Industrial Entrapment

     Attack One responds to a report of a person "trapped in a machine." The call is at a familiar factory that produces soap. It's a large facility, with a number of machines that mix raw materials, add fragrances and coloring materials, then compress and cut the products. Typical calls here involve slips and falls in the mixing areas. But on this arrival, the crew is directed to the compressing and cutting area of the plant.

     Security guides the crew to a machine area where several employees huddle awkwardly around a male whose left arm is not visible. The area is about 20 feet above the factory floor. The workers are on a small ledge up a narrow ladder. The trapped man is in extreme pain.

     A supervisor on the floor gives a quick report: The worker was attempting to clear a machine that moves soap through the finishing process. This part of the machine, similar to an auger, compresses and pushes the soap product through a narrow tube. It's a high-pressure machine that uses a piston-type device to pull and rotate. The diameter of the tube is just a little larger than the man's arm.

     The Attack One crew agrees to split up, with one member to climb up and assess the patient, one to develop an action plan with factory experts, and one to serve as Command. A complete rescue and extrication response is en route, including the technical rescue crew that serves the region.

     The crew member assigned to patient assessment ensures that it's safe to climb, then ascends. The patient is a healthy man, but is in extreme pain, with his left arm up to the shoulder in the machine. He says he's trapped just below the elbow, and feels the arm is crushed through the bones.

     The machine is shut off, and the safety switching won't allow it to accidentally restart. The workers are standing on a small platform that accommodates just three people. The worker is close to passing out from pain, and there's not enough space to lie him down or support him upright. There is no indication of significant blood loss, but the crush injury is incredibly painful, and the patient cannot move any portion of his upper arm.

     On the factory floor, the plant supervisor briefs other members of the extrication team. He says this machine can't be put into reverse, and the man's arm has jammed the drive mechanism. The machine shut itself off and can be restarted, but will only pull further on the arm. The tube encasing the arm cannot be cut or bent. There is, however, an outer housing on the machine, and by cutting that open, the crews could have more room to work and likely see the arm down to the elbow.

     Command has been established, and the immediate priorities are controlling the man's pain and creating a better workspace to manage him. Attack One crew members get immediate supplies up to the paramedic working with the patient, and an intravenous line is established, pain medication is started, and the patient is given a cold, wet towel to place on his forehead to reduce his nausea and try to prevent a syncopal episode. The paramedic suggests that a larger platform be built at an elevation where the patient can lie down. The man has stable vital signs, but could collapse at any point from pain, and there's not enough space for people to hold him up.

     Command works with the factory supervisor to quickly arrange for a platform to be built. They will work with the rescue team to use a hydraulic lift, some lumber and metal bands to construct it. The paramedics suggest that a cot from the plant's clinic area serve as a stretcher.

     There is a quick discussion among the leaders of the Attack One crew, the technical rescue crew, Command and the factory supervisor about the management plan. There is only one way to remove the patient from the machine: to complete the amputation of his arm. The patient, familiar with his machine, had actually suggested this to the paramedic, and asks only that the process be done quickly. He would like to be put to sleep if possible. Command asks for the consent of the entire team that this is the only option for removal, and each of the leaders (and the patient) agrees. The plan includes these elements:

• Build a work platform to accommodate the patient and enough people to provide care;
• Have the extrication team cut open the machine housing to give a surgical crew access to the patient's arm;
• Have a cot brought up and placed so the patient can be laid down;
• Have enough medical equipment and airway gear available to put the patient to sleep to perform the extrication;
• Be able to manage the patient immediately after the amputation is done, and the amputated arm once it can be removed from the machine.

     The Attack One crew contacts the local trauma center to request a team to perform a field amputation. The hospital has a protocol for this, and quickly pulls together the necessary tools, medications, supplies and surgeons. An ambulance is dispatched to pick them up.

     The surgical team arrives at the plant at about the same time the platform is completed and secured to the side of the machine. The housing around the core of the auger is peeled away, and the two-man surgical crew climbs to the patient. The Attack One paramedics work with the surgical team to sedate him. The extrication crew prepares to lower the victim to the floor once he's freed, and the transport unit prepares inside the plant. A second ambulance readies to receive the amputated lower arm.

     A tourniquet is applied just above the site, a surgical amputation is performed, and the victim is freed. The patient's arm is secured in a sling, and he's quickly packaged for removal to the hospital. When the auger is flipped, the lower arm and hand are found to be intact. The amputated extremity is preserved and sent to the hospital.

Hospital Course
     On arrival in the ED, the patient is assessed by the emergency physician and surgical team. He is stable. When the arm arrives, it's in extraordinarily good condition. The surgeons decide to reattach it, and the patient is moved to the operating room. While the initial surgery is successful, the reattachment ultimately doesn't take, and the man loses his lower arm.

Case Discussion
     EMS providers should be prepared for complex operations in industrial settings. Managing ill or injured workers at such work sites often requires cooperation with people knowledgeable about their specialized machinery, facilities, hazards and safety measures. Emergency crews should strive to include these workers, supervisors, engineers and/or managers in developing management plans.

     Injuries with trapped extremities are not uncommon. This was an unusual case in that the extremity could not be freed, and had to be amputated. As EMS providers in agricultural communities know, farm equipment is a much more common culprit in these kinds of cases. Extremity entrapments can also occur from motor vehicle crashes, building collapses and recreational mishaps. There have been cases of persons amputating their own extremities to save their lives.

     Trapped and crushed extremities typically aren't actively bleeding. Crushing forces damage deep compartments of the extremity, usually compressing the blood vessels. Pain is typically very severe, and can be so intense that the victim has a vagal reaction, resulting in a very low pulse rate and blood pressure, and ultimately passing out. Rescuers should be prepared for this. Pain control during extrication will allow a little more time for planning the removal, and offers merciful relief for the patient as the extrication is performed. It is helpful to use some simple ancillary tools to further assist in pain control, like careful positioning of the patient and the extremity, use of ice packs, and cold towels to the face.

     Prior arrangements for these unusual events should be made with local trauma centers and, in some areas, air ambulance crews. A developed protocol assists in timely response to a request for field amputation.

Learning Point: The industrial setting is frequently a challenge for EMS and rescue personnel. Injuries and illnesses may be dramatic. The setting may be unstable. EMS personnel need to be good listeners and welcome the input of work supervisors and coworkers. In some circumstances, these workers should be enlisted for physical assistance or to operate machinery.

Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.