The dispatcher crackles over your radio: “17-Bravo-1.”
You and your partner are all too familiar with what that means-typically a fall with no further information available, most likely uneventful. But en route, you’re updated that the patient is possibly stuck in a tree. When you arrive, you find a 47-year-old man dangling upside down, 20 feet in the air, trapped by his leg and bleeding profusely. The tree trunk is stained red from blood and the patient is ghostly white.
The patient was standing in the fork of a tree cutting the trunk above him, which separated into another fork. The top fork fell, straddling the fork he was standing on. The branch crushed his leg below the knee and flung him into the air. It’s likely his inversion helped to prevent immediate exsanguinating hemorrhage from his partially severed limb.
You apply a combat action tourniquet (CAT), which decreases some of the bleeding. However, it’s clear the patient is still deteriorating, so you call the on-duty physician and request orders to amputate.
You call your medical director and manage to reach him just as he’s arriving home.
“Doc, we have an adult male who was trimming a tree when a large part of the trunk fell and crushed his leg,” you tell him. “He’s hanging upside down 20 feet in the air. He has a partial amputation of his right leg below his knee, which is continuing to bleed. We’ve placed two tourniquets and packed the wound with hemostatic dressing, but he’s still bleeding. The fire department is trying to remove the tree to free him but haven’t yet been able. I think we may need to amputate.”
Your medical director has developed a standard response to requests to amputate, which is the most important when weighing the request: “Is the patient dying?”
The supervisor on scene with you explains to the medical director that the patient is alert and oriented times three, so he fails the first inclusion criterion for the amputation protocol. The patient’s vital signs are stable and his pain is being controlled with fentanyl. You’re given orders to continue pain management, bleeding control and fluid resuscitation, and add another tourniquet, and to call back if anything changes. Your request to amputate, however, is denied.
The fire department works feverishly to support the victim who is dangling in the air while trying in vain to remove the 1,200 pound tree trunk. The tree is too heavy to lift with the tower truck, so it’s stabilized while pieces are carefully removed to lighten it enough to be lifted. It’s a time-consuming process, but moving too quickly places the patient and the rescuers at risk. Not more than 10 minutes later, you decide to call your medical director again.
“Doc, the patient is now in a harness and being supported by the tower truck. As soon as he was flat, he started bleeding again. He now has altered mental status; he says he can see Heaven and Jesus.” Of course, as in this case, one of the first signs of hemorrhagic shock is a change in the mental status.
It’s important to remember this isn’t simply a transition from conscious to unconscious. It’s often more subtle and may manifest with confusion, hallucinations, or a transition from words to sounds. You can expect to also see an elevation of the heart rate and eventually a lowering of the blood pressure. In the case of a patient who is entrapped and suspended in the air, simple things like blood pressures and monitoring become extremely difficult.
Your medical director enquires about drugs and dosages and asks if you and your supervisor need to be walked through the amputation procedure, as he’s still 35-40 minutes away. You walk through the plan with him and realize that you and the medical director and venturing off into unchartered waters … no protocol for this, no specific equipment for this, and no amputation training. Nonetheless, he sounds confident in your ability.
The On-Scene Procedure
Your supervisor retrieves the ketamine and hurries up the ladder. The patient isn’t alert but responds to your voice: “Sir, I’m about to deliver some difficult news. We need to amputate your leg and get you out of here to the hospital.”
He has a moment of clarity and replies, “What? You mean I’ve been hanging up here for however long and you could have taken the leg off a long time ago? Hurry up and take it!”
The choice is made to use ketamine for sedation because of its positive hemodynamic effects and airway protective attributes. He’s given 4 mg/kg intramuscularly in his thigh, but the supervisor isn’t able to reach the leg below the knee because he’s on a ladder below the patient.
Your partner climbs an adjacent ladder and, using a scalpel, initiates the amputation, cutting through skin, muscle and tendons. The scalpel quickly breaks and trauma shears are used for the remainder of the procedure. The patient is given a second dose of ketamine, and your partner continues cutting with trauma shears. Eventually, he is freed from his entangled limb.
The patient is lowered to the ground, but as soon as he becomes horizontal, he starts bleeding again. A third CAT is placed and the wound cavity is packed with five rolls of the hemostatic dressing and secured in place. The patient is transferred to the flight crew for transport to a Level 1 trauma center. It took another 45 minutes to free his severed limb from the tree.
The need for field amputations in typical EMS functions remains an incredibly rare event. A 1992 survey of the 200 largest metropolitan areas in North America revealed that only 26 cases existed in a five-year period from the 143 systems that responded. Of those systems, 89.6% reported that amputations were done by a trauma surgeon or emergency medicine physician and only around 1% of programs had system guidelines to address the need for field amputations.1 Although it has been more than 20 years since that paper was published, it’s likely these numbers haven’t significantly changed.
Often, this issue is placed in the “too difficult” basket regarding designing a system that’s practical and timely. This creates an illusion of impossibility in managing these situations, which then often amounts to ongoing attempts to extricate until the patient is freed or dead.
The decision has to be made by an EMS physician at the point when the individual’s life is in imminent danger. Amputation is an acceptable risk, particularly if paramedics think more like clinicians than technicians and are able to improvise in unusual circumstances.
Most requests to amputate in the field involve an extremity, usually fingers or hands stuck in farming equipment or an industrial device of some kind. This call, however, was a bit different. It not only happened 20 feet in the air with an inverted patient, but it was a 45-minute emergency response away. Additionally, the lack of the equipment to perform the procedure wasn’t ideal.
In considering equipment purchase and guideline development, there are two distinctly different circumstances that should be considered. The first situation is the stable patient who requires a careful extrication by surgical amputation because traditional methods of extrication aren’t possible or practical. To address this need, there are commercially available field amputation kits available with various supplies, which include tourniquets, sterile drapes, betadine, a bone saw and other assorted instruments. This is an appropriate kit for the circumstance when you’ve developed a physician field amputation guideline that requires an EMS physician, EM physician, or trauma surgeon to respond to the scene and perform the procedure.
The second situation has an immediate need for the patient to be extricated because attempts to stabilize have failed and there’s imminent risk of death. This situation may require the addition of a sturdy scalpel, Gigli saw to cut bone, and a set of Kelly forceps to create a tunnel under the bone for passage of the saw. The other items needed should be readily available on any ambulance these days, including tourniquets, hemostatic dressings, trauma dressings and elastic bandages. Beyond the equipment, this situation requires either the ability to have a field EMS physician immediately available or a small cadre of senior paramedics who are trained to perform the procedure with online EMS physician support.
A field amputation, while extremely rare, is a situation that is better addressed by carefully thought out guidelines, training, and equipment purchases. This situation was a clearly improvised amputation in austere conditions which turned out well because of the excellence in care received from the fire department first responders, the paramedic crew on scene, the HEMS team and trauma center. It isn’t acceptable to allow patients like this to bleed to death because there’s no mechanism to address the need for amputation.
1. 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.