Forward-thinking surgical solutions by air

Erik Bornemeier NREMT /BSEM describes how training for the worst scenarios can lead to better outcomes when it comes to in-field amputations
 
There are only a few regions in the US that have solid protocols when it comes to in-field amputations. In Utah, a joint agency consortium, along with the University of Utah, have put modern protocols to the test.    
 
The problem
Removal of a patient from the scene of an accident needing in-field amputation(s) presents rescuers with many problems and questions. Without protocols and training, it is easy to get stuck into the ‘analysis paralysis’ phase of the rescue, which could lead to prolonged patient extrications, worse outcomes, and possibly death. Many first responders encounter the absences of solid directions to follow when it comes to extricating a patient from the scene of an accident involving an entrapped victim. This problem is exacerbated with the lack of effective training and access to the correct materials for the job, and this is even more true in rural communities. In pre-hospital emergency medical services (EMS), in-field amputation is a low-frequency, high-risk event that warrants a systematised approach. An evaluation in 1996 discovered that the majority of EMS agencies did not have protocols, nor did they have sufficient training and supplies for such an event.1  Of over 200 emergency centres polled, 143 responded and noted the following:
  • Over a five-year period, 26 field amputations were performed
  • The most common reason for amputation was a motor vehicle crash
  • 53 per cent of amputations were performed by a surgeon, 36 per cent by an emergency physician and 12 per cent by ‘unknown’
  • No training was available for this procedure
  • Only two EMS systems at the time had known existing protocols.
So, the problem presented itself, and agencies across the US started to develop  or adopt protocols and checklists that would aim to find answers to questions such as: how long do you work on a patient in the field in order to save a limb, how do you perform the amputation, and who has the ability to perform the procedure?   
 
The solution
The State of Utah is divided into 29 counties, contains roughly three million people, and geographically, is the size of England and Scotland combined. The population is densely centered in the Salt Lake Valley or scattered in rural agricultural communities. There are only three Level One trauma-rated facilities, and one of those specifically is dedicated for paediatrics only. Following lessons learned from historical rescues, and utilising multiple articles on in-field amputation, the University of Utah AirMed and Trauma Service developed a comprehensive guide, which clearly defines how to prepare and respond to pre-hospital field amputation. This programme was developed as a regional response with over a 200 nautical mile reach for surgical emergencies specific to counties without a Level One trauma facility, and critical to this protocol is the use of an air ambulance service. The University of Utah Hospital is a Level One trauma facility that has the surgical staff on hand to deploy a quick response amputation team using AirMed, while AirMed has the resources and equipment to get the surgical staff to the scene in a timely manner. 
 
 
 
How the AirMed policy works
When a flight request is made for a field amputation, it is done through the AirMed Flight Centre, and goes as follows:
  • Flight Centre to notify the University of Utah Medical Centre (UUMC) emergency department (ED) Charge Nurse that a field amputation is needed
  • Charge Nurse to call for a Level One trauma activation and flight time from UUMC to the scene.
  • On-scene flight team to contact the ED Charge Nurse and ED attending position about the request.  
  • One AirMed staff member to accompany the trauma surgeon in a second aircraft
  • Prior to the surgeon’s arrival, 2gm cefazolin (Ancef) should be administered
  • Prior to the surgeon’s arrival, a tourniquet should be placed on the extremity being amputated; if the amputation is being done on the thigh, consider using two tourniquets
  • AirMed to provide the trauma surgeon with a helmet/headset for communications while in flight.
  • The trauma surgeon to both retrieve and return the appropriate flight attire and field amputation kit, and blood product
  • AirMed personnel to intubate the trauma victim and maintain sedation as per guidelines
  • Upon in-field amputation, the patient will be taken to the University of Utah Health Centre for additional trauma care.
Putting in the practice
On 6 November 2017, The University of Utah and a joint agency training force consisting of Layton City Fire, Davis County Sheriff, Utah Training and Education Center (UTEC),  AirMed, and North American Rescue came together to practise dealing with in field amputation. The following scenario was built by Utah Training and Education Center:
Reports of a 70-year-old male who was working at a construction site when large concrete debris shifted and trapped him. To complicate things, he also has a piece of metal in his leg pinning him to the ground. 
The morning of the training was cold – 300F – and cloud cover was off and on with light snow. There was a real-world concern of hypothermia to role players, so precautions were taken to keep people warm. The use of actual people as role players and victims proved invaluable to the quality of training as it forced EMS personnel on the ground to ‘engage and interact’.  
In addition to live actors, UTEC had created realistic body limbs out of animal bone, pork loins, PVC tubing and pig skin to simulate the tib/fib area of the leg and fastened this to a 70-year-old amputee role player. 
The scenario was designed to be performed twice. On the second iteration, lessons learned from the first were polished and the best practices continued. 
In the first round, EMS personnel that arrived were shocked to find a realistic event staged, but after three seconds of ‘wide-eyed surprise’, immediately engaged and immersed into the scenario. They followed their protocols and assessments. When they determined that the patient could not be moved, they followed the new protocol and requested the surgical team and helicopter transport. Within 10 minutes, the surgical team was in the air and responding to the scene. The surgeon arrived with O-negative blood and the equipment needed to extricate. Again, the surgeon was surprised to find an anatomically correct leg to amputate. This allowed the surgeon to put equipment to the test and prove its effectiveness. Upon extrication, the patient was packaged and flown to the hospital, where the scenario continued through the assessment in the emergency room.
In each of the two scenarios, teams commented on how beneficial it was to practise through each of the steps and validated the effectiveness of the protocol. Because of this training, the EMS agencies on the ground and in the air have a solid plan to respond to in-field amputation emergencies. This equates to faster, more effective patient care in our region. Former US President Abraham Lincoln wisely stated: “By general law, life and  limb must be protected; yet often a limb must be amputated to save a life; but a life is never wisely given to save a limb.”  
 
Reference
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.
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