# Trapped pt with amputation



## falcon-18 (Sep 19, 2009)

Hello, every body.

If pt is trapped in a machine with crush injury and incomplete amputation of 

one lower leg. in any crush injury heavy fluid resusitation is essential before 

extrication to avoid acute renal failure. in this scenario, as the pt is trapped 

so life saving limb amputation is necessary at the scene. time is crucial, so if 

a surgeon could not available, assuming that the scene is in far remote area.

in this case supposing to be in wilderness, can an EMT iniate amputation, 

while ligating bleeders and securing haemorrhage with onlline medical 

direction? AS this is a life saving procedure in this scenario, so I suggest that 

EMTS, specialy working in far remote areas or wilderness should have short 

courses to handle such a situation. I know that this life saving amputation in 

a trapped pt should be done by surgeon it is very difficult for EMT to perfom

amputation even then sometimes to save a life, this topic can be considered.


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## Akulahawk (Sep 19, 2009)

One word: Tourniquet...
2nd word: helicopter
3rd word: Surgeon.

Not necessarily in that order...


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## exodus (Sep 19, 2009)

Tourniquet above, that will stop bleeding, and help control alot of the pain.


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## falcon-18 (Sep 19, 2009)

Akulahawk said:


> One word: Tourniquet...
> 2nd word: helicopter
> 3rd word: Surgeon.
> 
> Not necessarily in that order...





exodus said:


> Tourniquet above, that will stop bleeding, and help control alot of the pain.





_*wilderness *_ EMT should be aware to face such situation 

spiceally if helicopter also not available or it will take long time to arrive, and 

pt limb is trapped .

Tourniquet useful to stop bleeding but how to get pt out. 

surgeon also will take a lot of time to arrive, and amputation is the only way 

to get the pt out. so how to procede.


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## vquintessence (Sep 19, 2009)

falcon-18 said:


> _*wilderness *_ EMT should be aware to face such situation
> 
> spiceally if helicopter also not available or it will take long time to arrive, and
> 
> ...



Really, use the tourniquet.  We don't perform field amputations, not even escharotomies.  If pt is trapped to extent you want the scenario to be, take as much of the "crushing stuff" off as possible, then transport whatever is necessary.  If it's truly a rural environment, then I'd hope the wilderness service would have cutting devices with them.

For the situation you want to create, the person would probably die.  

Consider this instead:  With the situation you described, of a prolonged and severely trapped lower extremity, you'd potentially be dealing with one hell of a crush injury.  Imagine all the lactic acids and other byproducts being created by the anaerobic metabolism of the trapped tissues.  Fluid resuscitation is only the beginning of your pts problems.

Forget the field amputation my friend, and do some worrying about the rapid release of those trapped lactic acids and byproducts into main circulation!


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## VentMedic (Sep 19, 2009)

falcon-18 said:


> in any crush injury heavy fluid resusitation is essential


 
As an EMT-B, how much fluid do you intend on running into the patient?  How much is too much?


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## falcon-18 (Sep 21, 2009)

VentMedic said:


> As an EMT-B, how much fluid do you intend on running into the patient?  How much is too much?



UNTIL WHEN YOU WILL GIVE HIM FLUID?

My point is ; if they are not comig early because mountain or weather...or for any reason and you do not have a cut machine. what you will do. only give him fluid . this is my point. for this pt, he needs amputation to save his life. 

 ??????


falcon-18


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## reaper (Sep 21, 2009)

As an EMT, you will never do an amputation. You will kill the pt with fluids, long before you would need to amputate!

EMS is about thinking outside the box. You need to look at the ways to get the pt out or get a surgeon there!


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## Akulahawk (Sep 21, 2009)

You must figure out a way to extricate the patient from the machine, or the machine from the patient. If that involves disassembly of the machine, so be it. EMT's of any level do not perform field amputations, that I'm aware of.

My feeling on this is if you can not disassemble or cut the patient from the machine you should apply a tourniquet and manually turn the machine backwards, while extricating the patient. Do NOT allow the tourniquet to be released. 

I would further suspect that such machinery would have been delivered somehow, and has a power source so I would suspect that waiting for several hours for a surgeon to arrive by ground or by air is still appropriate if a field amputation is necessary.

