Is your rescue team prepared for a field amputation?
Activating the surgical team: A low-frequency, high-risk emergency procedure in the field
Did you read this news story: Ala. rescuers amputate man's leg to free him after tornado?
The account is a gripping tale of a five-hour rescue by paramedics, EMTS, police, firefighters, surgeons and nurses that included the field amputation of a man’s leg. After a massive oak tree, felled by an EF-3 tornado, trapped Arnoldo Vasquez-Hernandez in his home, rescuers determined the only way to free him from the entrapment was on-site trauma surgery.
I am grateful for the willingness of the patient to share his story and the rescuers to share the incident with us. I am also grateful for the excellent reporting that creates a training opportunity for all of us. The article is a must-read article for fire and EMS personnel, and the information contained could be discussed around the dinner table or during a training session. After reading the article, start by discussing these questions:
- What would we do if a patient was trapped and unable to be freed with available rescuers, tools and resources?
- How would we determine if a limb amputation was indicated to save the patient’s life?
- How would we notify or activate a trauma surgical team?
As you read and discuss the article, here are a few of my takeaways.
Field amputations are rare
Field amputations, to preserve life or what remains of a limb, are exceptionally rare in the U.S. Most of us will go our entire career without ever having to consider field amputation as part of our treatment plan, let alone request a trauma surgical team response to the scene.
Gordon Graham, a former police officer, lawyer, risk management expert and Lexipol co-founder, would classify a field amputation as a low frequency, high risk incident in his four-quadrant classification for categorizing incidents. Because field amputations are rare, we must prepare for them through training and pre-planning, especially with response partners.
High-risk for the patient, field personnel and hospital personnel
Obviously, entrapment, crush injury and blood loss put Vasquez-Hernandez at high risk for death and severe injury, but it is also worth considering the danger the scene presented to others. The patient was trapped in his tornado-damaged home, underneath a huge tree, with significant uncertainty about the stability of the structure. The scene was never safe, but rescue personnel took action throughout this incident, as they would at any incident to make the scene safer by:
- Donning all appropriate PPE – helmet, gloves, eye protection, respiratory protection and puncture/abrasion resistant clothing.
- Restricting access to the scene to minimize the risk of the structure further destabilizing, further injuring the patient or putting rescuers at additional risk of injury.
- Determining a treatment plan, regularly reassessing the effectiveness of the treatment plan and adapting the plan as necessary.
Rescuers, already challenged with ensuring their own safety, had the additional responsibility of minimizing the risk of injury to the trauma surgical team, who had to climb through the rubble pile to reach the patient and then perform a surgical procedure in conditions vastly different than an operating room. Bringing in hospital-based providers means bringing in people who are likely unfamiliar with incident operations and working within the incident command system or a hierarchical rescue team.
Patient care considerations
Use this incident as an opportunity to discuss, review protocols or conduct high-fidelity patient simulations on crush injury treatment, the trauma triad of death – hypothermia, coagulopathy and acidosis, and control of severe bleeding. Additionally, most EMS incidents are resolved quickly. Discuss prolonged patient care demands like:
- Patient monitoring and vital sign tracking over several hours
- Rotating rescuers into and out of the scene
- Providing hands-on care when parts of the patient’s body are inaccessible
- Communicating to the patient about the treatment plan, status of the rescue, words of encouragement and consent for surgery
- Informing the patient’s family about rescue efforts and patient condition – in an incident like this one and if resources allow, assigning a liaison to care for the patient’s family, to receive and relay updates to the family, and help the family plan their next steps makes sense
Early notification of the trauma surgeon? It depends.
The answer to the question, “When should we request a trauma surgeon for a field amputation?” will almost always be answered with, “It depends.” The patient’s condition, availability of rescue resources, the probability of successful extrication, distance from the hospital, weather, structural conditions, risks to the patient and providers, and other variables are likely part of the decision. In this incident, rescuers called for surgical help “after about two hours” and it took another “couple of hours” to assemble a team and get the team to the incident.
For the surgical team, response isn’t as simple as racing to the scene in a personal or hospital vehicle. The surgical team needs to pick a response team from available staff; assemble surgical supplies, including medication, tools and blood; and determine if the team will travel by air or ground. While preparing to leave, the surgical team is likely receiving field reports and advising the on-scene paramedics on airway management, sedation and pain control in preparation for surgery. Planning should also include who will accompany the patient after the field amputation as it is unlikely that the full team is riding to the hospital with a paramedic in the patient care compartment.
During an incident with prolonged patient care and the potential for field amputation, early notification should also include activating the department’s:
- Public information officer to brief the media; post messages to the department’s social media channels; and field in-incident and post-incident media requests to interview the patient, patient’s family, rescuers and hospital personnel
- Mental health response for rescue personnel, including assets like a department chaplain or counselor, for post-incident availability to small groups or individuals. It is also important to remind all personnel about the availability of a peer support team and how to reach the department’s employee assistance program; and to implement comfort care measures like a therapy K-9 or bringing in off-duty personnel to cover the remainder of the shift for rescuers.
Learn more about field amputation
- Exclusive: Field amputation difference between life and death
- University of Utah Hospital develops emergency field amputation guidelines
- Firefighters use new field amputation team to save worker
- Field EMS Physician Limb Amputation Training and Guidelines from the Medical College of Wisconsin
- Field Limb Amputations Used as an Extrication Option in Complicated Entrapments or Disaster Events