orthopaedic surgeons, seven pediatric surgeons, three plastic surgeons, one urologist, one oral-maxillofacial surgeon, one ophthalmologist, one vascular surgeon, and one gynecologist. Specialty surgeons are integrated into all aspects of the COT and play a major role in updates to the ATLS course and other educational programs, as well as the development of verification criteria and quality metrics relevant to the specialty.

In 2020, the Executive Committee formally adopted the term “central” to clearly depict the centrality of the COT’s role and relationship to the regional committees, other trauma organizations, and liaison organizations, as well as to acknowledge the global nature of the membership beyond the US and Canada (see Figure 1).

FIGURE 1. COT Membership Categories

There is a nice symmetry to the fact that there are 100 members of the central COT as we celebrate this anniversary year. These members have been ably led and inspired by 20 chairs over the past 100 years.

Committee Structure

COT committees and subcommittees have evolved over time to support the expanding work of the committee (see Figure 2, page 14). In 2009, a series of strategic planning sessions reorganized the COT committees into the pillars of Education, Quality Programs, and Advocacy to better integrate the work of the committees. To enhance engagement with the global community, the International Injury Care Committee was established in 2010. In 2018, the Quality Programs Pillar was further divided into the Trauma Systems Pillar and the Trauma Center Quality Pillar to better reflect the focused growth of the quality programs at both the trauma center and systems level. Advocacy, Injury Prevention, and STOP THE BLEED^® compose the fourth pillar.

FIGURE 2. COT Pillar Structure

Guiding Principles of the COT

All COT activities at the local, regional, and national levels are carried out to conform with the committee’s guiding principles, which are:

• What’s best for the patient is the central focus of all programs and decisions.
• Trauma care begins at the point of injury and extends until recovery and reintegration into society, and the COT is responsible for optimizing every step in this continuum of care.
• Strive for optimal standards, not minimum standards, and ensure accountability to these standards.
• Trauma education is critical for all providers caring for injured patients, including the nonmedical bystander, emergency medical services provider, nurse, advanced practice provider, and physician.
• When possible, make data-driven or evidence-based decisions and if the data or evidence are lacking, devise a strategy to obtain it.
• Develop a culture of continuous quality improvement.
• Once the goal is identified, pursue it relentlessly and from every angle. Be tireless advocates on behalf of the injured patient.
• Take a comprehensive, multifaceted public health approach to system development and injury prevention.
• Seek to collaborate and partner with all organizations that will advance the mission of the COT.
• Develop practical programs and ensure wide dissemination, adoption, and implementation through the Regional Committees on Trauma.

COT Contributions

An overview of the major contributions of the COT to trauma care are outlined in this article by pillar area, many of which evolved in parallel over the past 100 years. More detail on the evolution and development of each of these programs will be provided in subsequent Bulletin articles.

Trauma Education

The COT has set the benchmark for education in injury care around the world. From the very beginning, the COF focused on improving education for the treatment of fractures, including the 1931 first edition of the “Principles and Outline of Fracture Treatment” in the ACS Bulletin. The third edition, published in 1939, was vigorously used by armed forces surgeons in World War II. In 1954, the fifth edition of this guide was titled The Manual on the Treatment of Fractures; the first edition of the Early Care of Acute Soft Tissue Injuries also was published. In the 1960s, these manuals were published separately and in a combined, bound manual, The Management of Fractures and Soft Tissue Injuries. In the 1970s the combined manual was renamed Early Care of the Injured Patient, which set the stage for the ATLS^® Course that launched in 1980.

Now in its 10th edition, ATLS has become the standard for educating physicians and advanced practice providers in the early care of the injured patient. ATLS is truly a global program with more ATLS courses now taught outside than within the US and Canada each year. In the early days of the COT, the importance of providing education across the continuum of care was emphasized. This commitment has persisted with the development of the Advanced Trauma Course for Nurses in collaboration with the Society of Trauma Nurses, and the PHTLS Course in collaboration with the National Association of Emergency Medical Technicians.