Extrication is, in my opinion, the most appropriate thing to work on... and rushing to perform a field amputation by personnel not trained/authorized to perform such an amputation is inappropriate.


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## falcon-18 (Sep 21, 2009)

reaper said:


> As an EMT, you will never do an amputation. You will kill the pt with fluids, long before you would need to amputate!
> 
> EMS is about thinking outside the box. You need to look at the ways to get the pt out or get a surgeon there!









Akulahawk said:


> You must figure out a way to extricate the patient from the machine, or the machine from the patient. If that involves disassembly of the machine, so be it. EMT's of any level do not perform field amputations, that I'm aware of.
> 
> My feeling on this is if you can not disassemble or cut the patient from the machine you should apply a tourniquet and manually turn the machine backwards, while extricating the patient. Do NOT allow the tourniquet to be released.
> 
> ...








I said you can not extiate pt and he is in criticale case and surgeon need more time to come. 

yes extrication you will do it but when you can not do it. what you will do?


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## VentMedic (Sep 21, 2009)

falcon-18 said:


> I said you can not extiate pt and he is in criticale case and surgeon need more time to come.
> 
> yes extrication you will do it but when you can not do it. what you will do?


 
What makes this patient critical? It seems as if you are so focused on one issue that you may be forgetting a few basic things that you can do for a patient as an EMT-B. Focus on the patient and not a mangled body part. If you let your own emotions get carried away, that will lose the patient faster than the situation they are actually in. 

If this patient is still conscious, you may kill the patient when you start sawing or chopping on their extremity. Even a knife can be traumatic depending on the location and alertness of the patient. Believe it or not but unconscious patients will still get some medication for patient and maybe something like Versed as a sedative even though they do appear unconscious. Whatever shock condition they are in will be enhanced at the hands of an inexperienced and minimally educated provider. Yes, there are many stories of individuals sawing their own body parts off but this is not the situation.

You also have NO way to maintain their BP once any pressure is relieved or as they go deeper into a shock state.

Stop watchinig the TV shows and start learning a little more about the body's responses to trauma and what you can do as an EMT-B.


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## VentMedic (Sep 21, 2009)

I think this thread needs some clarification.

Falcon,



falcon-18 said:


> I am an EMT-P and I am 23


 
Are you a Paramedic in the United States and what are your protocols?

Or, are you asking specifically about the U.S. EMT?

In the U.S., the EMT has only 120 hours of basic first-aid.


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## falcon-18 (Sep 21, 2009)

falcon-18 said:


> Hello, every body.
> 
> If pt is trapped in a machine with crush injury and incomplete amputation of
> 
> ...







VentMedic said:


> What makes this patient critical? It seems as if you are so focused on one issue that you may be forgetting a few basic things that you can do for a patient as an EMT-B. Focus on the patient and not a mangled body part. If you let your own emotions get carried away, that will lose the patient faster than the situation they are actually in.
> 
> If this patient is still conscious, you may kill the patient when you start sawing or chopping on their extremity. Even a knife can be traumatic depending on the location and alertness of the patient. Believe it or not but unconscious patients will still get some medication for patient and maybe something like Versed as a sedative even though they do appear unconscious. Whatever shock condition they are in will be enhanced at the hands of an inexperienced and minimally educated provider. Yes, there are many stories of individuals sawing their own body parts off but this is not the situation.
> 
> ...




I do not know why you say that my scenario is very clear . I said *so I suggest that 

EMTS, specialy working in far remote areas or wilderness should have short 

courses to handle such a situation.*

I do not say you should doing amputation by your self. I discuss it only.


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## VentMedic (Sep 21, 2009)

falcon-18 said:


> I do not know why you say that my scenario is very clear . I said *so I suggest that *
> 
> _*EMTS, specialy working in far remote areas or wilderness should have short *_
> 
> ...


 

No it is not clear.

What makes you think this patient is critical?

Patients have been entangled in wrecked or entrapped with partially amputated extremities for hours and even days until they have been found.


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## falcon-18 (Sep 21, 2009)

VentMedic said:


> I think this thread needs some clarification.
> 
> Falcon,
> 
> ...



No, I am not from US . I just discuss. this Q come to me when I am 

reading PHTLS book sixth edition.


