At 2:47 a.m., the 9-1-1 call center received a call from a train conductor stating that he struck a person on the train tracks in Northeast Philadelphia.
The conductor of a CSX freight train had noticed something on the track. He attempted to stir the object by blowing the horn in hopes it was an animal, but it didn’t move. The conductor slowed the train as quickly as possible, but still ran over the object with its lead engine. When he exited the train, he noticed the object he hit was actually a person.
The initial dispatch assignment, without knowing the severity of the injuries, was for an engine, ladder, chief and an ALS unit. Accessing the patient was difficult and took several minutes due to the terrain leading to the tracks. Once an access point was gained, the paramedics quickly assessed the situation, noting that the patient was still alive and breathing on his own.
The patient was lying between the rails of the train tracks-his left leg below the knee was caught in the wheels of the train car. He appeared to be acutely intoxicated and admitted to drinking alcohol that evening, but was unable to provide further details or complaints. The paramedics applied a tourniquet to the proximal left thigh and placed an IV.
Discussions began among the conductor, the paramedics and the firefighters regarding the options to free the patient. He was still lying on the tracks between the rails with his lower leg twisted between the first and second wheel of the first set of wheels on the engine car. If the car was moved, the patient could be struck by any of the structures on the underside of the train. The leg would potentially become more mangled when the wheels moved in either direction.
The conductor contacted the train company and was told it would take over two hours for a crane capable of lifting the engine to arrive-the Philadelphia Fire Department (PFD) suppression units aren’t capable of lifting an engine, which weighs over 400,000 pounds. The EMS chief, paramedics and fire department incident commander (IC) decided it was in the patient’s best interest to activate the surgical response team procedure to consider amputation in order to extricate the patient.
Surgical Response
The need for a field amputation is a rare occurrence and is potentially fraught with danger.1 A plan or protocol for such an incident can be vague and sometimes incomplete. Many questions arise before, during, and after such an incident.2 The proper staff, equipment and resources are essential to having a good outcome. By creating a protocol and a strong EMS community, the local population stands to benefit from these resources.
The PFD’s triage physician and/or surgical response team activation procedure is in place to transport one or more physicians and support personnel to an incident scene when requested by the IC. The procedure focuses on two specific types of scenarios: 1) a mass casualty incident (MCI); or 2) a patient entrapment where a field amputation may be required to extricate the patient. At an MCI, the physician’s role would be to assist with triage and potentially treat and release low-acuity patients or designate them for an alternative means of transport to definitive medical care. Depending on need and availability, multiple physicians and at times nurses may be requested. In the case of incidents that have extended operational periods (i.e., hours or days), the physician can provide a higher level of expertise, directly oversee the medical care rendered by EMS providers, and serve as a medical liaison with other healthcare agencies and providers who may be summoned to the scene. Per the PFD procedure, the physician must be a Pennsylvania state-certified medical command physician and work at a medical command facility contracted with the PFD.
The other section of the protocol deals with the surgical response team, which consists of an attending trauma surgeon or orthopedic surgeon and at least one assistant. The team members are required to be trained to operate on victims in a confined space.
The decision to activate either team should be made by the IC in conjunction with the on-scene EMS field supervisor. The criterion for activating a triage physician team is whenever the number and/or severity of patients exceeds the capability of PFD personnel/resources. The criterion for activating a surgical response team is when surgical intervention is required at the scene of an incident (e.g., the amputation of an entrapped body part) in order to facilitate the extrication of a trapped patient.
MCIs may include a large building fire, public transportation collisions, a terrorist bombing, severe weather events or natural disasters, but most incidents are of small enough scale and duration that they can be managed without physician involvement. For example, a building collapsed in Center City, Pa., in 2013, but didn’t require the activation of a triage physician or surgical response team. Most victims were discovered and evacuated relatively quickly. One survivor was pulled from the building 13 hours after the collapse, but fortunately, her injuries didn’t require advanced medical care on scene.3
A surgical response team is less likely to be requested due to the infrequent nature of complex entrapments that may require a field amputation. The last major incident in Philadelphia that needed a surgical response team was over 20 years ago.
In the morning rush hour of March 7, 1990, a subway train derailed underground at 30th Street Station with more than 200 passengers on board. The location of the derailment was near several hospitals, and hospital providers were able to react quickly at the request of the PFD. The protocol for such a response had been established with designated system resource hospitals. The responders included emergency medicine physicians and trauma and orthopedic surgeons. They borrowed protective gear and helmets from the firefighters on scene.
