CHAPTER 64: Field Surgery

INTRODUCTION

Field surgical procedures are for the most part relatively uncommon with few cases reported and published. Barriers to reporting likely include a preponderance of poor or unfavorable outcomes and the perceived risk of litigation in these high acuity scenarios. Although some hospital-based surgical “go teams” exist,^1,2 it is more likely that an EMS physician will be responding to these incidents in most communities. Rather than task a system to make available an additional trauma surgeon it is seemingly more appropriate for EMS physicians (of all primary training backgrounds) to maintain their education and training in these potentially lifesaving procedures. The following text is meant as an introduction to these procedures as they are likely to be performed in the austere and limited environment of the prehospital setting and in no way meant to substitute for, or replace the need for, EMS physicians to study and train on these techniques in the controlled environment of the anatomy lab or operating theater.

FIELD SURGICAL PROCEDURES

• Extremity amputation

• Thoracotomy

• Escharotomy

• Fasciotomy

• Perimortem cesarean section

FIELD SURGERY KIT

EMS Physician Basic Instrument Kit (Centurion SUT17530)

• 1 Fenestrated drape

• 4 Cloth towels

• 1 Spinal needle, 20 gauge × 3 ½ in

• 1 Needle, 18 gauge ×1 ½ in

• 1 Needle, 27 gauge × 1 ¼ in

• 2 Syringes, 10mL

• 20 Gauze sponges

• 1 Safety scalpel with #11 blade

• 1 Safety scalpel with #15 blade

• 1 Safety scalpel with #21 blade

• 1 Tracheal hook

• 1 Tracheal dilator

• 1 Forcep, 1:2 teeth

• 1 Curved scissors

• 1 Needle holder, 6 in

• 1 Needle holder, 8 in

• 3 Curved hemostats

• 3 Straight hemostats

Additional Instruments

• 2 Gigli saw handles

• 4 Gigli saw blades

• 1 Safety scalpel with #10 blade

• 1 Rib spreader

• 4 Tourniquets (CAT or SOFT-T style)

• 1 Disposable OB kit

• 2 W35 skin staplers

• 2 Syringes, 20mL

Optional Instruments

• 2 Army navy retractors

• 1 Curved (Metzenbaum) scissors

• 2 Russian forceps, 5½ in and 8 in

• 1 Bladder retractor

• Other instruments as preferred by EMS physician/team

FIELD AMPUTATION

Field extremity amputation is a relatively uncommon procedure for any EMS physician to have to consider; however, there is a documented need for this capability in the prehospital setting.^3-10 Because of the potential for an awake patient to possibly require such a drastic and potentially painful intervention, it is appropriate for the EMS physician to ensure the availability of sedatives (eg, ketamine, midazolam, etomidate) and analgesics (eg, fentanyl, morphine) on the scene, by either carrying them with them or having them available by other means within the system.

Indication

• When the entanglement of an extremity (or extremities) precludes timely rescue and patient care that is deemed necessary to sustain life, and it is believed that survival of the patient without the amputation ...