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The Best Way To Amputate A Limb
#1
Published in last week's Emergency Medicine Journal (full paper is Open Access and available at this link)

Quote:ABSTRACT
Objective Prehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital emergency amputation.

Method A guillotine amputation of the distal femur was undertaken in fresh frozen self-donated cadavers. A prehospital doctor conducted a surgical amputation with Gigli saw or hacksaw for bone cuts and firefighters carried out the procedure using the reciprocating saw and Holmatro device. The primary outcome measures were time to full amputation and the number of attempts required. The secondary outcomes were observed quality of skin cut, soft tissue cut and CT assessment of the proximal bone. Observers also noted the potential risks to the rescuer or patient during the procedure.

Results All techniques completed amputation within 91s. The reciprocating saw was the quickest technique (22s) but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than a minute. The quality of the proximal femur was acceptable with all methods, but 5cm more proximal soft tissue damage was made by the Holmatro device.

Conclusions Emergency prehospital guillotine amputation of the distal femur can effectively be performed using scalpel and paramedic shears with bone cuts by the Gigli saw or fire service hacksaw. The reciprocating saw could be used to cut bone if no other equipment was available but carried some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but would not be a recommended primary technique for medical staff.

Table 1 - Results of Amputation Technique

Plusses and minuses for each technique, looking at time to completion and damage to remaining tissue.  The Holmatro didn't fare too well but would work well under water.  The reciprocating saw did quite well but sprays debris everywhere.
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#2
Decided to google 'gigli saw' and looked at a video of it in use. Will be a while before I forget that noise #scarredforlife

I'm surprised the holmatro did such a bad cut. You'd think it would be perfect for the job.
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#3
Heard of it done once years ago using the cutters from the RTA gear.
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#4
(24-08-2016, 09:25 AM)Blackbolt Wrote: Heard of it done once years ago using the cutters from the RTA gear.
Heard that story locally too, I think.

Well, now we've got evidence about the best way to do it.

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#5
There's no fucking way I'd be able to cut someones limb off with Holmatro......................and I have absolutely no feelings 04
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#6
I believe the subbo would not ask any of his men to do it so he did it himself and from what I heard was never the best after it.


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#7
Id wonder who would take responsibility for this call ? The fire officer in charge or the lead paramedic on scene? Seems like one he'll of a decision to make especially considering the restrictions that are already being put on both services in Ireland ! Fire crews who can't use chainsaws because they are "too dangerous" and paramedics who are not allowed use certain life saving interventions because they are "too risky for the road "
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#8
(25-08-2016, 12:26 AM)Eighttoamile Wrote: Id wonder who would take responsibility for this call ? The fire officer in charge or the lead paramedic on scene? Seems like one he'll of a decision to make especially considering the restrictions that are already being put on both services in Ireland ! Fire crews who can't use chainsaws because they are "too dangerous" and paramedics who are not allowed use certain life saving interventions because they are "too risky for the road "

I believe it was a doctor on scene.
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#9
It would have to be a doctor on scene....no way would anybody else make that call. Sure we don't even have an amputation CPG!  75

It reminds me of that poor guy who drowned a few years back in the UK, remember he was caught in a drain during a flood? A decision like that could've saved his life.
It's not the HSE's opinion, it's not managements opinion, it's mine. All mine.
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#10
(24-08-2016, 11:36 PM)Blackbolt Wrote: I believe the subbo would not ask any of his men to do it so he did it himself and from what I heard was never the best after it.
Probably the correct decision though.  You can't ask someone to do something that you wouldn't do yourself, particularly something like that.

(25-08-2016, 10:23 AM)MRX Wrote: It would have to be a doctor on scene....no way would anybody else make that call. Sure we don't even have an amputation CPG!  75

It reminds me of that poor guy who drowned a few years back in the UK, remember he was caught in a drain during a flood? A decision like that could've saved his life.

They have the indications for performing the amputation listed as:
Quote:The indications to perform prehospital amputation include:
an immediate and real risk to the patient's life due to a scene safety emergency
a deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
a completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation
the patient is dead and their limbs are blocking access to potentially live casualties.

For the dead person impeding access to a casualty I don't think you'd need oversight.  It's just a decision to be made.  Also, the technique used won't matter.  For the scene safety emergency you're talking about fire or water unfortunately.  In that case it'd most likely be a firefighter going in to do the job.  In that situation you're not going to be able to either look for i) permission or ii) for someone else to do it.  For the water in particular, the Holmatro is the only technique that will work and I'm the least trained in it.....  (Not that I'm really trained in any of the other techniques, mind.)  Zero visability after the first cut means the Gigli saw or hacksaw are out.
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#11
There were some videos of Holmatro cuts on dead pig limbs, at some course or other I was at a few years ago - it looked a lot tidier than I thought it was going to.

The UK case in the drain makes for a very tough what-if - looking at it from the point of view of the victim, I reckon if he had been able to (and knew the likely outcome) he'd have chosen the cutter.
http://metro.co.uk/2007/12/10/doctor-i-c...eg-588370/
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#12
(25-08-2016, 04:39 PM)civdef Wrote: There were some videos of Holmatro cuts on dead pig limbs, at some course or other I was at a few years ago - it looked a lot tidier than I thought it was going to.

Dead pig limbs though very simular to humans from an anatomical point of view are missing one key feature and that is a beating heart. I'd imagine (and thankfully it's just that) that even with tourniquets and other haemorrhage control cutting through someone's femur will be a very messy affair
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#13
You probably would get a fair amount of ooze, as well as the blood that happened to be in the limb when a tourniquet was put on.  The article also recommended putting on a double tourniquet, one beside the other, as even in the cadavers there was some leakage of blood with the tourniquet.

Again, thankfully not something that I've had first-hand experience of.
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#14
In terms of "tidy" I was thinking more of the effect on bone than blood - on the video, the bone wasn't as crushed and splintered as I thought it would be before seeing it.

In terms of pure mess, I'd say the recip would be fairly rough, especially with the 10-14 Tpi blades used for extrication.
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#15
Lots of meds for the patient is what I would like first and then keep the crowd around to a minimum. After that all depends on what tools are available


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