Building on the strength and educational expertise of the ATLS program, the COT has continued to develop courses to meet the needs of trauma systems, including the Rural Trauma Team Development Course^© and the Disaster Management and Emergency Preparedness Course. The COT also offers training in advanced surgical skills for trauma, including Advanced Trauma Operative Management, Advanced Surgical Skills for Exposure in Trauma, and Basic Endovascular Skills for Trauma courses. Taken together, the COT’s educational programs have ensured that all providers of care to the injured patient speak a common language and are working from a standard framework of priorities and principles to optimize patient care.

Quality of Care

The ACS was founded with the motto “To serve all with skill and fidelity” and seeks to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The approach that the COT pioneered focuses on establishing high standards, ensuring the right infrastructure, collecting reliable data, and verifying performance.

From the beginning, the COF sought to standardize the care of fracture patients by developing fracture services in hospitals and improving care in emergency departments, which, at the time, were poorly resourced and staffed by the most inexperienced providers. In 1960, the ACS developed the Field Program of the COT, led by Dr. Kennedy (1960–1968), to evaluate the quality of care in emergency departments through the regional committees. These efforts led to the publication of the Guide to the Organization and Management of Hospital Emergency Departments.

This work was the precursor to the development of the original Optimal Hospital Resources for Care of the Seriously Injured, first published in 1976, now known as Resources for Optimal Care of the Injured Patient, which extended standards into the hospital and established the concept of a trauma center as we know it today. The development of what is now known as the Verification, Review, and Consultation Program was advanced through the persistence of COT Chairs C. Thomas (Tommy) Thompson, MD, FACS (1978–1982), and Donald D. Trunkey, MD, FACS (1982–1986). The first Verification Review Ad Hoc Committee, under the leadership of Frank L. Mitchell Jr., MD, FACS, was established in 1987. In parallel to the work establishing the standards, the COT led the development of trauma registries by establishing the National Trauma Data Standards and the National Trauma Data Bank^® under the leadership of former COT Chairs David B. Hoyt, MD, FACS (1998–2002), J. Wayne Meredith, MD, FACS (2002–2006), and John Fildes, MD, FACS (2006–2010). The COT also supported the collection of data for the Major Trauma Outcome Study led by Howard R. Champion, MD, FACS. Findings from this study laid the groundwork for the development of the Trauma Quality Improvement Program (TQIP^®), led by Avery B. Nathens, MD, FACS. TQIP now provides risk-adjusted benchmarking of outcomes across trauma centers and generates evidence-based best practices for trauma care.

The COT takes pride in having established both landmark programs to enhance the quality of trauma care and a model for quality improvement and the impact they have had on similar ACS Quality Programs and throughout the US healthcare system.

Trauma Systems

ACS Past-President A. Brent Eastman, MD, FACS, COT Chair (1990–1994), championed the concept of trauma systems and was instrumental in forming a multidisciplinary Working Group for Trauma System Evaluation in 1994 and the development of the COT Trauma System Consultation Program. Site reviewers for this program have visited nearly every state in the US, and the program has spurred growing global interest in the development of trauma systems. Dr. Eastman’s working group in 1996 developed the initial framework for trauma systems as described in Consultation for Trauma Systems.

In 2007, Michael F. Rotondo, MD, FACS, then-Chair of the Trauma System Evaluation and Planning Committee, along with Dr. Nathens, revised the Consultation for Trauma Systems book to incorporate a public health approach. With the support of the COT leadership, the lessons learned in the development of civilian trauma systems were adopted by the US military in the development of the Joint Theater Trauma System in the recent conflicts in Iraq and Afghanistan; a military trauma system manual also was developed. The ongoing mission of trauma system development continues in response to the 2016 National Academies of Sciences, Engineering, and Medicine report, which underscored the need for a national trauma care system. Once again, the COT’s approach has served as a model to optimize healthcare delivery across the US.

