Translational Health Science, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.
BMJ Open. 2024 Sep 25;14(9):e088159. doi: 10.1136/bmjopen-2024-088159.
Non-compressible abdominal haemorrhage (NCAH) is a potentially preventable cause of death due to injury. Limited exploratory laparotomy by a non-surgeon is a temporary intervention to sustain life until definitive surgical intervention by trauma surgeons can be obtained. This study aims to establish consensus on a protocol for general surgery physician assistants performing limited exploratory laparotomy to manage NCAH in an austere environment.
This study included anonymised trauma surgeons and general surgery physician assistants from military and civilian backgrounds. Participants were recruited from various professional surgical organisations, including direct interaction with trauma surgeons and surgical physician assistants. Participants used a modified Delphi survey with a 9-point Likert scale in two rounds. The two surveys were categorised into three parts: protocol for NCAH (part A), the potential role of general surgery physician assistants (part B) and measures of success (part C). A total of 24 statements were voted on and assessed. Votes were divided into three zones: agreement (median 7-9), uncertain (median 4-6) and disagreement (median 1-3). To reach a consensus, 70% agreement was required within a zone. If more than 30% of the votes fell outside of a specific zone, consensus was not achieved. After consensus, the original protocol was revised in an online meeting with experts.
The initial analysis involved 29 participants. After 2 survey rounds, 19 out of 24 statements reached a consensus. Part A: 10 statements gained consensus, including in austere environments, controlling NCAH can be challenging. A qualified general surgery physician assistant should intervene. A focused assessment with sonography for trauma examination can be used for screening. Bleeding can be managed with packing and pressure. After managing the haemorrhage, the abdominal wall should be left open with a temporary closure technique. Part B: nine statements gained consensus, including in austere locations, a licensed general surgery physician assistant with a minimum of 3 years of experience working under the supervision of a trauma/general surgeon can perform interventions for limited exploratory laparotomy for patients with NCAH. Part C: general surgery physician assistants will be required to have the same success rates as any qualified surgeon.
Gaining consensus and implementing a revised protocol for managing NCAH by general surgery physician assistants is attainable. General surgery physician assistants will need formal training to manage NCAH. With the support of trauma surgeons who provide direct and indirect supervision, general surgery physician assistants can develop a comprehensive understanding of the necessary skills and make sound decisions when treating patients with this condition. This teamwork can also increase surgical capacity and potentially decrease mortality rates for patients with NCAH in austere environments.
非压缩性腹部出血（NCAH）是一种由于外伤导致的潜在可预防的死亡原因。非外科医生进行有限的剖腹探查术是一种临时干预措施，可维持生命，直到创伤外科医生能够进行确定性手术干预。本研究旨在就普通外科医生助理在恶劣环境下进行有限剖腹探查术以治疗 NCAH 达成协议。
这项研究包括来自军事和民用背景的匿名创伤外科医生和普通外科医生助理。参与者是从各种专业外科组织中招募的，包括与创伤外科医生和外科医生助理的直接互动。参与者使用改良 Delphi 调查法，采用 9 分 Likert 量表进行两轮调查。两轮调查分为三个部分：NCAH 方案（第 A 部分）、普通外科医生助理的潜在作用（第 B 部分）和成功措施（第 C 部分）。共有 24 项声明进行了投票和评估。投票分为三个区域：同意（中位数 7-9）、不确定（中位数 4-6）和不同意（中位数 1-3）。要达成共识，需要在一个区域内获得 70%的同意。如果超过 30%的投票落在特定区域之外，则无法达成共识。达成共识后，在与专家的在线会议上修订了原始方案。
最初的分析涉及 29 名参与者。经过两轮调查，24 项声明中有 19 项达成了共识。第 A 部分：有 10 项声明达成共识，包括在恶劣环境下，控制 NCAH 具有挑战性。合格的普通外科医生助理应进行干预。创伤超声检查可用于筛查。可以通过填塞和加压来控制出血。在处理出血后，应使用临时闭合技术将腹壁敞开。第 B 部分：有 9 项声明达成共识，包括在恶劣地点，具有 3 年以上在创伤/普通外科医生监督下工作经验的持牌普通外科医生助理可以为 NCAH 患者进行有限剖腹探查术干预。第 C 部分：普通外科医生助理需要达到与任何合格外科医生相同的成功率。
普通外科医生助理管理 NCAH 的协议可以达成共识并进行修订。普通外科医生助理需要接受正式培训才能管理 NCAH。在提供直接和间接监督的创伤外科医生的支持下，普通外科医生助理可以全面了解必要的技能，并在治疗此类患者时做出明智的决策。这种团队合作还可以提高在恶劣环境中治疗 NCAH 的患者的手术能力，并可能降低死亡率。
