Page 119 - JSOM Summer 2023

4
encountered, which was drained and irrigated. Vessel ligation carried out later. In this case, closure was carefully consid-
and tissue dissection to the femur was complete within 90 ered by the medics. The environment with limited access to
minutes. The left femur was approximated within an inch of follow-up care made them feel that closure was the best op-
the right based on availability of viable tissue. Closure and pen tion. Had there been improved access to follow-up surgical
rose drain placement was conducted in the same manner as the care, this is one area that the operating team would have likely
right leg without complication (Figure 5). changed in their surgical treatment plan.

FIGURE 5 Amputations complete.
Lessons Learned
Training that had been instilled in these 18Ds throughout their
Special Forces Qualification Course and through continuous
team internal cross training provided the knowledge and con-
fidence to perform this lifesaving procedure.

In After Action Review (AAR), there was conversation on the
appropriateness of wound closure immediately following the
procedure. While a two-stage closure may have reduced long
term complications and/or reduced risk of infection, the au-
thors still felt that the one stage approach was more appro-
priate in this situation as there was no clear option of a future
second stage. 5
Internal ODA cross training and leadership’s support of med-
ical capability was critical and remains to be a center focus of
training within this unit. ODA members, while not mentioned
above, were able to provide crucial support by retrieving med-
ical supplies when needed, performing duties somewhat like a
circulating nurse.

Conclusion
Traumatic amputations in the combat environment offer a
The sedative medications tapered off and the patient began to unique challenge that Army Special Forces Medical Sergeants
slowly rouse as dressings were being applied. He departed the are capable of treating. Training and equipping these pre-
field operating room with open eyes and deliberate movements hospital providers are necessary to ensure optimal care re-
at approximately 0320hrs, nearly eight hours after induction. mains available for future deployments.
Post-op nursing care, wound care, and medication instructions
were translated to Pashtun and the patient was provided with Author Contributions
cephalexin 500mg (three times daily (tid) × 7 days), ibuprofen TS and BF performed the prolonged casualty care operation
800mg (tid × 7 days), acetaminophen 325mg & oxycodone and drafted the initial manuscript. JE and AS provided initial
5mg (8 total), diazepam 5mg (10 total). 18D(a) and 18D(b) telemedicine consult and revised original manuscript to its cur-
were able to follow up on the patient after two weeks and he rent form. All authors read and approved the final manuscript.
was reported to be recovering well.
Disclosure
The authors have no conflict of interest to disclose.
Discussion
Traumatic amputations and/or mangled extremities should Disclaimer
rarely undergo surgical treatment in the pre-hospital setting. This manuscript was reviewed and approved for publication by
1
The above case highlights a unique operational environment 1st Special Forces Command (Airborne) Public Affairs Office.
in which the combination of poor weather, limited evacuation
support, and highly competent Special Forces Medical Ser- References
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New York, NY: Elsevier; 2017.
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related amputations. J Surg Ortho Adv. 2010; 19(1): 35–43
This patient will likely have decreased function and possibly 3. Mitchell SL, Hayda R, Chen AT, et al. The Military Extremity
psychosocial complications due to his bilateral lower extrem- Trauma Amputation/Limb Salvage (METALS) Study. J Bone Joint
ity amputations. However the risk of further complication Surg Am. 2019; 101(16):1470–1478.
2,3
and possible death from infection, the authors of this arti- 4. Gordon W, Balsamo L, Talbot M, et al. Amputation: Evaluation
and treatment. Mil Med. 2018 Sep 1;183(suppl_2):112–114.
cle felt that his long-term outcome was improved from the 5. Fisher DF Jr, Clagett GP, Fry RE, et al. One-stage versus two-stage
intervention. amputation for wet gangrene of the lower extremity: a randomized
study. J Vasc Surg. 1988;8(4):428
Preservation of limb length is a critical consideration during
assessment of surgical sites for retention of viable tissue and PMID: 36951633; DOI: 10.55460/5HLH-TW89
possible delayed wound closure, which is more optimally

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