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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Near-amputation in a boating accident

You arrive to find a 23-year-old male whose right leg has been nearly amputated above the knee. What are your treatment priorities?

By Patrick Lickiss

Post your assessment in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!

While volunteering as an EMT with the local sheriff’s department marine patrol, you are dispatched to a report of a boat accident. The deputy you are assigned to patrol with helps you load your gear into the launch and you begin the five-minute ride to the reported location. 

You are currently patrolling a large inland lake over a holiday weekend. The lake is a popular destination for water sports, and this weekend has been particularly busy. 

As you approach, the driver of the boat waves to you. You see that there are three people in the back of the boat crowded around a fourth person who has obviously been injured. Once the two boats are tied together, you step aboard and survey the scene. 

Patient assessment

Your patient is a 23-year-old male who is conscious and oriented but in obvious distress. The driver of the boat reports that the patient was water skiing when he fell. The driver circled back to where he thought the patient was but overshot the location and struck the patient.

As you visually assess the patient you see that his right leg has suffered significant trauma and has been nearly amputated above the knee. The patient currently has uncontrolled bleeding from his leg despite direct pressure being applied by bystanders. 

Your ALS ambulance is en route with a 15 minute ETA. There is a community hospital 25 minutes from the scene and a trauma center approximately 90 minutes from the scene. 

Think about the following questions:

  • What are your treatment priorities?
  • What additional equipment do you need to package the patient? 
  • Which hospital should the patient be transported to?

Post your answers below in the comments.

