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. The following presumes that the procedure will be done by a physician who is based at the trauma center. It will be different if performed by other trauma professionals.
Getting there includes an obvious problem: what happens when the physician leaves the hospital? During the daytime, others may be available, although they may have other responsibilities to keep them busy. At night it becomes more of an issue, as they may be the only surgeon or ED physician available for the hospital. And 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 in-house 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 center, 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 physician 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: Each trauma program must think through these details in advance and develop a policy for who goes to the scene and how they get there. 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 trauma professional, the ultimate decision is yours.
Monday, 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 for trauma professionals due to the austere environment. 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 are far more papers written on it than actual documented cases. There is one old paper that is cited frequently which consisted of a survey of EMS directors 19 years ago! A total of 143 directors responded.
Here are the factoids:
- 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 an American College of Surgeons meeting a few years ago 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.
Tomorrow, I’ll dig into the indications for performing a field amputation.
Reference: In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehospital and Disaster Medicine 11(1):63-66, 1996.
I’m going to be revisiting my series on field amputation over the next few days. We will be reviewing our own policies and procedures regarding this topic at the trauma operations committee here at Regions Hospital.
I’d like to query my readers, all of you trauma professionals out there in any discipline. Who is qualified to perform this procedure? What special training is required? Can it safely be done by an emergency physician? A paramedic? A nurse? I’ve reviewed quite a bit of the literature. But as we all know, research and reality don’t always coincide. And I’m particularly interested in responses from my international readers.
Please take a moment to email or leave comments below. I’ll compile them over the next few days and publish a compendium next week. Thanks!
All trauma professionals are aware of the evils of anticoagulation in patients who sustain traumatic brain injury. Warfarin is one of the most common anticoagulants encountered, but there is also a growing number of poor outcomes in patients with the newer, non-reversible agents.
But what about antiplatelet agents like aspirin and clopidogrel (Plavix)? Many physicians worry about these drugs, but is it warranted? Two Level I trauma centers in the Chicago area reviewed their experience. They retrospectively reviewed the records of patients over 40 years old who sustained blunt head trauma. A total of 1547 patients were identified over a 4 year period. They analyzed these records for in-hospital mortality, need for neurosurgical intervention, and length of stay.
Here are the factoids:
- 27% of patients were taking antiplatelet agents. Patients also taking warfarin were excluded.
- 21% were taking aspirin alone, 2% clopidogrel alone, and 4% both drugs
- Patients taking the drugs averaged about 10 years older than those who were not
- Overall, injury severity was relatively low (average ISS 10). A disproportionate number of more severely injured patients were not taking antiplatelet agents.
- There was no difference of incidence of intracranial hemorrhage (45%), neurosurgical intervention (3%), or mortality (6%) between the two groups
- Hospital length of stay averaged about 6.5 days, but long LOS was a bit more common in the antiplatelet agent group.
Bottom line: This is one more in a series of papers scrutinizing trauma and antiplatelet agents. A few previous studies have shown an adverse effect, but they have been much smaller series. I don’t believe the jury is in yet, so watch these patients carefully. A 6 or 12 hours repeat scan is probably in order, along with frequent neuro monitoring. It’s probably not worthwhile to actively try to reverse them by giving platelets unless there is obvious life-threatening hemorrhage or sudden neurologic change (see below).
Reference: Outcomes in traumatic brain injury for patients presenting on antiplatelet therapy. Am Surg 81(2):128-132, 2015.