The collapse of a structure with entrapment of individuals represents a very dangerous environment for entrapped persons and rescuers alike. Earthquakes are one of the most frequent causes of this type of situation. Although many survivors are extricated through the efforts of bystanders and first responders,Reference de Bruycker, Greco and Annino1Reference Noji, Armenian and Oganessian2Reference de Ville de Goyet3 some may be entrapped to such a degree that highly specific expertise and equipment are required to provide safe rescue. The challenges are exponentially increased when the structures involved are reinforced concrete. Urban Search and Rescue efforts have evolved internationally during the past several decades as a distinct discipline to address the medical, search, and rescue techniques required to locate and safely extricate these persons.Reference Barbera and Macintyre4Reference Cone5
It is well documented that some deeply entombed individuals may survive for extended periods in a confined space before being rescued.Reference Macintyre, Barbera and Smith6 Although extreme times to survival have been documented, the majority of entrapped persons are rescued within 5 to 6 days.Reference Macintyre, Barbera and Petinaux7 Multiple factors contribute to their ability to survive. Access to food (coincidentally located with the person), water (eg, rain), and minimal injuries from the initial collapse have all been documented as contributing factors (among others) to lengthen times to rescue.Reference Macintyre, Barbera and Petinaux7 Preexisting medical conditions would presumably affect survivability; however, multiple case reports describe successful rescues of persons with co-existing morbidity or those who are young or elderly.Reference Macintyre, Barbera and Petinaux7 Having early medical care while still entrapped is also cited as a factor contributing to the individual's survival, as there is a high potential for injuries such as crush syndrome, which could cause sudden deterioration or death during extrication.Reference Jagodzinski, Weerasinghe and Porter8Reference Sever, Vanholder and Lameire9 The most critical factor related to survival is the development of a void space (also referred to as “survival space”) that is large enough to permit maintenance of vital functions. For this reason, search techniques are, in part, based on identifying potential void spaces in the collapsed structure that could support life.10
Due to the chaotic fashion in which structures collapse, individuals may become entrapped in such a way that their extremities become pinned under heavy structural elements. In addition, densely populated structures may result in persons becoming entrapped in close proximity to or even entwined with other survivors or the deceased. Both situations create challenges for rescue teams. In the former, great effort may be required to release, breach, or otherwise shore up the structural elements in an effort to remove the individual. Some of these efforts can evolve over many hours, with day-long rescues being common.Reference Macintyre, Barbera and Petinaux7 In extreme cases, extremity amputation may be necessary to remove the person from the environment. Similarly, when persons are entrapped with the deceased, extreme circumstances may force dismemberment of the deceased to gain access to and remove a living person. These highly sensitive procedures should be ones of last resort and protocol driven. In this way, appropriate application is assured in the chaotic and dangerous collapsed structure environment, which may also be extremely politically and culturally sensitive. Protocols must address not only technical aspects of the procedures but, perhaps more importantly, administrative ones as well.
This report discusses the relevant literature and provides several case studies to promote effective understanding of amputations and dismemberments in collapsed structures. Also included are technical considerations and administrative approaches for these procedures, which should be considered ones of last resort. Table 1 includes guidance established by an international body.
Medical Working Group Clinical Guidance Note: Amputations and Dismemberment
LITERATURE REVIEW
The literature search was conducted using the terms “amputation” or “dismemberment” in conjunction with numerous different hazards (eg, field, earthquake, accident, train, motor vehicle, industrial, mining) and the search engines PubMed, Ovid, and LexisNexis. The international literature from 1960 to the present was included. Particular attention was paid to indications for field amputations or dismemberments and management issues related to these procedures. Few publications that addressed these infrequent procedures were found. Some provided case reports related to the transportation sector or industry.Reference Finch and Nancekievill11Reference Stewart, Young, Kenney and Hirschberg12Reference Ebraheim and Elgafy13Reference Ho, Conterato, Mahoney, Miner and Benson14Reference Dunn, Wynn and Polanco15Reference Jaslow, Barbera, Desai and Jolly16 Only one directly addressed the procedure performed in the collapsed structure environment.Reference Jaslow, Barbera, Desai and Jolly16 One publication described an amputation conducted by a paramedic under indirect medical supervision.Reference Kelly, Thompson and Gervin17 One group tested the ability to use hydraulic cutting tools frequently carried by fire departments to perform the procedure using cadaver legs.Reference McNicholas, Robinson and Polyzois18 They demonstrated minimal tissue damage with use of the tool.
