In the prehospital setting, field amputation is a low-frequency, high-risk event. Although typically utilized in disaster scenarios, field amputation must be considered in the management of severe injuries from motor vehicles collisions, industrial accidents and agriculture mishaps.1
Special considerations for non-disaster scenarios include utilizing industrial workers and agricultural machine specialists for assistance, and the augmentation of amputation with tourniquet application.2-4
Authors of one of the earliest evaluations of prehospital field amputation in 1996 found that the majority of EMS agencies didn’t have a protocol addressing prehospital amputation, and that prehospital personnel weren’t being instructed on the potential needs for field amputation.5
The development of protocols should focus on the timely notification of the field amputation team, the method of transporting the field amputation team and destination decisions following amputation.5
EMS personnel also need to be educated on the indications for field amputation, how to assist in the procedure, and how to manage potential complications of the entrapment and amputation.5
Surgeons are the most qualified personnel to perform amputation, but they should be educated on prehospital emergency operations, particularly the incident command system.5
A 2009 report from Dallas described the city’s surgical emergency response team’s experience with a field amputation protocol; they saw about 3-4 activations per year with a total of nine amputations performed.6 Three clinical scenarios in which field amputation was performed with successful rescue and clinical outcomes were also described. Based on their experiences, the authors of the report suggest field amputation teams are an important component of EMS systems.
Discussions regarding field amputation protocols in large, metropolitan EMS agencies exist,6 such as the Miami-Dade Fire and Rescue Field Surgical Kit/Amputation Protocol;1 however, literature is lacking regarding surgical emergency response teams for entire regions rather than specific EMS agencies.
The aims of this report are twofold: 1) to describe the Columbus Division of Fire’s (CFD) Surgical Emergency Response Team (SERT) protocol, which serves as a detailed operational guide for collaboration between large EMS systems and regional trauma centers; and 2) to describe the Fairfield County EMS Field Amputation Guide, which serves as a detailed guide for nonurban prehospital surgical emergencies.
Field amputation must be considered in the management of severe injuries from motor vehicle collisions, industrial accidents and agriculture mishaps.
CFD is the primary EMS provider for the city of Columbus, responding to approximately 130,000 calls requesting EMS per year. The CFD is an all-ALS system with over 700 paramedics, 32 ALS ambulances and 32 ALS engines.The city of Columbus, located in central Ohio, has an estimated population of 787,033 and is situated on 217 square miles. The population density is 3,624 persons per square mile. Columbus is located in Franklin County, which has an estimated population of 1,163,414.7
Columbus SERT Protocol
There are seven EMS officers who oversee EMS operations in their respective battalions. Non-Columbus regions of Franklin County are served by numerous fire-based, suburban EMS agencies.
Four healthcare systems serve Franklin County and operate 10 hospital-based EDs. Two of the hospitals are Level 1 adult trauma centers, and an additional two are Level 2 adult trauma centers. All four centers receive trauma patients from the region of central Ohio. A dedicated pediatric, tertiary care hospital operates a pediatric ED and a regional Level 1 pediatric trauma center.
Despite the rarity of field amputation, the need for a SERT protocol in our region was promulgated following an incident in which successful patient disentanglement was prolonged due to multiple factors.
The patient was a 25-year-old male who became trapped in an industrial mixer when he fell or was pulled into the mixer from above. This left him entangled in the mixing blades in a fashion infrequently encountered by rescuers. Although he was successfully extricated after 85 minutes, he required in-hospital amputation and extensive rehabilitation.
Through standard debriefing sessions and EMS quality review, the CFD determined that field amputation was a potential treatment option if protocols had been in place for such incidents.
In consultation with local trauma surgeons and the Central Ohio Trauma Systems (a regional conglomerate of EMS agencies and hospitals focused on trauma and emergency care), the SERT protocol was developed. (See Table 1.)
The two Level 1 trauma centers in Columbus are responsible for fielding a SERT, consisting of two hospital-based providers: the on-call trauma surgeon and either a trauma nurse, advanced practice provider or surgery resident.
An on-call schedule for SERT activation is published yearly by the CFD, with each Level 1 trauma center alternating between first-call and second-call on a monthly basis. Only EMS officers specially trained in advanced clinical care and EMS operations are permitted to activate SERT-never paramedics or other EMS personnel.
Indications for SERT activation include situations requiring emergency amputation, entrapment with uncontrolled massive hemorrhage, or situations where emergency administration of blood products is required.
The Fire Alarm Office (FAO) is the emergency dispatch center for CFD, but also serves adjacent EMS agencies within Franklin County. The FAO maintains the SERT on-call schedule and a direct telephone line to each ED in the city. In the SERT protocol, the direct telephone line is referred to as the “red phone.”
