Page 73 - 2022 Spring JSOM

Use of Knives and Multitools to

Perform a Cadaveric Limb Amputation

Russell A. Baker, DO*; Ryan Worth, DO; Nima Pourrajabi, DO;
Joseph Martin, MD; Sara Mitchell, MD; Sunny Baker, PA-C

ABSTRACT
Background: An austere field amputation can be a life-saving are required to perform life-saving amputations, as was the
procedure for an entrapped patient when standard equipment case of rock climber Aron Ralston, who used a multitool to
is not available or operable. The objective of this study was to self- amputate part of his arm. In these situations, one must
4
use hand tools to perform cadaveric amputations in < 2 min- consider available options, such as a simple hand tool, for am-
utes. Methods: Timed guillotine amputation of the extremities putation if it is the only equipment available.
on three cadavers was attempted using four available hand
tools: a multitool, a rescue tool, a hunting knife, and a fixed- Few studies exist regarding prehospital field amputations, and
blade knife. The primary outcome was successful amputation most are case reports of the procedure. Porcine and cadaveric
5
of the extremity in < 2 minutes. Results: Amputation success studies using standard tools carried by emergency medical ser-
was different among the tools. The multitool amputated 78% vices (EMS), such as reciprocating saws, hack saws, and hy-
of attempts; the hunting knife, 67%; the rescue knife, 56%; draulic devices, have been examined. One study concluded
6,7
and the fixed-blade knife, 44%. The distal tibia/fibula and ra- that amputation of the distal femur is possible using a scalpel
dius/ulna were amputated successfully in 100% of attempts, and paramedic shears to cut through soft tissue and perform-
whereas none of the tools could amputate the femur. The mul- ing bone amputation with a Gigli saw or hacksaw. Unfor-
8
titool received the best subjective ranking—1.4 (p = .001)— tunately, a literature review resulted in only a single abstract
by amputators, with the fixed-blade knife receiving the worst that reported on amputations using standard hand tools. The
score. Conclusions: In the rare circumstance that an emergent authors evaluated the difficulty and safety of cadaveric ampu-
field amputation requires a hand tool, the multitool is a capa- tations using multiple instruments, including seven total am-
ble instrument for a distal extremity amputation. putations using a Gerber knife, Gerber multitool saw, and a
Leatherman Wave multitool. 9
Keywords: amputation; knife; saw; prehospital; field; emergency
Patients with a prolonged scene time have increased odds of
mortality and require rapid rescue. This study aimed to evalu-
10
ate whether limb amputations are possible using four common
Introduction
hand tools to successfully amputate a cadaveric limb. We ex-
Field surgical limb amputation is a rare but potentially life- amined these tools under the presumption of a life- threatening
saving procedure. Indications for amputation include a trapped scenario in which death is expected unless a rapid amputation
patient threatened by a scene emergency, rapidly deteriorating is performed.
clinical status, exsanguination or cardiopulmonary arrest, a
mangled nonsalvageable limb that is delaying extrication and
compromising either the patient or the rescue team, and a de- Methods
ceased patient who is preventing access to potentially live per- This was a prospective cadaver-based study to evaluate whether
1
sons. In the ideal circumstance, medical personnel trained in four standard hand tools could successfully amputate cadaveric
amputations would complete an amputation using the proper limbs. The primary outcome was to complete the amputation
equipment. Emergency medical personnel or first responders in < 2 minutes. The secondary outcome was the subjective ex-
often carry Gigli saws or reciprocating bone saws suitable for perience of the amputator using the knife or tool. The institu-
amputations when a trained surgical team cannot go to the tional review board exempted this study because it involved
scene. However, in the rare circumstance that these tools are previously collected nonidentifiable human tissue.
unavailable or inaccessible, first responders may be required
to perform a field amputation using the tools they carry. The amputators included four men and one woman of varying
2,3
size, from 1.6 m to 1.9 m (5 feet 4 inches to 6 feet 5 inches) in
Wilderness, combat, disaster, and austere rescue scenarios may height. They included four emergency medicine residents and
include remote or desolate areas where standard equipment one attending physician, all with various comfort levels, de-
and power sources are unavailable or have limited battery life. grees of experience, and amounts of previous exposure to the
Space restrictions may preclude the use of devices requiring knives and multipurpose tools used in this experiment. Three
full access around a limb. Circumstances may exist where of the amputators also have EMS experience. All the amputa-
rescue units cannot respond, and medically trained individu- tors have experience with cadaveric dissections, but none had
als with a basic knowledge of anatomy and bleeding control previously performed a live or cadaveric amputation.
*Correspondence to Russell.baker@ttuhsc.edu
All authors are affiliated with the Department of Emergency Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX.

71