Gaining consensus on a protocol for general surgery physician assistants in the management of non-compressible abdominal haemorrhage in military austere environments: a Delphi study
Authors: Adams Donald , McDonald Paige L , Mader Michael , Holland Seth , Nunez Timothy , van der Wees Philip 
Published: September 2024

Background

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.

Method

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.

Results

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.

Conclusion

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.