Two amputations were performed during the incident: One was performed on a deceased patient to gain access to another patient lying below him in the wreckage, and the second was performed on a woman who had deteriorated quickly as the emergency responders were attempting to free her from the wreckage. Unfortunately, she later died at the hospital from her multiple injuries.4
The current PFD protocol is undergoing revision given the advancements that have been made in medicine and EMS in recent years. Under the current protocol, the IC determines the need for a triage physician or surgical response team in discussion with the on-scene EMS field supervisor. The request is made through the Philadelphia Fire Communications Center (FCC). The FCC contacts the medical command hospital closest to the incident to request mobilization of a physician team, based on the nature of the incident. The physician will coordinate the hospital response, collecting the necessary personnel and equipment.
If a hospital is unable to provide an appropriate team or equipment, the FCC will contact the next closest medical command facility. The FCC will arrange transportation of the physician team from the hospital to the site of the incident, utilizing an ambulance or other PFD vehicle. Prior to departure from the medical command hospital to the incident scene, the FCC will verify with the IC that there’s still a need for the team.
Once on scene, the medical command physician will work with the IC and the EMS field supervisor to direct the team and the resources. If the event is an MCI, the team will assist with triage until the situation has been deemed under control by the IC. If the situation requires a surgical procedure to be performed, the physician will accompany the patient to the hospital. After care has been transferred to the receiving hospital, the physician and/or the team will be returned to their originating hospital.
How the PFD can best support a physician response team is currently under discussion. A top priority is the safety of all emergency responders, physicians and other hospital-based providers at the scene. Alternative ways to provide personal protective equipment and other supplies for physicians are also being discussed, as it’s not feasible for all supervisory vehicles to carry the additional equipment.
The Gigli saw is a collection of multiple wires, twisted together in order to create various cutting surfaces. Photo courtesy Integrated Medical Systems International
Another topic of discussion is what sort of training the physicians should have to enable them to do scene response safely and effectively, how that training should be provided, and how frequently. Liability coverage for the physicians is an important consideration.A number of other issues are being discussed with the five PFD-contracted medical command hospitals. These issues include the medications and other supplies physicians should bring with them to the scene. Currently, PFD ambulances only carry medications approved by the Commonwealth of Pennsylvania for use by ground paramedics. These protocols don’t include paralytic agents, ketamine, blood products or tranexamic acid-all agents that may be very helpful in some scenarios.
Finally, all medical command hospitals under contract with the PFD are required to be able to provide a triage physician and/or a surgical response team if requested. The appropriate model to provide a timely emergency response is being reviewed.
Enlisting just one or two hospitals specifically for a surgical response team may be more desirable. The infrequency with which physicians are requested by EMS makes the development of a viable and sustainable program challenging.
On Scene
At 3:13 a.m., the FCC contacted Einstein Medical Center Philadelphia (EMCP), the closest facility to the incident, to make the request for a surgical response team. The medical command physician staffing the ED collected the information regarding the incident and confirmed a team would be available.
At 3:17 a.m., the on-call EMS physician was contacted at home and drove to the hospital. While the responding EMS physician was en route to the hospital, the physician in the ED contacted both the surgical service and the orthopedic service to request surgical support at the scene. Given the existing demands of the Level 1 trauma center and early morning hours, neither service could provide another physician on such short notice.
The EMS physician arrived at the hospital with her own turnout gear, medications and equipment approximately 45 minutes from the initial 9-1-1 call. She obtained some additional orthopedic surgical equipment and followed the paramedic unit to the scene of the train accident. An additional physician and two nurses from EMCP traveled by PFD ambulance to the scene to provide assistance.
The EMS physician arrived on scene approximately 65 minutes after being requested. The EMS field supervisor gave a report on the patient’s status; he’d remained somewhat altered since the initial ambulance had arrived, and, despite being struck by a train, his airway was patent and he was mumbling words. A tourniquet had been placed by paramedics on the proximal left thigh, which was controlling the bleeding. He was receiving normal saline through the IV in his right hand. Shortly before the physician arrived, the patient had begun to complain of being in pain, so he was given morphine 4 mg IV. His blood pressure had dropped slightly after the administration of the medication.
