Limb-and-Life Decisions

It had been 25 years since the Philadelphia Fire Department had last needed its physician response team in the field, but when a train struck a pedestrian late one night last summer, it was time again. The 46-year-old victim was not killed but entrapped, his left leg mangled beneath a wheel. Freeing him would require its amputation. 

Such calls are rare, but the department can answer them with a plan that calls for bringing hospital-based physicians to the field when surgical extrications are required. On this night docs Megan Stobart-Gallagher, DO, and Melissa Kohn, MD, of Einstein Medical Center answered the call. 

The doctors crawled under the train and, using a surgical saw and Gigli saw, removed the foot at the ankle. 

“It was the right thing to do at the right time,” Stobart-Gallagher later told the press, “and getting that patient out when we did probably saved his life.”¹ 

‘Move the Process Forward’

You probably don’t do a lot of field amputations, and truth be told, you’re probably not very ready for them. A 1996 survey found just 13% of responding systems had performed an in-field extremity amputation in the previous five years, and 96% said they had no training for it. Only two of 143 systems even had a protocol.² 

That was 20 years ago, but there’s no reason to think things have changed much since. 

“I don’t think there’s probably been much improvement,” says Craig Manifold, DO, chair of ACEP’s EMS Advisory Committee, who presented on the subject with Philly Fire’s EMS medical director, Crawford Mechem, MD, at February’s Gathering of Eagles conference. “And even if we have a protocol in place, we face challenges in using and practicing and experiencing it so it works smoothly when we need it. But we have seen improvements in protocol development, and now we have an EMS subspecialty and are developing EMS fellows, so I think it’s a perfect time to include it in training and move the process forward.” 

As one aspect of that, EMS World will host a special amputation lab for medical directors at this year’s EMS World Expo, October 3–7, in New Orleans. Visit EMSWorldExpo.com for more information.

But even if you can’t make it to New Orleans, there’s plenty to learn from the Philadelphia train case and other field amputations. 

Team Considerations

Philadelphia’s team gets its medical supplies and medications through a local hospital and uses PPE from the PFD. It’s unfunded, however, and lacks ongoing training. 

What training should it be getting? It’s hard to know, because there’s not much literature to draw from or experience, for most people, beyond small exercises. 

“We have no science to really help us determine that,” says Manifold. “I think any of our protocols, at a minimum, should be dusted off, reviewed and practiced on an annual basis, if not more frequently—even every six months. It depends on the emphasis and interest of the agencies involved.”

Note here not only that skills degrade, but that personnel change—colleagues you trained with a year or two ago may have moved on and been replaced. Frequent training helps get and keep newcomers at speed. Also, field amputations will generally be high-profile calls with interest from the mainstream media—you’ll want to be well-polished in performing them.

Who should be on the team? Start with physician expertise—an emergency medicine physician, EMS medical director and/or trauma surgeon. Local hospital, trauma and orthopedic specialists should be involved, and the perspectives of front-line providers should inform all plans, particularly where they may be doing the cutting. 

“We absolutely need input from the field providers who may be asked to do this—the leadership team will be responsible for the involvement of their personnel,” says Manifold. “I’d also include as potential ancillary personnel the chaplaincy and critical incident stress management folks,” as these calls can be emotionally taxing. 

Systems vary, of course, and the resources and personnel available won’t be standard. Local leaders must determine what’s suitable for their jurisdiction. 

As far as equipment, there are simple handheld tools and surgical instruments that can disarticulate an extremity fairly easily. Appropriate saws include electric and manual surgical saws and a Gigli saw; reciprocating saws are available on most rescue trucks. Hydraulic tools like a Hurst work effectively but can damage bone. 

Complement these with basic surgical equipment such as scalpel, pickups and spreader. Include tourniquets and hemorrhage-control dressings; a way to gain vascular access (IV or IO); and airway management options. Don’t forget suturing equipment and a way to secure tissue and transport any salvageable parts. Coordinate all this at the hospital level. 

Ketamine is an excellent anesthesia for these cases—“probably the safest and best medication to use,” says Manifold. Etomidate can be a good option too, and analgesia (of course) and antibiotics are called for as well. 

Follow Through

With so little information on how often EMS performs field amputations, their outcomes and what impact team and equipment configurations might have, it sure would be nice if someone pulled together available cases and started trying to learn something from them. That’s a near-term goal of Manifold’s. 

In the meanwhile, departments should at the least proceed with crafting protocols  and conducting training. 

“I think people often do a good job of sort of putting this kind of thing in place,” Manifold says, “but we’re not always good with the follow-through of exercising it and making sure folks at the ground level really know how to access it and perform it efficiently. It does no good if it takes us two hours to assemble our equipment and team and get them out to the scene.”

References

1. Williams S. Doctors Amputate Man’s Foot on Philadelphia Train Tracks. WVPI-TV, https://6abc.com/news/doctors-amputate-mans-foot-on-philadelphia-train-tracks/892350/. 

2. Kampen KE, Krohmer JR, Jones JS, Dougherty JM, Bonness RK. In-field extremity amputation: prevalence and protocols in emergency medical services. Prehosp Disaster Med, 1996 Jan–Mar; 11(1): 63–6.