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Emergency surgical amputations are rare and resource-intensive lifesaving interventions. Most emergency medical services (EMS) lack a formal protocol to manage these high-risk but low-occurrence events. There has been limited attention in the EMS community to address this issue. Without a literature-based approach, the EMS community has been offered little guidance on managing surgical field amputations.
Case Report
A 38-year-old man was terminally entrapped below the waist in an industrial auger. As a last resort, the decision to initiate a field amputation was made. We outline an adaptive strategy to address the circumstances surrounding this entrapment scenario.
Why Should an Emergency Physician Be Aware of This?
A carefully preplanned protocol may lead to increased overall survivability for entrapped patients requiring emergent field amputation. Based on the lessons learned from the outcome of this case, previous cases, and a literature review, we have devised a simplified planning tool in the form of a “LIMB” mnemonic to aid EMS services in developing their own traumatic amputation protocol (TAP). “LIMB” is an acronym for: Lists of resources and equipment, Initiate TAP checklist, Manage the extrication, and Bring the patient in. The LIMB mnemonic may also be used as a checklist to assist EMS personnel in performing a field amputation. We offer rescuers a starting point to develop their own TAP capable of being executed in their own rescue environment.
Performing a surgical amputation in the field to save the life of a terminally entrapped victim is a rare but resource-intensive event. These exceptional salvage events could possibly be made more efficient with an established protocol. However, according to two national surveys of emergency medical services (EMS), only 1.38–1.4% of the respondents had established field amputation protocols (
). In one of those surveys published in 2000, only 29% of respondents in the 125 most populated cities in the United States indicated the existence of a physician-led field response team in their EMS systems (
). Few studies have been published addressing this issue. We present the challenges of an entrapped patient requiring a field amputation. In this complicated case the victim was successfully rescued. However, a retrospective review demonstrated the need to establish a protocol to streamline the coordination and execution of a field amputation.
Case Report
A 38-year-old man was terminally entrapped in an industrial auger at the right proximal thigh. Repeated rescue attempts by the on-site industrial response team, emergency medical technicians-paramedics, and firefighters were unsuccessful. The on-site rescuers recognized the complexity of the entrapment and the need for additional expertise. The impending exsanguination and lack of progress in the extrication required a change in tactics. A call for help was placed to the nearest Level I trauma center and a report was received by the attending emergency physician. No established EMS or hospital protocol existed at the time, so an impromptu plan was devised. Information regarding the patient's position in the auger, including his condition and anticipated medical needs, was relayed by EMS and included cell phone photos (Figure 1). The physician quickly assembled a team to procure the necessary items needed to complete an amputation in the field and enough medical supplies to provide prehospital resuscitation. The items gathered included tourniquets, anesthetics, analgesics, blood products, i.v. fluids, airway, and surgical equipment. Simultaneously, a local 911 dispatcher was tasked as the emergency operation center (EOC) to coordinate resources and facilitate the mobilization of the physician-led surgical extrication team (
). The operation became complicated when it was realized the rescue would require additional EMS personnel and law enforcement spanning several counties. After assuming the role of EOC, the “centralized” 911 dispatcher became responsible for coordinating transportation and scene safety due to their direct access to EMS, police, and fire personnel. Inclement weather complicated transportation logistics to and from the scene. Weather conditions were unsuitable for flight operations. This necessitated plans to support a prolonged ground transport distance of > 50 miles one way. Travel on a highly congested interstate highway during rush hour prompted the need for police escort to clear the path for the responding ambulance to expedite the response time. The estimated time saved through the use of law enforcement during transport was approximately 20 min in each direction.
