RE: RE: MDs for field amputations/abgl-response

["Laurie A. Romig, MD" <laurie.romig@verizon.net>]

I've actually been sitting back and trying to figure out what my opinion is.
Technically, I don't think that there's any question that RN's or paramedics
could be trained to do field amputations. The actual ability to perform a
procedure is seldom a major consideration in my mind. The special
considerations that Wesley has elegantly outlined make this procedure less
of a "finesse" procedure than it would be in the OR, where a detailed
knowledge of anatomy and wound healing are required. Although I have, in the
course of my training, made that final cut that let a leg drop to the OR
table, I don't particularly consider myself to be any more adequately
trained to do a field amputation than what other providers could be trained
for.  (Incidently, a favorite game for surgery residents is to let the med
student do the actual "saw through the bone" work, with a giggly (yup!) saw.
It's a manual, wire-like sawing instrument that takes a certain knack to get
going and keep it going. The residents love to watch the med student
struggle with it while working up a good sweat.)

That being said, the other considerations have also been touched upon.
Maintaining skills competency becomes an increasingly greater challenge the
more rarely a skill is performed. And the judgement question of when the
procedure is appropriate needs also to be included in training, even though
it can be addressed via protocol and direct medical control. I certainly
wouldn't encourage the use of the procedure unless  *all* of the tools
needed, including adequate pain management, sedation, and amnestic, and
probably blood are available. If you have to send somebody to the hospital
to pick up blood and/or meds, you may as well pick up a surgeon while you're
there. Also, remember that this is an irreversible procedure! "Ooops, let me
just fix that for you" isn't an option.

I can also hear some of my trauma surgeons having major heartburn about
people doing surgical procedures who cannot take care of potential
complications, therefore "dumping the patient in our lap to fix their
mistakes". We get this argument about chest tubes and central lines (even
about ED physicians doing central lines, believe it or not) already.

Now, having laid out some of the arguments, what's my opinion?

Could RN's and EMT's be trained to do field amputations?  Yes

Should they?  Yes and no, depending upon local circumstances. (You didn't
think I could come up with a black and white answer, did you?) If surgeons
are readily available, or if you don't have all of the
equipment/meds/training to do it right, no. If you're in the wilds of
Alaska, and on your own, or have extended response times for an
appropriately trained physician to the scene, yes, but I would involve your
receiving surgeons in your protocol evolution, training, followup and QA.

Thanks for letting me put more than my two cents worth in.

Laurie

> -----Original Message-----
> From: flightmed-admin@flightweb.com
> [mailto:flightmed-admin@flightweb.com]On Behalf Of
> copterrn@bellsouth.net
> Sent: Sunday, June 16, 2002 11:53 AM
> To: flightmed@flightweb.com
> Subject: Re: RE: MDs for field amputations/abgl-response
>
>
> Dr. Romig,
>
> I am interested in your opinion on this thread about training
> field personnel to provide amputations.
>
> Being deeply involved with trauma care at our trauma center, I
> have an opinion, but am presently biting my electronic tongue.
>
> From a physician perspective, what is your take on this complex
> and complication ridden task being provided by RNs and paramedics?
>
> Awaiting your response!
>
> David Summers RN, CEN, CFRN, EMT-P
> Peds Trauma Coordinator
> West Palm Beach- FL
> >
> > From: "Laurie A. Romig, MD" <laurie.romig@verizon.net>
> > Date: 2002/06/16 Sun AM 11:44:58 EDT
> > To: <flightmed@flightweb.com>
> > Subject: RE: MDs for field amputations/abgl-response
> >
> > And here I was, trying to figure out why goat ropes put people
> at such high
> > risk for emergency amputation.... :-)
> >
> > We would also fly one of our trauma surgeons out to the scene,
> but I don't
> > think that we have any organized plan or equipment for it. We
> would probably
> > just manage with our usual selection of meds, unless the doc happened to
> > grab some of his favorites on the way out the door.
> >
> > Laurie Romig, MD
> > Bayflite, St. Pete, FL
> >
> > > -----Original Message-----
> > > From: flightmed-admin@flightweb.com
> > > [mailto:flightmed-admin@flightweb.com]On Behalf Of David Steele
> > > Sent: Saturday, June 15, 2002 11:02 PM
> > > To: flightmed@flightweb.com
> > > Subject: Re: MDs for field amputations/abgl-response
> > >
> > >
> > > The last amputation that was done on our freeway system was
> done I believe
> > > with a standard hacksaw by an ED doc.  The accident was a few
> minutes away
> > > from the level one trauma center.  The first doc on the scene was
> > > to big to
> > > get into the compartment so they had to get the smallest doc
> on duty to go
> > > to the scene...
> > >
> > > Now I am in no way advocating training to do amputations in
> the field.  It
> > > would be one of those procedures that you wouldn't do enough
> of to stay
> > > current in.  However I don't believe by going to med school
> > > qualifies you to
> > > do a amputation either.  I have always said you could train
> anyone to do
> > > procedures in our industry and this isn't any different.  We could be
> > > trained to do this.  It would be an emergent procedure, Life saving
> > > procedure, you surely wouldn't worry about your stump closure..
> > > Who do you
> > > think did them during Vietnam??  talk with some of those hero's in the
> > > field.  I can guarantee you they weren't physicians...
> > >
> > > So now that we know we can do them..  should we.....  Again..
>  I think it
> > > boils down to can you stay current in the procedure..  or in
> your training
> > > and what is the industry standard.  I don't think you
> probably could stay
> > > current, nor is the industry standard to let aeromedical
> crews (RN,Medics)
> > > do amputations in fields (that I am aware of).
> > >
> > > Now to the question.
> > >
> > > We don't have a procedure at our program either.  I am also sure
> > > it would be
> > > a goat rope (new term for me)..  We probably would fly to one of
> > > our level 1
> > > trauma centers and pick up a ED doc a minute away (airport
> based service)
> > > and proceed to scene.  They would be responsible to bring their own
> > > craftsman tools.
> > >
> > > David Steele
> > > email   dsteele1@mn.rr.com
> > >
> > >
> > >
> > >
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> >
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>
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