Amputation in the field?!

[Just Plain Ruff]

nail file and nail clippers. Works every time.

I was on a call one morning where the other crew had a patient (very very critical) who had some tendon, muscle and femoral artery left but not much else at the level of injury.

They had profuse bleeding that was uncontrolled. Patient was unconscious.

he was trapped by the dashboard and engine -head on crash at about 60 miles per hour.

They were just about to do a field amputation with the consent of our medical control until the patients leg just popped out from under the dashboard and voila.

Unfortunately the patient ended up coding in the ER and didn't make it.

[Doczilla]

Field amputation in the scenarios provided are feasible, and I agree that the chances of doing it are incredibly low. Entrapment with immediate threat to life or entrapment without the possibility of extrication means the limb has to come off. What any surgeon will tell you is that it doesn't really matter how you do it in the field, since they will be going to surgery to do a proper job of it once the patient gets to the hospital. Apply a tourniquet, go as distal as possible, cut through everything you can with the scalpel, then cut bone (if necessary) with a saw of any kind. There is always some discussion in (remote, wilderness) field medicine texts regarding cutting of the bone, soft tissue, and skin at varying lengths to ensure good stump healing. This is crap, since the surgeon will take care of that in the OR. Just save them as much tissue and bone as you can. If it's a leg, make every effort to save the knee if possible (this makes a big difference to the patient as far as function with prosthetics). Same thing with the elbow.

Hesitate before making the determination if a limb is salvageable or not. With external fixators, wound vacs, grafts, microsurgical techniques, and other technologies, you will be amazed at the regaining of function. Much of the time, you won't be able to predict this in the field.

If you've ever wondered if you can do it with your pocket knife...

Aaron Ralston

Sampson Parker

For the field c-section, I remember some discussion in Virginia back in 2003 that they were adding an "extreme measures" protocol to the peninsula's EMS protocols to allow it on a gravid pulseless patient. Field c-section in this setting is not really that complex a concept: vertical incision from the umbilicus to the pubis, cut until you get uterus, then cut until you get amniotic fluid. Finish the uterine incision with scissors, and try not to cut the baby. Deliver through the incision, clamp and cut the cord as usual, and resuscitate the baby per protocol. Whether or not you really want to face the regulatory consequences later is up to you. It had better be an iron-clad decision.

'zilla

[ccmedoc]

We had one paramedic in the area amputate a womans leg after she was trapped under a train car. From the report I read, he used a hacksaw at mid femur and the patient tolerated it surprisingly well.

She later died from sepsis. He was cleared by Med Control due to his experience and their knowledge of him. No approval was given via HERN or other communication. No protocols exist for this, however, and I would say it is on a case by case basis.

There are classes around here that teach field amputation. They are about 16 hrs long, and include a cadaver lab. Necessary background is necessary, such as college level sciences, to ensure understanding of the concepts and repercussions. There is no certification, per se, but I believe that on the right day, with the right staff at the med comm..it could happen with approval....

[Dustdevil]

Hey Zilla, let's set up an amputation and c-section certification class! We'll be richer than the guys running the Walter Mitty TacMed schools!

[WestSideBorderPatrol]

When it comes to field amputations, I'll leave it up to the professionals, we have the "GO Team" that flys out of the University of Maryland Medical Center.

GO Team

The only time that I remember having them on-scene was when we had this 12 year-old girl stuck up to her waist in "quicksand". It was really more like mud, but she was so stuck that it was just a suction thing going on. We it was a 4 hour extrication and we were worried about compartment syndrome so we had the GO Team stand-by in case we needed to amputate. Luckily we finally got her out and flew her to the trauma center were she was treated and released.

[JakeEMTP]

12 year-old girl stuck up to her waist in "quicksand". It was really more like mud, but she was so stuck that it was just a suction thing going on. Well, it was a 4 hour extrication and we were worried about compartment syndrome so we had the GO Team stand-by in case we needed to amputate.

Just wondering, which appendage were you planning to amputate? :shock:

[spenac]

Just wondering, which appendage were you planning to amputate? :shock:

Me too. Give the chainsaw BOB going take her lower half off. :shock:

[Asysin2leads]

You know, while in humor, Dust does have a bit of a point. Including 'Zilla, there is general agreement on these points:

1. Situations where it is necessary to remove the limb or lose the patient in the field are real, and while not as common as other scenarios, can and do happen.

2. In this situation, it is medically and ethically necessary to undertake the procedure.

3. A prehospital care provider can reasonably be expected to have to perform this procedure.

If that is all true, then I think it is enough criteria to if not have a formal protocol for limb removal, than to at least touch on some of the points like 'Zilla did in an advanced life support class. Personally, I've seen this situation arise far more times than situations where a needle or open cric is needed, but we're trained on that. In other words, if we may have to do it, its worth having formal training, planning, and documentation procedures for.

[firedoc5]

All in all, it sounds like a blow-hard, with an over active imagination that might have had a few. Maybe even a "wanna-be". I've known of cases where limbs being caught in machinery and had to have a doc brought in. But in the original scenario presented, I don't see it happening. But I do have a cool swiss knife just in case.