The role of the surgical first assistant in managing haemostasis and preventing clot formation
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Birmingham City University (BCU)
This essay is about the role of the surgical first assistant in managing haemostasis and preventing clot formation.
It is an anonymous case study which includes the role of the SFA and their legal and professional responsibilities.
The Role of the Surgical First Assistant in Managing Haemostasis and
Preventing Clot Formation.
The case study I am going to present is about a 69 year old gentleman (Mr B) who was
scheduled to undergo an elective laparoscopic cholecystectomy (LC). Mr B’s journey from
the pre-operative through to the post-operative recovery period and the legal, ethical and
professional responsibilities of the Surgical First Assistant (SFA) will be explored. The focus
of this essay is examining my role as an SFA in promoting, ensuring and maintaining good
patient haemostasis and clot prevention.
Mr B was to undergo a laparoscopic cholecystectomy for the treatment of biliary colic due to
gallstones. It was beneficial for Mr B to undergo this procedure as removing his gallbladder
would alleviate his discomfort and prevent future gallstone complications such as obstructive
jaundice and pancreatitis (Burkitt et al 2007). He had a history of mechanical mitral valve
replacement two years ago for which he was taking long term Warfarin, Warfarin decreases
the body’s ability to form blood clots by blocking the formation of vitamin K, vitamin K is
required to make clotting factors and prevent bleeding (Blann 2008). As Mr B was at high
risk of developing clots due to his mitral valve replacement (NHS Choices 2019) he required
long term Warfarin.
At Mr B’s pre-operative assessment it was recorded that Mr B had a high body mass index
(BMI) over 30 and was over the age of 60 years. These two factors increase the patient’s
risk of developing a VTE. (Appendix 1). It was imperative then that Mr B had effective
management of his Warfarin medication prior to surgery (Appendix 3a, 3b) therefore advice
was sought from the anti-coagulation team, this collaboration with other healthcare providers
at pre-operative assessment is recognised as a responsibility of an SFA (AORN 2019) and
supports the view that the SFA is not working outside their scope of practice.
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,I informed Mr B early in the process, of the bleeding risks and equally the risks of emboli or
VTE so that this would help him make an informed choice whether to proceed with surgery
or not. Research indicates that If he was under coagulated this would increase the risk of
VTE (Radford et al 2011) and also increase his risk (15%) of developing embolic stroke (Heit
2001), similarly if over coagulation occurred the risk of intraoperative haemorrhage would
increase (Tan et al 2017). I provided verbal and written information to Mr B’s and ensured
that he had a good understanding of these risks and the measures in place to reduce the
risks. By ensuring Mr B is fully informed this helps to ensure compliance with proposed
treatment (Beauchamps and Childress 2013) and helps to create trust between the
healthcare professional and the patient (Beauchamps and Childress 2013 and Eyal 2014).
Mr B was fully aware that non-compliance in the anticoagulation plan would mean that his
surgery would get cancelled. If, for example he omitted the Warfarin and did not bridge with
Dalterparin then this could have increased his risk of VTE and embolic stroke (Heit 2001).
Prior to any procedure the surgeon or the nominated healthcare professional, such as
myself, needs to acquire informed consent from the patient, not only to ensure the patient is
fully informed but to protect themselves against criminal or civil charges (Lynch 2010).This
includes providing Mr B with information about his health status, diagnosis, treatment options
and prognosis (Lynch 2010). The patient should participate in the development and decision-
making of the plan of care, including the right to consent to or refuse medical or surgical
treatment (Farmer and Lundy 2017) and where appropriate should be involved in their care
and treatment so as to make informed decisions (NMC 2018). Traditionally the surgeon
would obtain informed consent prior to the procedure however in recent times specialist
nurses have taken on this role (Lynch 2010). In my role as an SFA I have extended this role
through in house education and supervision and have been deemed competent by the
consultants within the surgical team. I have also recognised the limitations in my role and
knowledge and work within my scope of professional practice (NMC 2018). On the day of Mr
B’s procedure I obtained consent for his procedure, I also clarified with him that he had
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, followed the anticoagulation plan and that his INR was below 1.5 (NICE 2019). I obtained
written informed consent prior to the procedure and for this I used a pre-printed consent form
to assist in facilitating the process, a pre-printed consent form is useful in that it gives the
likelihood in percentages of the risk occurring (Appendix 3). The pre-printed consent form
has been recognised as being beneficial for both the healthcare professional and the patient,
a view supported by Farmer and Lundy (2017). Lynch (2010) argues however that consent
should be an ongoing process which includes all members of the surgical team. In my
workplace the surgeon and I provide both written and verbal advice and information to the
patient, this process begins in the surgical clinic and is an ongoing process throughout the
patients’ journey. Mr B gave informed consent to the procedure and was fully aware that the
consultant surgeon would be performing the procedure and that I, as a non-medical
practitioner with a nursing background, would be assisting in theatre as the surgical first
assistant. Legally the Consultant is responsible for ensuring the patient has given informed
consent prior to the procedure (The Department of Health 2009) however guidance from the
General Medical Council (GMC 2008) recognises that a person may be delegated to seek
consent if that person has sufficient knowledge of the procedure and understands the risks
involved. I felt that due to my experience within this role I had knowledge equal to the
Consultant in providing information so that the patient was able to give informed consent, a
view recognised by Quick (2013) who suggests that non-medical staff who take on these
roles must perform the role to the same standard as their surgical colleagues.
It is important that not only is the patient provided with all the relevant information to make a
decision to give consent but that they have the capacity to give consent and that it is given
voluntary (Tingle and Cribb 2007). As the SFA I had built up a relationship with Mr B from his
many contacts with the hospital in the process leading up to his procedure. I was able to
determine through our conversation that Mr B was giving his consent voluntarily, was fully
informed and he had the capacity to make a decision about his own healthcare and
treatment. Within my SFA role it is important to recognise that the information provided to Mr
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