Upon arrival, EMS on scene consisted of the medical response team of the facility, paramedics, and firefighters. No specialized technical rescue teams were on scene. The victim was assessed to be in critical condition and required urgent disentanglement from the auger. There was evidence of significant blood loss based on the amount of blood on the floor. The patient's mid right femur was traumatically amputated by the auger, while the proximal femur remained entrapped in the machine (Figure 1). The left lower extremity sustained multiple comminuted fractures, and was disarticulated in a nonanatomical position; the Mangled Extremity Severity Score was calculated at 10 and it was deemed unsalvageable (
The responding emergency physician assessed the remnants of the right femur and made the decision to complete the amputation and extricate the patient. The proximal femur and soft tissue sustained severe destruction. The actual amputation required minimal additional intervention due to the profound tissue destruction. He was guided out of the machine with some additional tissue loss. No anesthetic was administered during the extrication due to the patient's critical condition, and after 3 h of entrapment, the entangled tissue was already nonviable. The patient was positioned on a gurney and given a full assessment. A more detailed assessment revealed the femoral artery was severed and retracted proximally. This did not allow the application of tourniquets, clamping, or ligation of the femoral artery without further exploratory surgery on scene. The rescue team maintained hemorrhage control using direct pressure and combat gauze (Figure 2) (
). The patient was alert and oriented, but very lethargic. He was responsive to verbal stimuli, but was quickly deteriorating as the rescue proceeded. He had a weak and thready radial pulse and he was assessed to be in shock. Because the injuries were limited to the lower extremities, he was able to maintain his own airway appropriately. The decision was made to defer intubation to minimize expected challenges in resuscitation, including postintubation hypotension (
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
). Two units of packed red blood cells were infused during transport. The patient arrived at the responding Level I trauma center approximately 4 h after becoming entrapped. He underwent further resuscitation in the emergency department (ED), followed by bilateral hip disarticulations in the operating room.
Figure 2Flight Medic volunteer for ground transport due to inclement weather providing direct pressure en route back to hospital.
The lack of literature and situational differences make it difficult to propose a universal traumatic amputation protocol (TAP) capable of addressing every entrapment scenario. Based on the literature review, there seems to be limited guidance or training to address the process of conducting a field amputation. There are multiple case reports publishing details of difficult field amputations conducted in the setting of natural disasters, motor vehicle accidents, or other industrial calamities (
). These events occur with enough frequency to cause concern regarding the preparedness of EMS systems for these challenging cases. Methodist-Dallas Medical center has had a surgical field team since 1984 (
Historically, a variety of providers have performed field amputations. Kampen et al.'s study reported approximately half of all field amputations being performed by trauma surgeons, a third by emergency physicians, and the rest by paramedics or others (
). In this case the emergency physician performed the amputation. Addressing the domains of the airway management, anesthesia, surgical intervention, and critical care management as part of the rescue and subsequent transportation plan are integral to the successful execution of a field amputation. The TAP protocol could be part of the foundation for supporting these domains of treatment while coordinating interprofessional team-based care.
The case we described coordinated a diverse group of disciplines including physicians, critical care paramedics, 911 dispatch, local and state police, EMS crews, and firefighters. Each discipline brought a skillset and focus to the mission to optimize the success of the rescue. Additional flight and critical care paramedics were recruited due to their skill and abilities to work in austere conditions. For example, providers rotated in the back of the ambulance to hold pressure on the exposed proximal femoral artery during the hour-long transport. A rescuer attempting to hold pressure for more than 20 min in the back of a swaying ambulance would develop digital numbness resulting in ineffective compression. Thus, the EMS personnel had to rotate to maintain compression of the vessel. Providers not holding compression would support critical care initiatives such as administering blood products or pressor agents. Incorporation of the TAP protocol would support the establishment of a multi-disciplinary team and avoid delays in addressing accountability and responsibility concerns. In the case described, the physician approached the rescue as a consultant and not as an extrication expert. Those efforts were led by EMS and firefighters who were experts in recovery. Overall control of the scene was deferred to the incident commander. The physician's role focused on the stabilization, amputation, and postresuscitation care. In our case, interprofessional collaboration proved pivotal to the successful extrication of the patient.
