The patient was then able to be pulled from the machine and placed on stretcher. The patient was given additional ketamine for sedation during the second amputation. The wound was bandaged with compressive dressings.

The patient was then transported by AirCare to the Level 1 trauma center nine minutes away. A physician team member flew with AirCare to continue patient care. Upon arrival, the awaiting trauma team did an initial primary and secondary survey, and the patient was taken to the OR emergently for washout and ligation of vessels. It was noted by trauma surgery that the patient had several traumatic fasciotomies from the initial injury that required the amputation to be extended several inches higher. Postoperatively, the patient had a good recovery; however, needed several more surgeries for washout and reconstruction.

Discussion

Performing a field amputation is an extremely rare and heroic procedure, but one that emergency physicians should be familiar with. There are limited data published on field amputation and the majority is anecdotal. In 1996, a survey was sent to 200 U.S. metropolitan EMS agencies regarding field amputation. Out of the 143 agencies that responded, only 26 amputations had occurred during a five-year period. The procedure was performed by a trauma surgeon in 53 percent of cases, emergency medicine physician in 36 percent of cases, and paramedic in 14 percent of the cases. There was no formal training and only two of the systems had an existing protocol.

Generally accepted indications:

• Unstable patient
• Unstable environment
• Relatively stable patient (after resuscitation), stable environment
• Stable patient, stable environment (prolonged extrication)

The first two indications are more straightforward and would fall under emergent consent. The second two indications typically would require more discussion of risk/benefits/alternatives, and this may be more difficult, especially after giving analgesia. Discussion with another provider if possible is recommended. In our case all three physicians, as well as air crew and fire rescue on scene, agreed amputation was necessary.

Equipment Needed

• Monitor for sedation
• RSI/sedation/analgesic medications
• If possible, blood products for transfusion
• Saline or lactated ringers
• Tourniquets (x2)
• Sterile gloves, towels, drapes
• PPE: eye protection, mask, gowns, gloves
• ABD bandages, gauze, laparotomy pads, Ace wraps, and Kling
• Sterile scalpel, scissors, hemostats, Kelly clamp
• Betadine/chlorhexidine
• Gigli Saw or battery powered hand saw

Procedure

1. Prepare monitor, dawn PPE, sedate patient
2. Brief time out so team is ready
3. Place tourniquets (if not already)
4. Identify site as distal as possible
5. Prep site with betadine or chlorhexidine
6. Drape with sterile towels/sheets
7. Using scalpel cut soft tissue circumferentially down to bone
8. Use hemostats to ligate any bleeding vessels
9. Use two sterile towels to wrap around bone and pull in opposite directions to create a soft tissue window to the bone
10. Use saw to cut bone
11. Irrigate wound and apply sterile dressing and compressive wrap
12. If possible, obtain amputated limb, wrap in moist sterile dressing, place in bag, and place on ice

Todd Burgbacher, DO, FACEP, is an emergency medicine specialist practicing emergency medicine in Augusta