After donning her turnout gear, the physician crawled underneath the train to make an assessment of the patient’s condition. The patient’s left lower leg was caught between the wheels of the engine and couldn’t easily be freed. The physician came out from under the train to discuss the situation. Because the patient’s blood pressure had dropped with the recent administration of morphine, an amputation was the only option available to free the patient in a safe and timely manner.
The physician provided a weight-based estimated dose of ketamine to the nurse who accompanied her to the scene. The conditions under the train were cramped and extremely hot. This incident took place on a hot and humid night in August; the existing weather conditions, compounded with the extreme heat from the engine, made for rather unbearable working conditions. Anyone working under the train wouldn’t be able to spend an extended period of time without overheating.
While one paramedic monitored the patient from outside the train, another paramedic crawled under the train near the patient’s head to monitor the patient’s airway. The physician crawled back under the train with the other physician to assist. Tools were passed through a small space alongside the train’s wheels. The ketamine was administered to the patient through the IV.
The first incision was made almost 90 minutes from the initial call. The scalpel easily cut through the skin, muscle and tendons. At this point, some bleeding was noted and the tourniquet was tightened to control the hemorrhaging.
The tibia and fibula were a tougher task. To cut through the bones, a Gigli wire saw was used in conjunction with a small surgical hacksaw. The Gigli saw is a collection of multiple wires, twisted together in order to create various cutting surfaces. The wires are attached to handles at either end, which are used to move the wire back and forth in turn cutting through the bone. After the bones were cut, the remaining part of soft tissue was dissected away using the scalpel.
Once the remainder of the leg was freed, the patient was extricated from under the train at the site closest to his head using a long backboard. He was immediately placed into a Stokes basket that was alongside the railroad tracks. The patient was carried to the waiting ambulance.
While in the ambulance, the patient’s level of consciousness decreased, raising the concern that he would be unable to protect his airway. The patient was intubated by the paramedic after the EMS physician administered etomidate and succinylcholine for sedation. Prior to administration, the patient had been on the cardiac monitor without obvious ECG evidence of hyperkalemia. The remaining leg was wrapped in gauze wet with saline. The tourniquet pressure was slightly released in order to encourage some perfusion to the limb but still maintain control over blood loss and prevent return flow.
A more thorough physical examination of the patient revealed significant abrasions along the left posterior torso and buttocks. After the endotracheal tube was secured, end-tidal carbon dioxide monitoring was established with a good waveform. The patient continued to have decreased breath sounds on the left, which was concerning for a possible pneumothorax, but a right main stem bronchial intubation was also considered. IV fluids continued to flow and the patient was given 1 amp of sodium bicarbonate as part of the Pennsylvania statewide crush protocol. The patient was maintained with mild permissive hypotension as he was transported to the closest trauma center.
Conclusion
At the hospital, the patient was confirmed to have a left pneumothorax and a chest tube was placed. He remained sedated while a thorough evaluation was completed and antibiotics were given. After a short period, he was taken to the operating room for debridement.
The patient was eventually transferred to an affiliated hospital for further debridement and a revision of the amputation. He was discharged to a short-term rehabilitation facility and ultimately to a family member’s home for recovery.
The patient’s overall outcome was likely significantly affected by the pre-established EMS procedures and the existing agreements with the local medical command hospitals. Although the need for a physician response team is a low-frequency event, such incidents may be considerably altered if the resources are not readily available to respond. Creating these procedures and relationships helps to forge a strong EMS community with support from the hospital community and other stakeholders. The population served by the EMS agencies and the hospital stands to benefit from these strong relationships.
References
1. Porter KM. Prehospital amputation. Emerg Med J. 2010;27(12):940-942.
2. Sharp CF, Mangram AJ, Lorenzo M, et al. A major metropolitan “field amputation” team: A call to arms “¦ and legs. J Trauma. 2009;67(6):1158-1161.
3. Boyette C, Lear J. (June 6, 2013.) Six dead in Philadelphia building collapse, 13 injured. CNN. Retrieved Jan. 14, 2016, from www.cnn.com/2013/06/05/us/pennsylvania-philadelphia-building-collapse/index.html.
4. Ruane ME, Acker C, Anastasia G, et al. (March 8, 1990.) 3 killed, more than 100 hurt as rush-hour subway derails some passengers trapped for hours under Market St. Philly.com. Retrieved Feb. 1, 2016, from http://articles.philly.com/1990-03-08/news/25903348_1_local-hospitals-market-frankford-line-passengers.
