Preparation and planning will get you just so far. But then, you actually have to act. There are four phases in this procedure. 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. Good IV/IO access needs to be in place, and the airway controlled via intubation. Adequate anesthesia, analgesia, and sedation must be provided. In addition to pain medication, broad-spectrum antibiotics should be considered, and tetanus toxoid given at some point.

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 that has not been 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. It is likely that the blades will 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 that they be tied 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 ensure that someone has been assigned to monitor the patient during the procedure. They need to ensure that everyone is aware of any adverse change in vital signs so that proper adjustments can be made.

Once the amputation is complete, inspect for bleeding, clamping anything that is a problem. It may not be possible to suture and tie given space limitations, so leaving the clamps in place works just fine. Then apply a bulky and compressive dressing, and get out of the way so the 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.

We’ve covered all the preparation for field amputation. Now, it’s time to do it! But wait, exactly what equipment is needed? There are two principles that you must adhere to: 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. I have included a link to a sample equipment 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, 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 presumes that the procedure will be done by a physician who is 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 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 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.

Various trauma professionals (prehospital, emergency physician, surgeon) may provide this “service” at various places around the world. In the US, it is usually a physician and typically a surgeon. In my opinion, anyone can be trained to do a basic field amputation.

Much depends on local policies and procedures, training, as well as availability. In most cases, prehospital providers are on the scene, so it makes sense that they could do a field amputation with appropriate training. Emergency physicians have more experience with airway management, sedation, and anesthesia and can thus add value to the process.

But again, in my opinion, a trauma surgeon is the best choice for performing this procedure. They have the technical skills and are usually facile with anesthesia and sedation. However, they also have a deep understanding of the anatomy involved and the eventual reconstruction process. This allows them to tailor the amputation to optimize the eventual recovery from this operation. The surgeon does not necessarily have to resort to a guillotine-type amputation. And they are better versed in performing amputations that involve the upper extremity, as well as more proximal amputations (shoulder, upper thigh). And if unexpected bleeding occurs that cannot be controlled by a tourniquet, they know what to do.

The only downside to using a physician is availability. Getting them to the scene will always take extra time since they are typically hospital-based. In contrast, the prehospital providers are already present and are used to working in an austere environment.

Bottom line: There is no cookbook for developing a field amputation policy and procedure. Look at your local resources and the logistics imposed by the environment, traffic, hospital, and other factors. Then figure out what works for you. Borrow from other centers and agencies, and make the process as simple as possible. Due to the very rare need for field amputation, you will need to periodically review the process and the location of your packs so people don’t forget.

In my next post, I’ll cover the challenging logistics of field amputation.

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 in 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, exploding, etc.
• Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. Waiting for additional extrication efforts is possible, 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 be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time passes, the less likely the extremity will ultimately be functional.

Obviously, a lot of thought and judgment goes into deciding to amputate. Having another physician to discuss the facts with is helpful, but as the treating trauma professional, the ultimate decision is yours. If appropriate, there may also be an opportunity to discuss with the patient and/or their family.

In the next post in this series, I’ll discuss who performs the field amputation.