Although it is not a common occurrence, there have been documented cases where medical resources have been requested and transported to motor vehicle collisions (MVC) for the purpose of conducting a field amputation. In just the greater Charleston area, surgeons have been requested three times in the last eight years, and those numbers are fairly consistent in other areas with similar capabilities.
Field limb amputations should be viewed as a last resort option to free a patient only after all other options have been exhausted, the patient’s condition requires immediate removal, or in cases where hazards create too much risk for lengthy operations. This procedure has received much discussion in recent years with the increased exposure of machinery extrication. From a MVC standpoint, field amputations are typically not considered a reasonable option and are often considered due to a lack of training and knowledge on the part of the responders.
It is important to understand the parameters necessary to conduct a justifiable field amputation:
- The patient must be entrapped to a point where all other options are exhausted.
- The patient must be stable enough during the early phases of operations to allow ample time for the requesting and transporting of medical resources to the scene.
- After arrival of the medical resources, the patient must have become unstable enough that the field amputation becomes a truly life-saving measure.
All Options Exhausted
An Executive Fire Officer report by Ivan Mustafa describes the conditions present during the massive earthquake in Haiti that destroyed the capital city, causing an estimated 230,000 deaths and 300,000 injuries. Due to the limited equipment and resources, removal of trapped victims often involved the amputations of extremities as the only viable method of disentanglement. In the case of this incident and other potential natural disasters, amputation becomes an option in the overall risk/gain analysis of multiple patients.
Although some fire departments have limited resources, for the most part they have a reasonable amount of extrication tools including hydraulic spreaders and cutters, reciprocating saws, lift bags, forcible entry tools, chains/straps/pulling devices and various amounts of cribbing. Even if the department is limited, they will more than likely have access to any of those resources within a reasonable time, as well as access to external agencies, such as recovery companies. Responders should have the ability to lift or move anything traveling on a roadway, as well as the ability to sever a vehicle into a million parts. It is very unlikely to find a situation in which trained and skilled responders cannot develop a reasonable plan to extricate the victim.
The patient condition must initially present a compromising entrapment and a trauma assessment that indicates extrication will not be possible within the patient’s time frame. These would be the minimum conditions necessary to request medical resources for amputation. Requesting hospital-based resources and/or advanced care providers such as flight services should be based on the ability to utilize more definitive care procedures such as blood product administration, chest tube insertion, anesthetics administration, etc.
For instance, the Baltimore Shock Trauma Center GO-Team provides definitive operative services to patients injured in the field who are unable to be rapidly transported to a trauma center or other medical facility. The team is dispatched for one of three general scenarios: priority patients who are expected to exceed one hour of total scene time, hemodynamically unstable patients with an undetermined extrication time, and mass-casualty incidents with multiple patients of varying acuity.
Once those resources arrive, the patient’s condition must have deteriorated to the point that the amputation becomes a life-saving measure. Otherwise the patient should be supported until additional resources arrive and disentanglement is completed. The primary goal of hospital resources is to provide advanced care to allow for an extended extrication time if needed. As long as we can support major body systems and the limb is viable, our efforts could extend for hours, and theoretically, days.
Discussions about the ability of a paramedic to perform field amputations include concerns over whether it fits into their scope of practice, their ability to conduct initial and refresher training, lack of reasonable training props and legal implications. Right now, the consensus is a field amputation should be performed by trained hospital-based resources. Unfortunately, most areas do not have formally trained teams or pre-incident planning, which leads to strategic and tactical questions:
- What is the timeframe for timely notification and deployment of the surgical teams, their method of transport, and the development of a plan as to where the patient will be transported to once the amputation is performed?
- Have communication means been established to the hospital resources after they have been requested? In a local incident, a surgeon was requested by emergency personnel and was being transported to the scene when the patient was ultimately extricated. In situations where a hospital has limited resources, just making the request may deplete those resources, especially if the patient arrives at the hospital before the surgeon returns.
- Will the medical personnel be subjected to an environment they probably have not been trained for?
- What assistance will the medical personnel need from responders? Are they prepared mentally and physically to be involved in an amputation? Will untrained responders actually hinder the surgeon from completing the procedure?
- Who will make the ultimate decisions on strategy and tactics?
In another local situation that involved machinery, a surgeon was requested for field amputation. He advocated sedation of the patient and reversing the direction of the machine to release the entrapment. This goes against most emergency services practices, but his logic was he could attempt to salvage the limb as long as it was attached. Amputation, however, is final.
Field amputation is a very serious matter and a life-altering decision. Though an extremely low-frequency event, it carries high consequences that should be outlined through multi-agency agreements prior to an incident. The incident commander, along with the disentanglement supervisor, should conduct a risk/gain analysis and call for additional resources early in an incident. If that involves hospital-based resources, there should be established lines of communication and responsibility with the intent of prolonging life until all attempts at extrication can be exhausted prior to amputation.
A special thanks to Division Chief Ivan Mustafa of the Seminole County Fire Department and MUSC Trauma Medical Director Dr. Crookes.