Some of the articles address to varying degrees of specificity team composition, required medical equipment, necessary protective equipment, or protocols.Reference Finch and Nancekievill11Reference Jaslow, Barbera, Desai and Jolly16Reference Snook19Reference Foil, Cunningham, Hale, Benson and Treurniet20Reference Sharp, Mangram, Lorenzo and Dunn21Reference Porter22 One author conducted a survey of North American emergency medical service (EMS) systems and found a general lack of protocols for field amputation to extricate victims.Reference Kampen, Krohmer, Jones, Dougherty and Bonness23 Of 143 surveys completed, 13% reported the occurrence of in-field extremity amputation in the preceding 5 years. The majority of respondents (96%) reported a lack of training and preparation for this procedure, and only 2 respondents (<1%) indicated the existence of protocols. Two authors included the issue of informed consent, agreeing that if the person is unconscious, it is most desirable to have 2 physicians document the need for the procedure.Reference Foil, Cunningham, Hale, Benson and Treurniet20Reference Sharp, Mangram, Lorenzo and Dunn21 One of these authors also addressed other considerations in protocols such as “communications, media interactions, crowd and rescue personnel control, and debriefing of EMS personnel.”Reference Sharp, Mangram, Lorenzo and Dunn21
One of the earliest references found that related to field amputation for entrapment was published in 1967.Reference Osmond-Clarke24 This author proposed amputation when the “patient cannot otherwise be extricated in time to save his life.” Another early publication included a case report of a worker trapped by both legs after a partial bridge collapse; bilateral lower extremity amputations were indicated, in part, out of fear for rescuers' safety.Reference Stewart, Young, Kenney and Hirschberg12 Only one publication in this review proposed specific indications for field amputation for the entrapped victim.Reference Porter22 Porter proposed that the procedure is indicated when (1) scene characteristics provide immediate threats to the patient or rescuers, (2) the person's clinical indication is such that the person will die with further delay, and (3) the limb remains minimally attached. In addition, this was the only publication found that specifically mentions dismemberment of a deceased victim. In this case, the author proposed that dismemberment be considered if the deceased is blocking access to potentially live casualties.
CASE STUDIES
Four case studies briefly highlight the complexities involved with field amputations for the living or dismemberment of the deceased. One of the dismemberment cases was not conducted to gain access to a living person. All cases occurred in collapsed structures of heavy reinforced concrete as the result of an earthquake within the past decade. The case studies are de-identified by the individual and also by the incident, as these were extreme instances and were covered in media publications. The procedures were carried out by professional Urban Search and Rescue teams. The authors were present, although not necessarily conducting the procedures.
Amputation Case 1
Circumstances of Entrapment
During an earthquake, a 25-year-old woman became trapped at ground level in a 3-story structure that had completely collapsed. The upper floors collapsed toward the street, falling over the woman at a 45° angle and entrapping her under 3 concrete slabs. She was in a void space that was created by a steel door and a large drum. She was prone, with her right arm under the collapsed slabs of concrete, which were supporting the debris field above. Her fingers could be seen from the other side of the slabs. She was originally located by voice call-out.
Reason for Procedure
Efforts to remove the concrete slabs pinning the woman's arm were judged to be too dangerous. The potential risk of destabilizing the structure and debris field was considered too high, threatening the woman and the rescuers alike.
