The physician team had a brief discussion with the patient regarding his condition and the need to amputate. The patient verbally agreed to amputation, however, the patient was noted to again be in considerable distress and had already received 200 mcg of. All the preparation done by fire rescue prior to EMS physician arrival helped minimize any delay to amputation and scene time.

Amputation

The patient is lowered from the auger. (Click to enlarge.)

The decision was made to intubate mainly for sedation. Ketamine was chosen because of the prior hypotension. In addition, this would provide both anesthesia and analgesia. The patient was given rocuronium for paralysis. The patient was found standing with most of his body in the concrete hopper and it was not possible to lay the patient down for intubation. One physician, Dr. Conner stood on a six-foot ladder above the patient to intubate using a portable glideslope kept on the EMS physician vehicle. Since the patient was already rigged in the position in which he was found, only head support was needed after paralysis. There was brief hypotension noted after intubation for which the patient was given a push dose of phenylephrine. The intubation was completed within 15 minutes of the EMS physician team arrival.

Post surgery, the patient was transported via helicopter to a trauma center. (Click to enlarge.)

After the airway was confirmed and secured, Dr. Burgbacher used a scalpel to cut through the remaining soft tissue. The patient’s foot was placed in a bag and in a cooler full of ice that was donated by the construction crew on scene. First amputation was completed within 20 minutes of EMS physician arrival.

At this point, the extrication team attempted to pull the patient out of concrete machine with the excavator and rigging, only to find that the patient’s leg was still entrapped. The patient’s lower leg was covered in soft concrete and once this was dug out, it was realized that the auger still had the patients right leg pinned at the upper calf.

After further discussion between the physician and rescue teams it was decided that a second amputation was required. Given the limited access inside the concrete hopper, the decision was made to attempt disarticulation at the knee. However, this proved to be too difficult to complete and was quickly abandoned in favor of an above the knee amputation. Using multiple scalpels to cut down any soft tissue to the bone, a commercial reciprocating saw borrowed by the fire department was used to cut through the distal femur. The second amputation was completed approximately 18 minutes after the first.