CASE OF THE MONTH
are etomidate, ketamine, fentanyl, propofol
and midazolam. 9 The overall complication
rate with ketamine, propofol and versed is
about 11%, and complications are primarily
hypoxia or apnea. 10
The experience in Afghanistan has shown
great success with ketamine. Ketmine has an
extremely low side effect profile and has been
used by personnel with little to no medical
training in Afghanistan. 11 The majority of
these medications are used for procedures that
typically last for minutes. In this case, the procedure was completed in 40 minutes with a
combination of fentanyl, versed and ketamine.
The American College of Emergency Physicians’ stance on procedural sedation is that
it’s acceptable to perform in the ED without
any indication of specific agents. 12 However,
recommended monitoring includes EtCO2
and standard telemetry.
In preparation for significant hemorrhage, the patient was administered plasma
and packed red blood cells. Prehospital blood
product administration is a controversial topic.
There are conflicting data likely due to multiple confounding factors such as flight time and
varying injury severity leading to blood product administration. Prehospital blood product
transfusion appears to confer an early survival
advantage but no difference in overall survival. 13
Furthermore, long flight times and head
injury are factors that complicate the deter-
mination of survival advantage with blood
product administration. 14 Although there are
many practical matters such as storage and
temperature regulation, with the appropriate
protocols, carriage of blood products appears
to be a safe, effective way of resuscitation in
the short term. 13
INSARAG, which is an organization coor-
dinated under the United Nations, recommend
that an entrapped limb should be amputated
as distally as possible without endangering the
patient or rescue team. 4 This is consistent with
what was done in the field.
In this case, after conducting the risk/benefit assessment, rather than amputating the
hand at the level of the wrist outside of the
hopper, it was decided that the best compromise between adverse events to the participants
and sparing the patient’s thumb function was
to have the surgeon amputate the distal metacarpals by inserting his body through an upper
inspection door with the auger blades above
and below him. Notably, light was provided
by a flashlight held in the surgeon’s mouth
during the procedure.
This case describes a patient who was
entrapped in the semi-erect position and
liberated with a thumb-sparing completion
traumatic amputation of the hand. It demonstrates not only the risk/benefit assessment
essential to decrease the greatest morbidity
to the patient but also the multidisciplinary
need for physicians in the field when necessary and unconventional use of resources to
improve a patient outcome. JEMS
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.
2. Sharp CF, Mangram AJ, Lorenzo M, et al. A major metropolitan “field amputation” team: A call to arms … and legs.
J Trauma. 2009;67( 6):1158–1161.
3. Raines A, Lees J, Fry W, et al. Field amputation: Response
planning and legal considerations inspired by three separate
amputations. Am J Disaster Med. 2014; 9( 1): 53–58.
4. Macintyre A, Kramer EB, Petinaux B, et al. Extreme measures:
Field amputation on the living and dismemberment of the
deceased to extricate individuals entrapped in collapsed structures. Disaster Med Public Health Prep. 2012; 6( 4):428–435.
5. Stewart RD, Young JC, Kenney DA, et al. Field surgical intervention: An unusual case. J Trauma. 1979; 19( 10):780–783.
6. Capener N. Emergency amputations: Lower limb. Ann R Coll
Surg Engl. 1967; 40( 4):216–222.
7. Osmond-Clarke H. Emergency amputations: Lower limb. Ann
R Coll Surg Engl. 1967; 40( 4):216–218.
8. Kelly JB, Thompson AS, Gervin AA. Field leg amputation by
a paramedic. Prehosp Emerg Care. 1999; 3( 1):77.
9. Tintinalli J, Stapczynski JS, Ma OJ, et al, editors. Tintinalli’s
emergency medicine: A comprehensive study guide. McGraw-Hill Education: New York, pp. 253–255, 2016.
10. Smits GJ, Kuypers MI, Mignot LA, et al. Procedural sedation in
the emergency department by Dutch emergency physicians:
A prospective multicentre observational study of 1,711 adults.
Emerg Med J. 2017; 34( 4):237–242.
11. Schultz CH, Koenig KL, Noji EK. A medical disaster response
to reduce immediate mortality after an earthquake. Ne w Engl
J Med. 1996;334( 7):438–444.
12. O’Connor RE, Sama A, Burton JH, et al. Procedural sedation
and analgesia in the emergency department: Recommendations for physician credentialing, privileging and practice. Ann
Emerg Med. 2011; 58( 4):365–370.
13. Holcomb JB, Donathan DP, Cotton BA, et al. Prehospital transfusion of plasma and red blood cells in trauma patients.
Prehosp Emerg Care. 2015; 19( 1): 1–9.
14. Sumida MP, Quinn K, Lewis PL, et al. Prehospital blood transfusion versus crystalloid alone in the air medical transport of
trauma patients. Air Med J. 2000; 19( 4):140–143.
Calvin Yang, DO, is an emergency medicine resident at
Charleston Area (W.V.) Medical Center.
William Ross, MD, is a plastic and reconstructive surgery specialist with the Charleston Area Medical Center Surgery Center
and clinical professor of surgery at West Virginia University.
L. Michael Peterson, DO, is a board-certified emergency
medicine physician, a critical care transport paramedic and
certified medical transport executive. He’s the medical direc-
tor of the paramedic training program for Mount-West Community and Technical College as well as the medical director
for HealthNet Aeromedical Services-a shared service of Cabell
Huntington Hospital, Charleston Area Medical Center and
West Virginia University Hospital.
Learn more from L. Michael Peterson at
the EMS Today Conference, Feb. 21–23,
in Charlotte, N.C. EMSToday.com
To view the video, please access the digital edition of this issue. Video courtesy William Ross, MD
Video: Bioelectric prosthesis following partial hand ampuation