Administrative Issues Addressed
Representatives from the multidisciplinary on-site Urban Search and Rescue team, which included rescue, safety, medical, and engineering personnel, provided input into the final decision to perform the amputation of her arm. In addition, representatives from 2 other international Urban Search and Rescue teams were consulted. Based on the risks presented, all supported the decision to amputate. The woman had altered sensorium and attempts to explain the procedure to her were futile. No family members were available. Three physicians from the multiple teams present agreed that the procedure was necessary.
Patient Outcome
The procedure was performed after the patient was administered midazolam and ketamine. The entire procedure took less than 5 minutes. She was subsequently rapidly extricated and transported to a field hospital. She was discharged from this facility in ambulatory condition 3 days later.
Amputation Case 2
Circumstances of Entrapment
An approximately 50-year-old man became entrapped on the ground level of a large multistory structure, which collapsed during an earthquake. He had been located by voice call-out and was in a relatively large empty space (permitting 2 rescuers to gain access to him simultaneously), but both his legs were crushed by a large structural beam. The left leg was pinned at the knee and the right at the level of the mid-tibia. No access to the feet was possible.
Reason for Procedure
By the time access was gained (>48 hours after the earthquake), the man was in a severe condition, with signs of shock and an altered mental status that persisted in spite of resuscitation efforts and treatment for crush syndrome. Given the potential time duration until multiple floors above the beam could be removed and with no possibility of undermining the floor, 2 different international Urban Search and Rescue teams agreed that amputation of both his lower extremities was necessary to facilitate rapid extrication before he died.
Administrative Issues Addressed
The decision to amputate was agreed to by 1 physician on each team. No family was available, and the man had an altered sensorium. Owing to his critical condition, an evacuation process was established before conducting the procedure; this included having a helicopter basket lift from a nearby clearing with an attendant on the line.
Patient Outcome
It was determined that the man's airway required control, and rapid-sequence intubation was done while he was still entrapped. A small monitor was used to monitor his vital signs. Treatment for crush and anesthesia/analgesia were administered. Bilateral amputations were performed (above the knee on the left and mid-tibia-fibula amputation on the right). The man was airlifted to definitive care. He died 3 days after extrication.
Dismemberment Case 1
Circumstances of Entrapment
An indeterminate-aged adult man was trapped on the first floor of a large multistory structure that had completely collapsed as a result of an earthquake. The man was dead on initial encounter and was positioned so that his body blocked access to a woman who was alive and trapped in a small void space.
Reason for Procedure
The large volume of debris (multistory) limited access to both people through a single passageway that was tunneled under the foundation of the structure. The collapse pattern prohibited any further breaching, delayering, shoring, or other activity that could improve access. The deceased man, whose left lower extremity was pinned between 2 large concrete slabs, blocked access to the woman. Verbal contact with the living person revealed a state of confusion.
Administrative Issues Addressed
The Urban Search and Rescue team decided to conduct a dismemberment of the man to gain timely access to the woman. An individual at the site was confirmed to be a family member of the deceased man. The team members explained to him the recommended approach to rescue the living woman. After the family member consulted with other nearby members of the family, he granted permission for the dismemberment to occur.
Patient Outcome
The man was removed after dismemberment of the lower extremity. The woman was rescued after another approximately 6 hours and transferred to a field hospital; she survived her injuries.
Dismemberment Case 2
Circumstances of Entrapment
A middle-aged adult man was trapped under a large slab of unstable sloping concrete on the third floor of a multistory structure that had undergone a pancake collapse as a result of an earthquake. The man was alive on initial encounter but soon died from his injuries. Although easily accessible, the area around the man was extremely dangerous, as the structure was unstable and the large concrete slab could not be moved without threatening total structural collapse.
