Field amputation is not thought of very often, and for good reason. It is unpleasant, uncommon, and not very safe for trauma professionals due to the austere environment. I will dedicate the next several posts to the topic, starting with some of the facts.

First, let’s start with definitions. Two distinct procedures are discussed here.

The first and most commonly described is field amputation. This is the removal of a body part in a living person to extricate them from a situation in which all other attempts have failed.

The other procedure is field dismemberment. This is the surgical alteration of a dead body to extricate another living person who is entrapped, where there is no other route of egress. This is less taxing, both surgically and psychologically, for all involved. For this reason, I’ll focus on field amputation for the rest of this issue.
In reality, these procedures are discussed much more often than performed. And there are far more papers written than actual documented cases. There is one old paper that is cited frequently which consisted of a survey from 1996! A search of the literature at that time only yielded two case descriptions.

In the 1996 study, surveys were sent out to EMS directors in North America’s 200 largest metropolitan areas. A total of 143 directors responded.

Here are the factoids:

• There were 26 amputations performed over a five-year period
• Nine additional cases were identified where it was believed that the procedure was indicated but not performed
• The most common mechanism was motor vehicle crash (27%), followed by industrial machinery (23%)
• 53% were (or would have been) performed by a trauma surgeon, 36% by an emergency physician, and a paramedic in 14%. Five respondents had no idea who would do it. (More than one choice was possible, hence total is > 100%)
• No training was available for this procedure, although a few had training on how to deal with the amputated part
• Only 2 EMS systems had an existing policy or protocol (1%)

An informal poll of trauma surgeons at a national American College of Surgeons meeting several years ago showed that only five had ever been called to do a field amputation, and only two had actually done it.

Uncommonly performed procedures are always problematic. It is extremely difficult to keep skills sharp (pun) and to remember the protocol, equipment, and where to find them. Furthermore, these procedures are prone to error and pose considerable risk to all involved

And if there are no policies or guidance, it is possible that the procedure may actually not be done in cases where it should. Therefore, effective policies must be put in place to accomplish these five things:

1. Define situations where in-field amputation may be necessary
2. Notify online medical direction of possible need for amputation
3. Notification and mobilization of the appropriate physician
4. Transport of the response team and equipment to the scene
5. Transport of the patient to the appropriate receiving facility

In the next post, I’ll review the indications for field amputation.

Reference: In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehospital and Disaster Medicine 11(1):63-66, 1996