Field Amputation for Trauma, Part 4
We’ve covered all the prep for field amputation over the past 3 days. Now, it’s time to do it. What equipment is needed? There are two principles: figure it all out in advance, and keep it simple.
It is crucial that the trauma program design and assemble equipment and drug packs in advance, otherwise critical equipment may not make it to the field. The pack needs to be conveniently located, have fresh instruments and batteries for the equipment, and should have essential anesthetics included. A sample list is available here, and I encourage you to modify it to suit your needs.
Paralytics, sedatives and analgesics are essential. I prefer vecuronium, midazolam and fentanyl, but there are many other choices. I would discourage the use of propofol because it is difficult to titrate outside the hospital and may contribute to hypotension.
The patient must be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Finally, don’t assume that your patient will be nicely positioned supine. Rescue workers may need to support the patient (or you) if he or she is in an awkward position.
Finally, don’t assume that you will accompany the patient (and possibly their limb) back to the hospital. Based on the specific aircraft used, there may not be room available. You may return by ground transportation or another aircraft. That’s why your backup surgeon needs to be mobilized!
We’ve discussed the numbers behind and indications for performing field amputation for trauma. Now it’s time to look at the logistics. There are two main considerations here: getting to the scene, and staying safe.
Getting there includes an obvious problem: what happens when the trauma surgeon leaves the hospital? During the daytime, other surgeons may be available, although they may have elective procedures or other tasks to keep them busy. At night it becomes more of an issue, as they may be the only surgeon available for the hospital. Once involved in the field amputation process, they may be unavailable for hours.
The easiest solution is to utilize the backup trauma surgeon. All Level I and II centers must have one. There are two possibilities here: the trauma surgeon leaves and the backup proceeds to the hospital for coverage (if in-house), or the backup surgeon is transported leaving the on-call surgeon to manage as usual.
The choice is up to the trauma program, but this is an issue that needs to be thought out in advance. The best solution takes geography into consideration. Since most transports to the scene will be made by helicopter, it is easier to use the trauma center’s helipad to pick up the on-call surgeon. If an in-house surgeon is not used, consideration must be given to the nearest safe landing zone and this may mean that an out-of-house surgeon would have to travel to the hospital for pick-up.
Once on scene, the surgeon must ascertain that the area of the incident is safe. This is important for the well being of the patient, the rescue crews and the patient. If the scene cannot be made safe, it is not possible to render care, even if the patient is in grave trouble.
Bottom line: The trauma program must think through these details in advance and develop a policy for who goes to the seen and how. And safety for all is of paramount importance.
Tomorrow I’ll discuss equipment and drugs needed for this procedure.
Yesterday I discussed how uncommon field amputation is, despite all the potential drama. Today, I’ll review the indications for performing it.
There are basically four indications, two absolute and two relative:
- Absolute #1: entrapped extremity with a lengthy extrication and a physiologically impaired patient who does not respond to fluids. In this case, there is occult blood loss into other areas that is killing your patient and they need to get out quickly for definitive management.
- Absolute #2: entrapped extremity with a lengthy extrication and an unstable physical environment. Examples include entrapment in a structurally damaged building or a vehicle in danger of falling.
- Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. It is possible to wait for additional extrication efforts, but vital signs must be monitored closely. At the first sign of recurrent hypotension, it’s time to amputate.
- Relative #2: entrapped extremity and physiologically normal, but extrication may take many hours or may be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time that passes, the less likely the extremity will ultimately be functional.
Obviously a lot of thought and judgment goes into making the decision amputate. It is helpful to have another physician to discuss the facts with, but as the treating surgeon, the ultimate decision is yours.
Tomorrow, I’ll talk about the logistics of getting to the scene of the potential field amputation.
Field amputation is not thought of very often, and for good reason. It is unpleasant, uncommon, and not very safe. I’m going to spend the next few days on this topic, starting with some of the facts.
In reality, field amputation is talked about much more often that it is actually performed. There is one old paper that is cited frequently which consisted of a survey of EMS directors 19 years ago! A total of 143 people responded and noted the following:
- There were 26 amputations over a five year period
- The most common mechanism was motor vehicle crash
- 53% were performed by a trauma surgeon and 36% by an emergency physician. (Who did the other 12%???)
- No training was available for this procedure
- Only 2 EMS systems had an existing protocol
An informal poll of trauma surgeons at the recent American College of Surgeons meeting in San Francisco showed that only 5 had ever been called to do a field amputation, and only 2 had actually done it.
Uncommonly performed procedures are always problematic. It is extremely difficult to keep skills sharp and to remember the protocol (or even where to find it). Furthermore, these procedures are prone to error and pose considerable risk to all.
Reference: In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehospital and Disaster Medicine 11(1):63-66, 1996.