Our thanks to Jon Mansfield for taking the time to sit down with us and talk about a “once in a lifetime” run. In this episode, Jon made several references to the fact that this is not a procedure that he had ever contemplated before, or was ever taught. Kudos to all involved for coming together to make the tough decisions that resulted in a life saved.
- This was not a flippant decision that was made.
- Several hours of grueling extrication took place before this procedure was even an option.
- The patient was buried under several layers of debris, a cargo trailer, and pinned in the crumpled cab of a semi truck.
- The patient’s leg was badly mangled and intertwined with machinery in the vehicle.
- Crew was watching patient actively decompensate during extrication and knew that if they waited any longer, the patient would surely die.
WHAT IF I HAVE NEVER BEEN TAUGHT TO DO IT?
- Historically, paramedics haven’t fared well performing skills outside of their scope of practice.
- The crew involved knew there was the possibility of all of them losing their jobs and still decided to act.
- Jon contacted medical control at the nearest Level II Trauma Center, explained the scene explicitly, and told them all of the work they had done thus far to extricate the patient without success.
- After detailing all of this, Jon requested that a surgeon or ED physician make the scene to perform the actual amputation; none were available. Medical control advised Jon that he could perform the procedure.
- Understanding the gravity of the situation, Jon contacted his on-duty supervisor, his director, and medical control over a recorded line to insure everyone was on the same page.
- Exhausting all other options, Jon receives the go ahead from all avenues to perform the procedure with guidance from medical control.
- Jon echoes that almost all ALS providers are prone to missing the BLS skills in this situation, reevaluates for airway patency and hemorrhage control.
- Gains large-bore IV access in the antecubital; small fluid bolus initiated.
- Attempts prehospital conscious sedation; opted not to fully knock down patient due to airway complications in a confined space. Administered 5.omg midazolam.
- Side Note: Jon was working out of a small pharmacological tool box, but we would suggest that if you have access to ketalar (Ketamine) that this agent would probably be preferable in an instance like this. Not only do you have the dissociative properties, but also some element of analgesia. You are much less likely to tank a blood pressure with Ketamime than Versed.
- Commercial tourniquet placed proximal to the amputation site; Jon states that he could hear the patient moan when cranked down on the tourniquet. If tourniquets are used properly, they are supposed to hurt, and require aggressive pressure to fully insure hemorrhage control.
- Cut away remaining skin and adipose tissue with a scalpel; used a large-tooth sawzall to cut through the actual femur. Jon equated cutting through the tibia/fibula with attempting to cut through a log; the saw didn’t do all of the work.
- It is incredibly easy after an emotionally taxing scene for our minds to shut down and not be aware of any other potential dangers that might present themselves to our patients or ourselves.
- Following the amputation, the crew still had approximately a 10 minute transport time to the trauma center where they had to immobilize the patient, maintain the patient’s airway, manage other presenting injuries, as well as titrate fluid boluses to manage the patient’s vital signs.
- If you have access to tranexamic acid, now is the time to use it (within your protocols).
- Don’t forget to look out for the basic things; i.e. gauging the stages of shock in your patient.
- Prevent the lethal triad to the best of your ability.
- “Napoleon stated that the moment of greatest danger was the instant immediately after victory, and in saying so he demonstrated a remarkable understanding of how soldiers become physiologically and psychologically incapacitated by the parasympathetic backlash that occurs as soon as the momentum of the attack has halted and the solider briefly believes himself to be safe.”- Dave Grossman, On Killing
If you are interested in seeing more footage of the accident, check out this video.