Once the process is initiated, the field EMS officer activating the response is connected directly to the SERT’s on-call trauma surgeon via the FAO. Such direct communication promotes a two-way exchange of critical information and provides an opportunity for the trauma surgeon to confirm the indication(s) for SERT activation. The trauma surgeon then calls in the backup trauma surgeon to cover hospital responsibilities.
Concomitantly, the FAO dispatches an ambulance to the trauma center to serve as the transport vehicle for the SERT to the incident scene. Upon arrival on scene, the EMS officer servers as the liaison between the SERT and the incident commander. This important role integrates the hospital staff into the prehospital environment, the incident command structure and safety procedures.
Section F of the SERT protocol addresses scope of practice concerns. The scope of practice for EMS providers in the state of Ohio is modeled on the National EMS Scope of Practice Model.8
CFD paramedics are only permitted to perform procedures and other interventions permitted by scope of practice and further delineated by CFD EMS protocol. Therefore, SERT personnel must perform all procedures that CFD paramedics aren’t permitted to complete.
Section G of the SERT protocol addresses transport destination concerns. Several factors may influence destination decisions, including age of patient, stability of patient, the procedures performed, associated burn injuries, the weather, and availability of helicopter EMS. Therefore, the SERT is responsible for final destination decisions.
Fairfield County Protocol
In contrast to the city of Columbus and Franklin County, in which several trauma centers and EDs are within short distances, Fairfield County is a rural county located in central Ohio directly adjacent to Franklin County.
Fairfield County has an estimated population of 150,381 and is situated on 504 square miles. The population density is 298 persons per square mile.7 Fairfield Medical Center, a 220-bed inpatient facility with approximately 52,000 ED visits per year, serves as the sole hospital for the entire county.9
The Fairfield County EMS Field Amputation Guide was developed specifically for prehospital surgical emergencies occurring in a county without a nearby Level 1 trauma center.
The initial portion of the protocol provides a decision table for EMS providers based on two sets of conditions: the stability of the patient and the availability of helicopter EMS services. (See Table 2.)
In life-threatening scenarios, the amputation guide provides an option for EMS personnel to perform field amputation after discussion with either the trauma center or Fairfield Medical Center, if timeliness is a factor.
The next section of the amputation guide addresses command priorities related to the field amputations. The incident command structure incorporates medical, safety and communications information from various officers to ensure that proper resources reach the patient, and that hospital-based personnel are provided a safe operating scene. A debriefing session is also specified for incident command.
The last section of the amputation guide describes required hospital actions and preparations for Fairfield Medical Center. Instructions for hospital personnel, equipment, communication and documentation are described in detail. Most importantly, a checklist is provided to assist preparations when such a low-frequency, high-risk event occurs. (See Table 3.)
Conclusion
The Columbus SERT Protocol and the Fairfield County Field Amputation Guide provide examples of dedicated regional processes for providing timely interventions for time-critical trauma diagnoses, particularly field amputation.
It provides an example of effective regionalization of trauma care despite organizational, political, geographic and economic obstacles. Further evaluation will be needed to assess patient outcomes and quality parameters.
The CFD’s Surgical Emergency Response Protocol and the complete Fairfield County EMS Field Amputation Guide can be downloaded at www.jems.com/field-amputation.
References
1. Mustaf IA. (n.d.) Field limb amputation used as an extrication option in complicated entrapments or disaster events. United States Fire Administration. Retrieved August 16, 2015, from www.usfa.fema.gov/pdf/efop/efo44926.pdf.
2. Augustine J. (June 1, 2008). Industrial entrapment. EMS World. Retrieved August 16, 2015, from www.emsworld.com/article/10321025/industrial-entrapment.
3. Augustine J. (June 1, 2010). Man vs. machine. EMS World. Retrieved August 16, 2015, from www.emsworld.com/article/10319526.
4. Augustine J. (Sept. 1, 2011). Disarmed. EMS World. Retrieved August 16, 2015, from www.emsworld.com/article/10335148/field-amputation.
5. Kampen KE, Krohmer JR, Jones JS, et al. In-field extremity amputation: Prevalence and protocols in emergency medical services. Prehosp Disaster Med. 1996;11(1):63-66.
6. Sharp CF, Mangram AJ, Lorenzo D, et al. A major metropolitan “field amputation” team: A call to arms and legs. J Trauma. 2009;67(6):1158-1161.
7. U.S. Census Bureau. (n.d.) QuickFacts. Retrieved June 25, 2015, from www.census.gov/quickfacts.
8. The National EMS Scope of Practice Model. (n.d.) National Highway Traffic Safety Administration. Retrieved June 25, 2015, from www.ems.gov.education/EMSScope.pdf.
9. Fairfield Medical Center. (n.d.) US News and World Report. Retrieved August 4, 2014, from http://health.usnews.com/best-hospitals/area/oh/fairfield-medical-center-6411510.