We offer a simple “LIMB” mnemonic (Figure 3) that can be used as a last-minute checklist to execute a field amputation. It can also be used as a starting point to develop a formal TAP (
). The LIMB mnemonic stands for the following overarching concepts of Listing resources, team members, and supplies; Initiating the checklist; Managing the patient on scene; and Bringing the patient and salvageable anatomy back to the hospital. The List of supplies and equipment for a surgical extrication box or “X-box” could be established preemptively; a “sample” packing list is provided in Figure 4 (
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
). A few items worth highlighting that rescuers could consider for hemorrhage control, airway, breathing, circulation of trauma, and resuscitation might include tourniquets, supraglottic airway devices or portable video guided laryngoscope, hemostats, combat gauze, tranexamic acid, ketamine, and universal blood products (
Secondly, the physician would Initiate the TAP checklist (Figure 5). The checklist further includes pertinent considerations such as securing departmental coverage, establishing the EOC, and procuring restricted medical items such as blood products and pharmaceuticals. Managing the extrication would include hemorrhage control systems, addressing the airway, breathing, circulation, analgesia, and a surgical plan. Finally, Bring the patient and any salvageable anatomy to the hospital using postextrication and damage control resuscitation techniques that my facilitate longer transports to higher levels of definitive care (
Figure 5Traumatic amputation protocol (TAP) checklist. ED = emergency department; HOPI = history of present illness; MVC = motor vehicle crash; EMS = emergency medical services; OR = operating room.
Retrospectively applying the LIMB mnemonic to our case would have saved time, improved coordination, and expedited the rescue. The Listing of on-call team members would have provided hospital coverage enabling other physicians to extend emergent care to the community. Preemptive Lists are extremely important due to the large amount of preparation required in a short amount of time and serve as a safeguard to ensure that critical items are brought to the scene (
). A TAP Initiation checklist would have been helpful for important coordination and establishing clear roles and responsibilities for each of the EMS entities involved and at each phase of the rescue. Managing and Bringing the casualty back with salvageable anatomy would have served as a mental rehearsal while en route to the scene and provided helpful guidance during the rescue and return.
Why Should an Emergency Physician Be Aware of This?
Performing field amputations to rescue terminally entrapped victims are rare life-saving events. With limited or no training, executing a field amputation may need preemptive guidelines or lists to help manage this complicated scenario. In retrospect, our collective experience with prior similar events proved to be paramount to this case's success. However, it is likely there will be variability to the outcomes of these rare events without having a uniformed approach. Although this patient survived, we feel that a protocol in place would have allowed for a smoother launch for the rescue team, decreased response time, and provided established guidance for EMS personnel. Upon reviewing literature of similar cases, we noticed the lack of standardized field amputation protocols across hospital systems in the United States. This case led us to develop a simplified and expedient TAP in the form of the LIMB mnemonic. The LIMB mnemonic can be used either as a last-minute guide to aid the responding physician or as a starting point for EMS teams to fully develop their own TAP. A TAP, in its simplest form, is responding to a call for help from the field, as in this case, and reacting accordingly. In the most advanced form, a TAP might have a dedicated, multidisciplinary team operating from a pre-established and agreed-upon protocol. The protocol would be supported with formal cross-training and exercises. A TAP could be somewhere in between, with a surgeon who volunteers to go if needed or an emergency physician who cross-trains in the operating room on occasion just for familiarity. Developing a formal TAP would likely need to be initiated by the regional EMS director by assessing the need for a formal TAP and interfacing all the parties that could be potentially involved in a rescue. Determination of legal liabilities, extension of insurance coverage of surgical procedures outside the operating room, and other concerns for each region would dictate the TAP for each region.
In summary, the LIMB mnemonic is intended as a helpful last-minute guide or beginning step for an EMS team to develop their own TAP. It is our hope that either application will assist providers in their efforts to rescue our terminally entrapped patients.
References
Kampen K.E.
Krohmer J.R.
Jones J.S.
Dougherty J.
Bonness R.K.
In-field extremity amputation: prevalence and protocols in emergency medical services.
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
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