Reason for Procedure
The deceased had been initially conscious and able to confirm his identity. All surviving victims had been recovered from the collapsed structure, and a cautious deconstruction process ensued using heavy machinery to retrieve the remaining deceased. Due to the instability of the structure and associated safety risks, a complete collapse might result from the process. If this were to occur, the ability to recover other deceased victims intact or in an identifiable state might be compromised. Because the exposed, deceased man was positively identified, a decision was made to retrieve his body before the deconstruction of the collapsed building. The man's right arm from the high shoulder and his complete right hind quarter were pinned under the large sloping concrete slab.
Administrative Issues Addressed
The engineering team managing the deconstruction process was consulted to determine the risks associated with conducting dismemberment and to verify the need for the procedure (ie, potential for blocking retrieval of other deceased). After concurrence from the coroner's office, the Urban Search and Rescue team decided to conduct the dismemberment.
Patient Outcome
The man was removed after dismemberment of the upper extremity and lower hind quarter. His body was transferred to the local coroner.
COMMENT
It is often difficult to extricate people entrapped in collapsed structures. Rescue can be complicated by both the entrapment of limbs and obstructions posed by deceased individuals blocking access to survivors. Amputation of the living person's limb(s) or dismemberment of a deceased person's limbs to retrieve the living should be considered procedures of last resort. As unsettling a topic as this might be, the need for these procedures is real, although infrequent, as highlighted in the cited case studies.
All planning must account for the unique environmental considerations in collapsed structures. Multiple hazards may pose a risk to the entrapped person and the rescuer alike. The collapsed structure environment may be made hazardous by the presence of inhalational contaminants, other chemical hazards, unsecured utilities, or environmental extremes. In many instances, these hazards may be mitigated before rescue attempts are made; in some cases, they cannot. Collapsed structures themselves are a significant risk, as they are often unstable and at risk of secondary collapse (with or without aftershock). Even if the main structure is stable in its collapsed position, significant risk may be posed by unstable overhanging hazards.
Extrication planning should consider parameters specific to the person caught in the collapsed structure. The physical space where these individuals are entrapped is often very small, allowing limited access. In many instances, only 1 provider/rescuer can gain access to the person at any one time. In some cases, the rescuer may need to back out and change position to achieve a different orientation before re-entering the confined space to perform the required task. Also, the presenting body part of the entrapped person may be at odd angles and/or below or above the rescuer. Full access to the individual's body is rare, and adequate room for large equipment or monitors even rarer. All of these considerations can make the simplest procedure challenging. When considering more complex procedures such as amputation, evaluation of the capability to even perform this procedure must occur first.
Finally, the multiple medical conditions that people in these situations have play a large role. Airway compromise and hypoxia are possible, although, if severe, the patient probably will have died before the rescuer gains access. More commonly, severe volume depletion with metabolic derangements can present life-threatening situations. Traumatic injuries that remain untreated for a prolonged period can increase the chance of a person being in critical condition. For example, sepsis associated with penetrating wounds and open fractures become life-threatening. Crush syndrome, referred to in the rescue literature as “smiling death” or the “grateful dead” syndrome, is an ever-present concern in which a person's condition may suddenly deteriorate as compressive forces are removed from muscle mass. The individual's condition suddenly deteriorates from third-space sequestration of fluids or the release of anaerobic metabolites or potassium into the general circulation from the damaged muscle. These and numerous other reasons increase the imperative to treat the entrapped person as soon as access permits and achieve extrication in an efficient manner; otherwise, the individual may die before extrication.
Few published reports have clearly articulated indications for amputations to free entrapped persons.Reference Porter22 No publication was found that addresses the decision process and associated relevant administrative activities. The indications for amputation are proposed, which differ slightly than those proposed by Porter:
• The person's clinical condition is such that any delay in extrication could cause loss of that individual's life.
• The environment poses such a high-level risk to person AND rescuer such that it cannot be ameliorated and is immediately life-threatening.
• The individual's degree of entanglement or entrapment is such that extrication is not possible without amputation.
