Page 116 - JSOM Summer 2023

An Ongoing Series

Bilateral Above the Knee Amputation in Afghanistan

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Travis Schoenberger, 18D ; Blake Foret, 18D ;
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Joshua Evans, PA-C *; Akira Shishido, MD 4

ABSTRACT
Prolonged Casualty Care (PCC) has become an essential Forces, the 18Ds requested telemedicine support from their
component to Special Operations Forces (SOF) pre-mission supervising Surgeon and Deputy Surgeon (unit medical team)
training. However, it has not regularly been required in recent via phone.
combat operations with the availability of medical evacuation
(MEDEVAC) support. Poor weather conditions at an austere Case Report
SOF outpost created an emergency unreachable by aeromed-
ical evacuation. Herein, we report a case of an emergency bi- The unit medical team discussed potential operative treat-
lateral above-the-knee amputation procedure performed by ment and advised direct consult with the Deputy Commander
three Special Forces Medical Sergeants (18D(a), 18D(b), and of Clinical Services (DCCS) of Craig Joint Theater Hospital
18D(c)) and supporting Army medics with minimal telemedi- (CJTH) on Bagram Air Field (BAF), who was a general sur-
cine consult and guidance. geon. The 18Ds discussed the case with the CJTH DCCS who
provided further telephone review of anatomical landmarks,
Keywords: amputation; austere; medevac; special operation; prophylactic antibiotics, anesthesia practices, and procedural
Afghanistan; emergency; telemedicine; combat techniques. Further communication measures were consid-
ered, including live video consultation, but were not feasible
because of limited internet bandwidth. Following consul-
tation, the ODA 18Ds, an Operational Detachment Bravo
Introduction
(ODB) 18D (18D(c)), and supporting medics began convert-
In November 2019, a surrendering ISIS-K supporter made ing the camp Casualty Collection Point (CCP) into a surgical
his way to a Special Forces Operational Detachment Alpha’s suite. The procedure was discussed with the patient through an
(ODA) outpost in Afghanistan. He went through the ODA’s interpreter assigned to the ODA and consent was given for the
established screening process and was moved to a nearby loca- surgery, including allowing photographs to document the case.
tion for medical attention. Partner forces isolated him from the These events occurred at approximately 1700hrs.
other surrendering ISIS-K personnel, allowing 18D evaluation
and consideration of further medical care due to the severity The CCP was segmented by tarps, isolating the operating area.
of his wounds. A surgical scrub area outside of this room and a consolidation
area for used instruments and garbage collection were estab-
He presented with one traumatic amputation of the right leg lished (Figure 2).
with the entirety of his right tibia exposed (Figure 1). The pa-
tient’s left leg had comminuted tibia and fibula fractures. Dif- The ODA leadership confirmed that weather and transpor-
fuse bilateral subcutaneous emphysema recognized on plain tation/MEDEVAC constraints would not change for six or
films indicated a gangrenous infection of bilateral lower ex- more days. Given the patient’s status and the likelihood of de-
tremities. Initial vital signs were assessed that morning during compensation without definitive care, the final decision was
the first evaluation at 1000hrs and included a blood pressure made for surgical intervention. Supporting medics assisted
(BP) of 110/75, heart rate (HR) of 140 beats per minute, tem- with trending patient vitals in preparation for induction final
perature of 103.7°F, and a respiration rate (RR) of 24 breaths pre-op vital signs of BP 140/75, HR 125, Temp 103.5°F, RR
per minute. With poor weather in the area, aeromedical evac- 20. In final stages of surgical preparation, the 18Ds adminis-
uation was requested but not available. To avoid the loss of tered IV cefazolin 1g and secured a saline lock in the patient’s
life of a surrendering enemy while under the care of Coalition left arm.
*Correspondence to 11joshevans@gmail.com
1 Travis Schoenberger and Blake Foret are Special Forces Medical Sergeants (18D) in 1st Special Forces Group (Airborne), Joint Base Lewis-
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McChord, WA. CPT Joshua Evans is a physician assistant affiliated with 1st Special Forces Group (Airborne), Joint Base Lewis-McChord, WA.
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4 Dr Akira Shishido is a physician affiliated with the Virginia Commonwealth University, Division of Infectious Diseases, Richmond, VA.
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