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## VentMedic (Sep 21, 2009)

falcon-18 said:


> No, I am not from US . I just discuss. this Q come to me when I am
> 
> reading PHTLS book sixth edition.


 
Please do us all a favor and put your country in your profile since this is a multinational site.

No, in the U.S. an EMT would probably not be doing an amputation.  The situation would have to be very, very dire with *absolutely no other options*.  Even at that they may have to answer to a medical review to keep their certification..


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## Mountain Res-Q (Sep 21, 2009)

Okay, so from the wilderness standpoint that you mentioned...

If the patient is trapped due to this crushing (let's say it is a bolder that has fallen and crushed/trapped a limb) then one of two things will happen:

1.  He will be dead faster than we can get there.
2.  He will be alive when we got there and, in all honesty, he will live a little longer for us to get a surgeon in.

However, playing this game:  Amputation in the wilderness setting is not something I believe any WEMT, WFR, or OEC class teaches... LOL... Under what cirrcumstances would it be a critical procedure to save the life (keeping in mind the above)?  If we are incapable of getting the surgeon in (lets say weather is now preventing a helo) then how would we get the pt. out in the timely manner that an pre-hospital surgical amputaion requires?  However, let's say that it was required to save a life (even temporarily, pre-getting-your-cert-pulled and getting investigated and arrested)...

It could be done, but it would not be pretty or skilled...  case in point... this is a true story (and a good one)... COULD YOU DO THIS?

http://www.cbsnews.com/stories/2003/05/02/national/main551979.shtml

Long story short, he was rock climbing when a boulder rolled on to his arm, pinning him against a rock face for sevral days, realizing that no help was coming and that he was going to die there, he actually amputated his own arm with a dull pocket knife and no anesthesia.  He also had to use a rock to shatter his radius and ulna because the knife was not going to cut through bone.  He then still had to get out of there and get help, which meant crawling out of the wilderness and even, at times, doing some one armed rappel work...  Chiling stuff...  The kinda of stuff that gives me SAR nightmares...


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## falcon-18 (Sep 21, 2009)

VentMedic said:


> No it is not clear.
> 
> What makes you think this patient is critical?
> 
> ...


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## VentMedic (Sep 21, 2009)

falcon-18 said:


> What makes you think this patient is critical?
> 
> good Q...
> 
> ...


 
Hopefully you as a rescuer can alleviate the some of the factors of the environment.

You can NOT treat any of the things mentioned as an EMT. You may make matters worse by cutting off the extremity. You can not control pain. You can not control BP either high or low. Get the surgeon enroute or an advanced practitioner that might be able to help. 

A tourniquet not stopping the bleeding? 

Okay, you are getting way too deep into the "what ifs" and haven't understood the basic realities of what you CAN do.

What are you a student of if you are already a Paramedic in your country? Even a Paramedic in this country would be addressing all the issues before considering amputation.

Why are you so concerned with what the U.S. EMT does?  It is an entry level position that only addresses the basic principles of first-aid.


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## falcon-18 (Sep 21, 2009)

VentMedic said:


> Hopefully you as a rescuer can alleviate the some of the factors of the environment.
> 
> You can NOT treat any of the things mentioned as an EMT. You may make matters worse by cutting off the extremity. You can not control pain. You can not control BP either high or low. Get the surgeon enroute or an advanced practitioner that might be able to help.
> 
> ...



please, let us talk in this subject. we have one coutry it is EMS country we discuss in it. did you see what Mountain Res-Q said you can go back and see it.

A tourniquet not stopping the bleeding? 

sure it is. did you think it is stop bleeding in brain. that is what I mean.

Even a Paramedic in this country would be addressing all the issues before considering amputation. also in my country
thanks VentMedic . I know my job.


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## Akulahawk (Sep 21, 2009)

Falcon, it's clear that you want us to go towards limb amputation. That is something that is highly unlikely to occur in the field. My feeling is that if you're that far out where you think the patient will die without immediate amputation and there's no chance of getting a surgeon to the patient (how are you going to evacuate the patient if you can't bring the surgeon to the patient?), the patient will likely die regardless of your amputation efforts. 

You have presented us with a high risk, low reward scenario... and the patient will likely die regardless of which option we take.

