MD1 Response: Field Amputation

MD1 Response is a recurring update on interesting out-of-hospital cases experienced by on-scene EMS physicians. Submit your cases to md1admin@md1program.org.

A 36-year-old male was struck by a forklift while unloading a trailer, trapping his right leg under the wheels. A call to 9-1-1 brought law enforcement to the scene first. Officers noted a significant amount of blood loss and applied a tourniquet.

Paramedics and fire personnel arrived to face a challenging scene. The patient was tachycardic but otherwise stable. Extricating him would be logistically challenging, given the equipment entrapping him and confined space in which he was situated. To add to the challenge, it was a hot summer day with temperatures exceeding 90°F. This posed the additional risk of heat exposure to both the patient and rescue personnel.

Rescuers made multiple attempts, first utilizing simple extrication techniques, followed by airbags, but their efforts were unsuccessful. In the interim the patient was becoming more tachycardic.

Given the complex scenario, concern for ongoing hemorrhage despite the tourniquet, and possible need for field amputation, rescuers requested an MD1 physician. The physician arrived to find the patient alert and responding appropriately but tachycardic, with a heart rate in the 120s. The complex entrapment limited further examination, but it appeared the patient’s primary injury was the entrapped right leg. The MD1 physician assumed medical control, established large-bore intravenous access, and administered fentanyl for pain control.

Critical Decision

The critical decision facing the team was whether to proceed with amputation. Having a physician on scene allowed full appreciation of the entrapment and extrication challenges faced by EMS and fire personnel, which can be difficult to relay to online medical control. The team decided to try to salvage the limb by continuing advanced extrication techniques, with a defined endpoint at which the physician would proceed with amputation. The physician continued to administer fentanyl for pain.

When the agreed-upon endpoint was reached without successful extrication, the doctor administered moderate sedation using ketamine and prepared for amputation. However, with the patient sedated, fire personnel were able to extricate him, averting the need.

The patient was packaged into an ambulance and transported to a rendezvous point for helicopter transport to the nearest Level 1 trauma center. En route the physician assessed for further injuries by performing a FAST (focused assessment with sonography in trauma) exam using a portable ultrasound machine and administered low-titer group O whole blood, given the patient’s ongoing tachycardia and blood loss at the scene.

The patient arrived at the trauma center in stable condition and underwent numerous lower-extremity surgeries. Ultimately the surgical team salvaged his limb.

Discussion

Field amputation is a rare but time-critical and potentially lifesaving procedure. Authors led by Michigan emergency physician Kathryn Kampen, MD, found only 26 occurrences in a five-year period in their survey of EMS medical directors in major metropolitan centers in North America.¹ Cases where field amputation may be required include building collapses, motor vehicle collisions, and industrial accidents. Prominent U.K. traumatologist Keith Porter describes a simple approach to the procedure,² and he and colleague Caroline Leech report, through a cadaveric study, which technique may be most effective and safe.³

Unfortunately, due to its low frequency, many EMS agencies may lack appropriate protocols for field amputations. University of Missouri investigators identified that of 132 publicly accessible EMS protocol sets, only 6% provided amputation protocols.⁴

We argue the very fact that this need is rare and often requires intense resource application demands a protocol be in place and regularly practiced. Responding personnel could include dedicated EMS physicians such as in the MD1 program. In lieu of an EMS physician response program, agencies are recommended to liaise with surgical, emergency medicine, and anesthesiology personnel at their receiving facilities to ensure they can respond if required and, importantly, that their safety is ensured, given they may not have experience working in the prehospital environment.

In our case the MD1 physician was trained and prepared to perform a field amputation, although it was ultimately unnecessary. Nevertheless, having a physician on scene conferred many advantages, including the ability of the physician (who had assumed medical control) to appreciate the scene’s complexity firsthand; providing experience-based decision-making for when and how to proceed with amputation (in this instance by placing a time limit on further extrication attempts and closely monitoring the patient’s physiology); and supporting and assisting the actions of medical and fire personnel with advanced techniques including pain control and sedation.

The early activation of the MD1 EMS physician, along with decisive decision-making and teamwork, allowed for a good outcome in this case. This represents another example of how a dedicated prehospital physician response system can augment the excellent care of nonphysician prehospital personnel. 

References

1. Kampen KE, Krohmer JR, Jones JS, Dougherty JM, Bonness RK. In-field extremity amputation: prevalence and protocols in emergency medical services. Prehosp Disaster Med, 1996; 11(1): 63–6.

2. Porter KM Prehospital amputation. Emerg Med J, 2010; 27(12): 940–2.

3. Leech C, Porter K. Man or machine? An experimental study of prehospital emergency amputation. Emerg Med J, 2016; 33(9): 641–4.

4. Emmerich BW, Stilley JAW, Sampson CS, Horn BG, Pollock KE, Stilley JD. Prehospital amputation: an experimental comparison of techniques. Am J Emerg Med, 2019; SO735-6757(19): 20614X [epub ahead of print].

Bryant Gray, DO, is an emergency physician with RWJBarnabas Health in New Jersey.

Dustin St. George, MD, is an emergency physician with RWJBarnabas Health in New Jersey.

Navin Ariyaprakai, MD, EMT-P, FAEMS, FACEP, is an EMS physician for the MD1 program and program director for the EMS and disaster medicine fellowship as well as core faculty for the emergency medicine residency at Newark Beth Israel Medical Center.

Ammundeep Tagore, MD, MSHA, MBA, FAAEM, FACEP, is associate program director of the EMS and disaster medicine fellowship and core faculty for the emergency medicine residency at Newark Beth Israel Medical Center, as well as serving as a physician and on the board of directors for MD1.

Zaffer Qasim, MBBS, FRCEM, FRCPC(EM), EDIC, is an assistant professor of clinical emergency medicine at the University of Pennsylvania.

Josephine V. Geranio, BS, is administrative assistant to Mark Merlin and the MD1 team and continues to work in the ED.