This last indication is the most difficult to ascertain of the 3 and ideally should be determined after input from a multidisciplinary team including rescuers, medical personnel, structural engineers, and other relevant persons.
As noted, Porter includes a fourth indication for amputation: when the limb is horrifically mangled and minimally attached to the body.Reference Porter22 This indication may be better placed in a different category of “completion of an amputation.” Osmond-Clarke proposes the application of various limb-salvage scoring criteria.Reference Osmond-Clarke24 Unfortunately, many of these criteria have been developed for the sterile environment of the surgical suite, where full access to the person is available. It is unrealistic to apply these criteria in collapsed structures. A recent publication by Jasper questions the application of these scoring criteria in the military arena as they often do not account for the heavily contaminated wounds seen in conflicts and (by these authors' estimation) this extends to the collapsed structure environment.Reference Clasper25
Important managerial considerations influence the decision process and relate to the medical indications. All of the following questions should be answered before amputation is considered.
• Does it need to be done? Careful review of the medical indications should occur. In a chaotic environment, decisions may become pressured and finalized in a rapid fashion. Evaluation of the indications should preferably be conducted by 2 medical providers and documented, if possible. Consultation with other disciplinary experts should occur for the third indication (ie, degree of entanglement), which can be the most challenging to definitively discern. Alternatives may often be found that are not immediately self-evident, especially to the medical provider. Undermining, breaching from a different position, or angling the extremity in a different fashion may permit rescue without amputation. One author (A.G.M.) has participated in 2 rescue scenarios in which amputations were considered but not needed because repositioning of the extremity (and the person), with appropriate analgesia, ultimately permitted release. Consultation with experts in other disciplines also provides the element of “exploring all possible alternatives with the view to saving the limb,” which may be relevant if issues arise afterward. Finally, photographs of the entrapment may be considered for documentation purposes.
• Can it be done? The physical ability to perform the procedure should be evaluated. As noted, performance of the procedure can be difficult, if not impossible, in the space available. Even with additional delayering, space may not be adequate. It may be difficult to obtain anesthesia and analgesia or, likewise, to support the entrapped person's airway adequately. Also, appropriate equipment may not be immediately available. It is the opinion of the authors of this report that rescue equipment such as saws and cutters are not viable alternatives to surgical equipment, and space constraints may preclude the use of these bulkier devices. A medical provider who is not only trained in the procedure but who is familiar with the hazards and challenges posed by collapsed structures is preferable. These considerations should be factored into the final decision-making.
• Does the patient want it to be done (if conscious)? If the patient is conscious, consent should be sought before performing the procedure. The practicality of this may seem challenging, but is necessary nonetheless. Consent may not need the degree of detail that exists in health care facilities (ie, documented informed consent), but witnessed verbal agreement from an awake and alert patient is minimally sufficient. The case for implied consent in an unconscious person can be argued, although any situation can be challenged in retrospect (even with good outcomes). As proposed in the literature, having 2 concurring, on-scene physicians is ideal but not always practical.
• Does the patient's family (if available) want it to be done? In the case of minors or incapacitated persons, seeking out the family to obtain consent may be feasible, if expedited. At a minimum, involving the patient's family in decision-making and keeping them informed is a good practice, as with all medical interventions.
• Do local culture and authorities permit it to be done? In some countries, the cultural stigma associated with amputees is significant, particularly those associated with field amputations to perform extrication.Reference Kirkup26 Interaction with local authorities should occur if the rescue team is not local to inform the authorities of the imminent procedure and its indications. Situations may arise in which local authorities will not permit such a procedure (eg, by people from another country) or in which religious considerations play a role.
• Can it be done safely? The hazards cited here should be considered. In addition, other factors can contribute to an unsafe environment, such as a combative person, the release of body fluids, or presence of large crowds. In most cases, these can be addressed prospectively.
