Program History & Rationale

The development of the Surgery and Critical Care Physician Assistant profession in Army Medicine began in response to Medical Corps (MC) personnel shortages in both U.S. Army Forces Command (FORSCOM) and U.S. Army Medical Command (MEDCOM) in 2005. The Office of the Surgeon General (OTSG) approved the program in 2012.

Positive experiences with physician assistants in preoperative, intraoperative, and postoperative care of the surgical patient have been reported by several authors in a wide range of practice settings as far back as the 1970’s [2-8] and have been a long standing component of trauma surgery teams in civilian practice. Sherwood and Price et al. demonstrated that PA’s providing initial trauma care typically performed by surgical residents at a Level I trauma center had a statistically lower overall combined mortality rate when categorized by standardized injury score, concluding that a PA trauma care delivery model provided outcomes as favorable as those reported by the National Trauma Data Bank. The PAs in these studies were also responsible for trauma patient management in the ICU in conjunction with their supervising trauma surgeons. They performed procedures normally done by residents, including chest tube insertion; central line placement; debridement and suturing of wounds; fracture reduction; and intubation[9]. Many trauma centers have documented similar benefits of utilizing PA’s in the capacity described. Miller and colleagues demonstrated that after incorporating physician assistants to the Trauma Care team, transfer time to the operating room, ICU, and the floor decreased, as did the length of stay; despite a 19% increase in standardized injury scores at their level II trauma center [10].

American College of Surgeons standards state, it is mandatory to have robust and sufficient back-up schedules for subspecialties as well as trauma surgeons. This redundancy is not only needed to care for multiple patients contemporaneously, but for the many patients whose injuries simply require additional trained “hands” to control hemorrhage[11]. The Armed Forces of the United States and their North Atlantic Treaty Organization (NATO) partners continue to be engaged in regions of conflict worldwide. Consequently, combat casualty care is a central focus of military medical teams[12].  Current deployment requirements demand the training and sustainment of many trauma and surgical providers to optimize outcomes for combat casualties[13]. Surgery and Critical Care PAs can play an integral role by augmenting the limited number of available surgeons within the military to help deliver surgical critical care in the far forward setting.

Considering the known capability gaps of available surgical capability along with the anticipation of future large scale combat operations (LSCO), ready and available surgically trained 65D clearly provide a meaningful option to fill this gap. As the current Surgery and Critical Care training program is tri-service, it is important to note that the US Air Force and US Navy each effectively employ GSPA’s. This is a critical wartime medical specialty identified in the DoD Personnel Management Plan for Trauma-Related and Other Wartime Medical Specialties, as determined by the Secretary of Defense. Navy Physician Assistants (PAs) formally trained in a program of General Surgery, Trauma, and Surgical Critical Care assist surgeons in these wartime and peacetime roles, materially contributing to surgical capacity and quality of care. These assignments primarily include, but are not limited to, Expeditionary Medical Facilities, Marine Corps Medical Battalions, Military-Civilian partnerships at high-volume trauma care centers, smaller military fixed treatment facilities staffed by a single surgeon, Surgical Shock Trauma Platoons, and Fleet Surgical Teams.

In the U.S. Army, FORSCOM Surgery and Critical Care PAs have been used to extend surgeon capabilities on forward surgical teams to increase access to surgical trauma and critical care patients in the forward environment. Future capability utilization across the services may exponentially increase available surgically trained PA’s and enhance combat effectiveness by providing outstanding patient care on the battlefield.

Bibliography

2. Hatcher, C.R., Jr. and W.H. Fleming, The role of physicians' assistants in a university teaching service. J Thorac Cardiovasc Surg, 1974. 68(5): p. 750-6.

3. Heinrich, J.J., et al., The physician's assistant as resident on surgical service. An example of creative problem solving in surgical manpower. Arch Surg, 1980. 115(3): p. 310-4.

4. Laws, H.L., et al., Training and use of surgeon's assistants. Surgery, 1978. 83(4): p. 445-50.

5. Maxfield, R.G., Use of physician's assistants in a general surgical practice. Am J Surg, 1976. 131(4): p. 504-8.

6. Miller, J.I., J.M. Craver, and C.R. Hatcher, Use of physicians' assistants in thoracic and cardiovascular surgery in the community hospital. Am Surg, 1978. 44(3): p. 162-4.

7. Miller, J.I. and C.R. Hatcher, Physicians' assistants on a university cardiothoracic surgical service. A five-year update. J Thorac Cardiovasc Surg, 1978. 76(5): p. 639-42.

8. Sherwood, K.L., et al., A role in trauma care for advanced practice clinicians. Jaapa, 2009. 22(6): p. 33-6, 41.

9. Miller, W., et al., Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center. J Trauma, 1998. 44(2): p. 372-6.

10. Gurney, J.M., et al., Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries. J Trauma Acute Care Surg, 2022. 93(2S Suppl 1): p. S6-s11.

11. Mertens, J. and M. Descoteaux, The evolution of PAs in the Canadian Armed Forces. Jaapa, 2017. 30(1): p. 1-6.

12. Dubose, J., et al., Preparing the surgeon for war: present practices of US, UK, and Canadian militaries and future directions for the US military. J Trauma Acute Care Surg, 2012. 73(6 Suppl 5): p. S423-30.