Injury Prevention, Advocacy, and STOP THE BLEED®

Widespread engagement of the COT in injury prevention efforts began in earnest in the 1950s based on the growing rates of morbidity and mortality associated with motor vehicle collisions. The first COT Subcommittee on Traffic Injury Prevention was appointed in 1955, and in 1956 R. Arnold Griswold, MD, FACS, COT Chair (1952–1957), testified before the US Congress to advocate for increased safety features in automobiles and the mandatory use of seat belts. The COT partnered with the American Association for the Surgery of Trauma and the National Safety Council to form the Joint Action Program that continued these advocacy efforts, along with a widespread public education campaign on automobile safety that the regional committees implemented. The result has been a dramatic reduction in motor vehicle fatalities despite the continuing growth in vehicle miles traveled.

The COT Injury Prevention and Control Committee crafted the first statement on firearm injury prevention in the early 1990s, with many revisions over the years. Under the leadership of Ronald M. Stewart, MD, FACS, COT Chair (2014–2018), the COT framed a public health approach to the problem of firearm injury and established a common narrative that supports our ability to move forward with injury prevention efforts.

The COT has established two strategy teams to further this work—the Firearm Safety team, which focused on initiatives and policies to improve the safety of firearm ownership, and the Improving Social Determinants to Attenuate Violence team, which has taken a multifaceted approach to addressing interpersonal violence.

Following the tragic shooting at Sandy Hook Elementary School, Newtown, CT, in 2012, Lenworth M. Jacobs Jr., MD, MPH, FACS, an ACS Regent at the time, and Dr. Rotondo, then-COT Chair, led an ACS-supported series of conferences in Hartford, CT, to develop what became known as the Hartford Consensus. This work has led to enhanced preparedness for mass shooting events, along with the development of the national STOP THE BLEED^® Program to train everyone in the basic skills of bleeding control and provide equipment to support bleeding control in public places (www.stopthebleed.org). Implementation of the STOP THE BLEED^® Program through the regional committees has been outstanding. As of 2021, more than 1.8 million people have been trained in more than 120 countries.

The ACS COT is supported by an outstanding advocacy team at both the state and federal levels, which continues to promote legislation that supports injury prevention and trauma research funding, along with policy that supports trauma system development and the STOP THE BLEED^® Program.

A Vision for the Future

The theme of our 100th anniversary celebration is “Looking to the Future through the Lens of Legacy.” We encourage the next generation of trauma surgeons to carry on this mission with the same passion and drive as their predecessors.

In the following 100 years, we aspire to achieve the following goals:

• Injury rates from all mechanisms will continue to decline with the implementation of evidence-based prevention programs enthusiastically supported by the public.
• Our communities will be structured to support the well-being and ability of all members of society to thrive and, as such, violence will be minimized.
• Disparities in both access to healthcare and outcomes following injury will be eliminated.
• Comprehensive education for the optimal care of the injured patient will be available in every country in the world.
• TQIP will encompass data from trauma centers around the world and will have comprehensive data on the long-term functional outcomes of patients.
• Social care will be integrated into medical care so that all injured patients will have access to comprehensive support to meet their needs during recovery.
• A comprehensive, efficient, and cost-effective trauma system will ensure access to optimal care for injured patients from anywhere in the world.
• The US will have a network of Regional Medical Operations Centers that feed data to state and federal emergency operations centers and support a coordinated response of the healthcare system to any mass casualty event or health crisis regardless of scale, thus minimizing loss of life.
• Funding for trauma research will be commensurate with the burden of injury in society, and we will have a National Institute for Trauma focused on injury prevention, acute care, and rehabilitation and recovery.
• The COT will continue to thrive as a collegial, diverse, and supportive community of surgeons working together for the common purpose of preventing injuries and improving outcomes for trauma patients.

We are indebted to all of the surgeons and staff of the COT who have worked tirelessly for the past 100 years on behalf of the injured patient. In 1997, in recognition of the COT’s 75th anniversary, Gerald O. Strauch, MD, FACS, then-Director of the ACS Trauma Department, wrote, “The single most impressive aspect of the Committee on Trauma, in my view, is the continuing well-spring of highly motivated, talented, dedicated, thoughtful, and innovative surgeons who elect to devote major portions of their professional lives to this work.” And Dr. Eastman spoke for all of us when he wrote, “I count the friendships that I have made through the COT as one of the single most important things in my life. These are men and women whom you can trust to do what is best for the patient, and, when all is said and done, that is what counts.”

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