That's the reality of it.

Extrication is only part of the story... evacuation is the other portion. If you can not get a surgeon (can't fly/drive in) you're not going to be able to evacuate your time-critical patient...


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## wvditchdoc (Sep 21, 2009)

Akulahawk said:


> You have presented us with a high risk, low reward scenario... and the patient will likely die regardless of which option we take.
> 
> That's the reality of it.
> 
> Extrication is only part of the story... evacuation is the other portion. If you can not get a surgeon (can't fly/drive in) you're not going to be able to evacuate your time-critical patient...


 
+2, excellent point. 

I think the scenario is quite a bit far fetched to begin with. Don't get me wrong, I like to think outside the box as well but the scenario(s) still have to be doable.

If this were in fact the case, you can do all the cool stuff you want but until you get the patient out to _*definitive* _care, chances are they are still gonna kick it. 

Marc


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## Mountain Res-Q (Sep 21, 2009)

Akulahawk said:


> Extrication is only part of the story... evacuation is the other portion. If you can not get a surgeon (can't fly/drive in) you're not going to be able to evacuate your time-critical patient...



In SAR we refer to this by the acronym LAST... Locate, Access, Stabilize, and Transport...  Falcon is talking about the Stabilize portion of this scenerio, somehting that could take hours, much manpower, and great danger... and every other step in this scenerio is going to present us with the same issues...  Heck, the act of locating and accessing the subject could take days on it's own... and trust me it has...  ans transporting?  Carrying anyone out of the woods is not an easy of quick process.  If we NEED to chop that arm off to save a life, lets also factor in the response time, the time to locate them, the time to access them, and the time to get them out...  Reality is that all that extra time is gonna kill a critical patient, a patinet that probably wasn't alive (if they were critical) when we got to him... been there done that...

Like you said, it is just unrealistic and the series events that would have to transpire would likely mean that the the subject would be dead by the time we got there or that they would be alive and we (EMT, Medics, OEC, and a Surgeon ASAP) would probably have the time to do things right and not have a First Aider grab a hack saw and go at it...


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## EMTinNEPA (Sep 21, 2009)

Where are you that you can't get a field surgeon there?  My county is EXTREMELY rural, and in this scenario, we could still have a field surgeon in less than half an hour and a helicopter in less than 15 minutes, to say nothing of the County's Rescue Task Force.


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## Mountain Res-Q (Sep 21, 2009)

EMTinNEPA said:


> Where are you that you can't get a field surgeon there?  My county is EXTREMELY rural, and in this scenario, we could still have a field surgeon in less than half an hour and a helicopter in less than 15 minutes, to say nothing of the County's Rescue Task Force.



You may find your area extremely remote, but I would venture a guess that any place you can have a helo in 15 mnutes and a surgeon in less than 30 minutes is not really remote... 

http://www.emtlife.com/album.php?albumid=70&pictureid=848

http://www.emtlife.com/album.php?albumid=71&pictureid=389

And even those areas are more accessable, but would take us hours to get in to and then, worse, to access the patient.  Trust me.  Me thinks you overestimate your areas wilderness-ness and/or your areas Wilderness Rescue Capabilities...  Best case scenerio, from injury to the time the subject could be in the OR... 6 hours...  more realisticlly... 12 to 36 hours... anything else and we are not talking about real wilderness (USFS definition: COMPLETELY WILD and UNTAMED).


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## Mountain Res-Q (Sep 21, 2009)

A word on the thought of "what is really remote?"

We ran a call last year where the subject had one of those new emergnecy GPS locaters, where you can push a button and send out a 911 signal.  Those coordinates are given to the local SAR team as soon as possible (<2 hours).  Of course, the reason he sent out the signal was becasue he was trying to beat an incoming early snow storm and got bluffed out (stuck on a cliff side).  He was located in the federally designated wilderness (112,000 acres of granite and alpine forests at 5,000 to 12,000 feet only access by law is on foot or horse, http://en.wikipedia.org/wiki/Emigrant_Wilderness) The weather made helo not possible for at least 36 hours.  We had his exact coordinates (or so we thought) and it took us, from the moment the call went out to the moment we (2 of us) were at those coordinates, 38 hours!  Only he wasn't there (coordinates were inacurate).  It took another 30 hours to locate him, deceased by now; and another 2 hours to access him with ropes...  