Technical considerations for amputation in collapsed structures are summarized in Table 2. It is beyond the scope of this publication to review the detailed procedure further, but important considerations occur in situations of a confined space (as opposed to a hospital).
Technical Considerations for Field Amputations in the Collapsed Structure Environment
In many ways, dismemberment of a deceased individual parallels the amputation process. The authors of this report believe that the only absolute indication is to permit access to a living person requiring rescue. Other indications that are less absolute are, for example, described in dismemberment case 2. In these instances, documenting the decision process and involving other available on-site specialty experts become even more important. Other than rescuing a living person, indications for dismemberment could include the following:
• Dismemberment of the individual provides the only safe means for rescuers to remove the deceased.
• A deceased individual is pinned in a very public fashion and removal of the body can only occur expeditiously with dismemberment.
• Dismemberment can prevent further structural collapse that could cause difficulties such as identification of other deceased individuals in the collapsed structure.
As uncomfortable as it is to consider such a procedure, important administrative considerations for it parallel field amputations. For example, on-site family members should be consulted about the procedure and, if possible, provide permission (cf, dismemberment case 1). Local authorities and, if possible, medical examiners or disaster victim identification teams, should be included in the decision process as well. Other considerations include the following:
• Dismemberment in any situation should be limited to a limb of the deceased (in most instances, this is enough to remove the individual). Other surgical procedures, such as hemi-corpectomy, are generally not indicated, potentially dangerous (eg, increasing chance for exposure to body fluid), difficult to perform in the collapsed structure environment, and emotionally challenging to the operator.
• Only a medical provider with appropriate training in collapsed structure situations and with the appropriate equipment should perform the procedure. Individuals not trained in anatomy or with inappropriate equipment (eg, rescue equipment) can encounter difficulties and actually make the procedure more difficult.
• Disposition of the body should be arranged before conducting the procedure.
• When possible, limbs that remain entrapped should be marked as matched to the deceased. If the limbs are subsequently recovered, they may be more easily reunited with the remains through more formal means of disaster victim identification.
Amputation of a living individual's limb and dismemberment of a deceased individual's limb are serious but real prospects in collapsed structures. Consequently, an international organizing body has published its own recommendations regarding this topic. The International Search and Rescue Advisory Group (INSARAG) is an organizing body under the Office for Coordination of Humanitarian Affairs (OCHA)/Field Coordination Support Section (FCSS) within the United Nations. The Medical Working Group has been in operation for approximately 5 years within INSARAG, providing advice and protocols related to the medical aspects of international operations in the collapsed structure environment. Representation from multiple countries includes the Americas, Europe, the Middle East, Africa, the Pacific, and Asia. The group's efforts have resulted in the protocol included in the Table 1. These recommendations parallel those made in this report.
The concepts described herein apply to collapsed structures (usually reinforced concrete). Other situations also occur in which individuals become entrapped (eg, transportation sector accidents). Application of these recommendations may be helpful but should factor in the relevant parameters in those scenarios (eg, ease in which changes may be made to permit removal of a limb or of the deceased).
CONCLUSION
Desperate times may call for extreme measures. Collapsed structures may occur for a variety of reasons including earthquakes, bombings, and poor construction. In these environments, individuals may become entrapped such that the amputation of a limb may be necessary to allow their rescue. In addition, a deceased individual's limb may require amputation to permit access to a survivor. These measures should be considered extreme; very few situations in medicine parallel the decision-making process and necessary administrative procedures. For this reason, any organization that could potentially participate in such a procedure in response to collapsed structures or other incidents should establish prospectively protocols that outline necessary steps before and while conducting such a procedure. Having these in place can ensure that the right decision is made for the right situation.
Funding and Support: Written in collaboration with US Aid for International Development/Office of Foreign Disaster Assistance. The opinions expressed in the manuscript (exclusive of Table 1) are those of the authors and should not be construed to represent official policy or opinion of any of the affiliated organizations.
This article was corrected for errors on December 19, 2012.
