Preparation and planning will only take you so far. But then, you actually have to act. This procedure has four phases. I’ll break them down one by one.

Patient preparation. The area should be shielded from curious onlookers and to control any airborne contaminants (dust, debris) at the scene. Portable monitors should be attached. Ensure good IV/IO access, and control the airway via intubation. Provide adequate anesthesia, analgesia, and sedation. In addition to pain medication, consider broad-spectrum antibiotics, and give the “life-saving” tetanus toxoid at some point. It can wait until the patient arrives in the ED.

Limb preparation. Expose the extremity, especially the entire area around the amputation site. Wash gross debris off with saline. Place a tourniquet at least 2 inches proximal to the amputation site so it does not interfere with the procedure. Do not tighten until ready to begin. Then prep with Betadine or other antiseptic.

The amputation. If not already done, administer anesthesia and tighten the tourniquet. Choose an amputation point as distal as practical to preserve as much future function as possible. Generally speaking, a guillotine amputation is performed; nothing fancy here. Use large blades on the skin, and have plenty of extra blades. The blades will likely get dull quickly in the scene environment. Cut through muscles next, saving the neurovascular bundles until last. These tend to retract when cut, so it is recommended to tie them off first.

Identify the spot where the bone will be cut, and scrape away the periosteum with the scalpel blade. Use an appropriate saw to actually separate the bone. Battery-powered hand-held saws are convenient and reduce the work. However, they may not readily fit into the space available, so a flexible wire (Gigli) saw may be preferred.

Always assign someone to monitor the patient during the procedure. They need to ensure everyone is aware of any adverse changes in vital signs so proper adjustments can be made.

Once the amputation is complete, inspect for bleeding and clamp anything that is still bleeding. Suturing and tying may not be possible due to space limitations, so leaving the clamps in place works just fine. Then apply a bulky, compressive dressing, and get out of the way so EMS providers can do their thing.

The aftermath. Once the patient has been extricated, double check the patient’s ABCs. Make sure the airway is well-placed and secure, or provide one now. Ensure adequate ventilation, and double-check for any bleeding from the amputation site or anywhere else. Then get the patient to definitive care so the trauma team can get to work.

But wait, what about the amputated part? If possible, it should be “dry-packed” in ice (remember the old bag within a bag?) and sent with the patient or soon after. Have you ever wondered why we do that? There is no hope for reimplantation, even if the amputation went flawlessly. There is little real return of function for extremities amputated above the fingers/toes. However, we can use skin and soft tissue from the lost part to help reconstruct the lost limb.

Click this link for a bibliography for this series.

Bottom line: This is a complex topic, and the process has lots of moving parts. If I have inadvertently left something out or you have your own experience to share, please comment or email. I would love to hear it! 

We’ve covered all the preparation for field amputation. Now, it’s time to do it! But wait, exactly what equipment is needed? Follow two principles: plan everything 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 should be conveniently located, include fresh instruments and batteries, and contain essential anesthetics. I have included a link to a sample equipment list at the end of the newsletter, and I encourage you to download and modify it to suit your needs.

Paralytics, sedatives, and analgesics are essential. I prefer vecuronium, midazolam, and fentanyl (simple), 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 should be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Ketamine is a good drug in cases where intubation is not possible. Finally, don’t assume that the patient will be conveniently 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 the backup surgeon needs to be mobilized!

Click this link to a sample equipment list.

The next and final post will review the field amputation procedure.

Now it’s time to look at the logistics involved in carrying out a field amputation/dismemberment. There are two main considerations here: getting the right people and equipment to the scene and keeping them safe. The following assumes the procedure will be done by a physician based at a 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? For emergency physicians, there are generally several on duty, so one will not be missed too much. For surgeons, it’s a bit different. Other surgeons may be available in the hospital during the daytime, although they may have other responsibilities keeping them busy. At night, it becomes much more of an issue, as there may be only one surgeon (or ED physician, for that matter) available for the hospital. They will probably be unavailable for several hours once they are involved in the field amputation process.

The easiest solution is to utilize the backup trauma surgeon. All Level I and II centers must have one available within a “reasonable” time frame, typically 30 minutes. There are two possibilities: the in-house trauma surgeon leaves, the backup proceeds to the hospital for coverage (if in-house is required), or the backup surgeon is transported to the scene, leaving the on-call surgeon to manage as usual.

The choice is up to the trauma center, but this issue needs to be considered in advance. The best solution depends on geography. 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, consider the nearest safe landing zone, which may mean an out-of-house surgeon must travel to the hospital for pick-up.

Once on scene, the physician must ensure the incident area is safe. This is important for the well-being of the patient and the rescue crews. If the scene cannot be made safe, it is impossible to render care, even if the patient is in grave trouble.

Bottom line: Each trauma program and EMS agency 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.

The next post will review the equipment needed for field amputation.