And I am in California, the most populated state... and we have that kind of remote area (and that wasn't as remote as it could have been, infact it was on the edge of the wilderness boundry).  Of course, by the end, we had the helo available and good weather and transport out took 30 minutes from the wilderness to the helibase, but it gets a lot worse when you are talking about "remote", especailly when you are talking about Northern Cananda, Alaska, the Andes, etc...  Even our neighbors in Yosemite, with a fully staffed expert SAR Team and a Helo on standby would take hours, if not days, to get a surgeon to the remote areas of the park (weather dependant).


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## VentMedic (Sep 21, 2009)

falcon-18 said:


> please, let us talk in this subject. we have one coutry it is EMS country we discuss in it. did you see what Mountain Res-Q said you can go back and see it.


 


falcon-18 said:


> A tourniquet not stopping the bleeding?
> 
> sure it is. did you think it is stop bleeding in brain. that is what I mean.


 
Brain? No, a tourniquet is for the extremity. As I already said if you have no other meds other than the IV fluids there may be little you can do for a TBI. 



falcon-18 said:


> Even a Paramedic in this country would be addressing all the issues before considering amputation. also in my country


 
So post your protocols. 



falcon-18 said:


> thanks VentMedic . I know my job.


 
You may know your job but you do NOT know the levels of the U.S. or the training. You were asking about an EMT and not a Paramedic which is the reason a clarification was needed. 

Why don't you post your protocols or the scope of practice for a Paramedic where you are at. 

And again, what are a student of? Are you a Paramedic or are you just starting your Paramedic training? 




> quote by *Akulahawk*
> That is something that is highly unlikely to occur in the field. My feeling is that if you're that far out *where you think the patient will die without immediate amputation *and there's no chance of getting a surgeon to the patient (how are you going to evacuate the patient if you can't bring the surgeon to the patient?), the patient will likely die regardless of your amputation efforts.


 
Yet, other than length of time, he has provided no information about the assessment of a patient. 

Sometimes people get fixated on one gross point and can not see the logic or reasoning beyond that. Some become so overwhelmed by that one point that they fail to properly assess and treat or alleviate the other factors.

It is not unheard of for a Paramedic in the U.S. to finish amputating an extremity that requires very little effort or equipment such as just tissue is all that is holding the parts together in the entrapment.  But, there is a difference between EMT and Paramedic in the U.S.


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## Akulahawk (Sep 21, 2009)

VentMedic said:


> Yet, other than length of time, he has provided no information about the assessment of a patient.
> 
> Sometimes people get fixated on one gross point and can not see the logic or reasoning beyond that. Some become so overwhelmed by that one point that they fail to properly assess and treat or alleviate the other factors.
> 
> It is not unheard of for a Paramedic in the U.S. to finish amputating an extremity that requires very little effort or equipment such as just tissue is all that is holding the parts together in the entrapment.  But, there is a difference between EMT and Paramedic in the U.S.


Indeed, there is precious little info about this patient other than basically being a critically entrapped, limb crushed patient in some remote place where you can't get a surgeon to the patient... and if you don't immediately amputate, the patient will die...

Completing an amputation, to me, is something far different than initiating one... which is what I gather (from scant info) Falcon-18 wants to jump right into...


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## Mountain Res-Q (Sep 21, 2009)

Akulahawk said:


> Completing an amputation, to me, is something far different than initiating one... which is what I gather (from scant info) Falcon-18 wants to jump right into...



For the record, amputating a limb is easy... having your patient survive is another story... especially when we tlk about transport time wihtout the helo (which must not exist if we couldn't get a Surgeon in to us)... which is why I will say again, if the patient is alive by the time we get there, then the patient is not critical, so why would I potentially change that by whacking off a limb?

Baed on the "scenerio" presented, I would be lead to believe that I should be ready to take off a limb at some point in the near future (hear that LucidResq and WarDance... clean up your hack saws ), and somehow I believe that the circumstances tht would present themselves in order to warrent this action are not likely or realistic, for many reasons expressed here.  But again, I say that if the stars alligned and there was no choice...  I would order a subordinate to start hacking away... :unsure:  LOL


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