About the author

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Paula Proffitt Paula Proffitt Thursday, July 24, 2014 1:03:01 PM ABCs, control bleeding, c-spine, and treating for shock. C.A.T., C-Collar and back board, O2 NRB, long/leg splint, blanket Transport to the nearer community hospital for stabilization. Do not pass a closer medical facility in order to go to a trauma center. The difference of 65 minutes is well outside of the golden hours. They should be able to stabilize the injury and the blood loss before getting him definitive treatment.
Jeff Mills Jeff Mills Thursday, July 24, 2014 1:17:25 PM Scene safety, ABC's, Tourniquet, O2 NRB, state of maine and assess for spinal immobilization, VS, treat for shock, IV access, warm fluid bolus, Fentanyl or appropriate pain medication, keep pt warm, splint leg, call for air ambulance if appropriate for trauma center. Transport to community hospital for transfer to trauma center.
Pete Riefel Pete Riefel Thursday, July 24, 2014 1:18:42 PM I agree with except..... evaluate the blood loss and seriously consider bypassing the community hospital...depending on its size probably has no blood products anyway. The tourniquet can stay in...the comm hosp probably has never seen this before and will call for immediate transfer xport. Just sayin.
Jennifer Bolton Rutland Jennifer Bolton Rutland Thursday, July 24, 2014 4:01:43 PM Have deputy call for helicopter, ABC. Control the bleeding with tourn. if it can't be stopped any other way. Stabalize the "almost amputated part" so u don't tear it further off. Treat for shock, full spinal precautions. Highflow 02, IV(in Alabama NS), monitor, According to how far out the chopper is... once als arrives on scene... if it isn't long then wait for chopper, if it will be quicker tspt to ER. I am only an Intermediate so I can't give pain meds but he needs pain meds.
Dominick Walenczak Dominick Walenczak Friday, July 25, 2014 3:32:00 AM First and foremost would be a tourniquet. But everything from then on is highly variable. Is HEMS available? What are the vital signs like? Any other injuries? Unless the bleeding is controlled, I would not administer any more fluids than necessary to maintain a MAP of 60-70, or peripheral pulses if I don't want to maths. If HEMS is not available, it come down to just how stable the patient is. If bleeding is controlled and the vitals are within acceptable threshold, this patient would benefit from trauma services available at he level 1. Hypotensive and still bleeding? I would probably suggest the community hospital. Depending on their capabilities, they may be able to administer blood products and even clamp the bleeder. If they're a Band-Aids station with none of the above, then the community hospital offers no benefit.
Roger Bernard III Roger Bernard III Friday, July 25, 2014 2:03:01 PM AS an EMT being that the scene has already been determined safe, BSI is done, and we have a first impression, first and foremost would be to tourniquet the leg above the injury while directing partner/deputy to find out if HEMS is available and time frame. If yes and appropriate time frame i would have them transported by air directly to trauma center, if not i would direct ALS to intercept in route to trauma center. The only reason to go to community hospital is if patient is still bleeding out and unstable to the point he would never make it to the trauma center. After controlling the bleeding I would do a rapid trauma assessment to ascertain any other injuries or life threats. I would then support and wrap the injury, backboard the patient, and access vitals in route back to shore. I would also immediately treat for shock and keep the patient warm. I would then pass on to HEMS or ALS care for a higher level of care.
Roger Bernard III Roger Bernard III Friday, July 25, 2014 2:04:14 PM and i didnt say it but obviously o2 goes with treating shock..
Jesse Bell Jesse Bell Friday, July 25, 2014 3:03:50 PM Immediate tourniquet, spinal immobilization, splint the leg, warm blanket, elevate lower half, start an IV with NS, call in a helicopter. If ALS arrives, they can give pain meds. Reassess vitals every 5 minutes. The community hospital doesn't sound like it would be equipped to handle such a call. Trauma center would be more appropriate. Alert the receiving facility. Also consider using clotting agents. Also, I'd keep suction on hand in the event he aspirated any water when he had his accident. Even if he doesn't have any breathing difficulty, it's better to be too safe. Also, comfort the patient. If he's awake, he's probably in a lot of pain and is very afraid. Calming him down can have a big effect on his outcome. Treat the patient like a person, not a mannequin.
Randy Murry Randy Murry Sunday, July 27, 2014 12:20:52 PM NOT IN CORRECT ORDER BUT!Treatment Priority: Control Bleeding via tourniquet, Splint, Spinal package, Asses Vitals, Apply o2, Pain Management, Fluid resuscitation, Reassess Vitals and contact Air Medical for possible scene flight or Transport to Level one trauma center.
Brian Steinert Brian Steinert Sunday, July 27, 2014 12:45:12 PM Get a helicopter on stand by or enroute depending on pt condition(stable enough to fly). Intercept ALS lakeside. Get the patient stabilized and to "solid ground" but first ensure adequate breathing w/ adequate tidal volume and a patent airway.Give O2 based on Oxygen saturation via NRB. It is also equally as important to simultaneously control all major life threats, major bleeding as the femoral artery is most likely severed. The leg should have a tourniquet applied dressed with clean dry sterile dressings and splinted as needed. I would have my partner start 2 large bore IVs with pain meds and for fluid replinishment. Consider the use of clotting agents. Stabilize the pt and prepare for a rapid transport. Keep the pt warm and remove any wet clothing to prevent further progression of shock. It may also be a good idea to put the patient in the area of the boat to prevent him from getting nauseated and " sea sick." as his vomit could be a cause for aspiration and a non patent airway.May be a good idea to have portable suction on hand, The pt should be transported to the closest most appropriate facility depending on pt stability and the availability of HEMS. If the pt remains stable and is able to fly and HEMS can land on scene and transport him directly to a Level 1 may be the quickest and in the pts best interest, otherwise an ALS Ground Intercept to Level 1 Trauma Center may be the next best option. In the best interest of time and pt outcome I feel in this case the quicker we can get this pt to a Level Trauma Center within the Golden Hour, the better his outcome will be. The community hospital depending on its capabilities and pt stability may offer few to no benefits, however in the event if the pt is unstable this may be our only viable option.
Jeffrey Flaker Jeffrey Flaker Sunday, July 27, 2014 1:34:16 PM Control the bleed with a tourniquet just above the wound or above the knee (which ever is more practical). Secondary since PT has an airway and is A&O, put pt on 02 @15lpm to try to delay shock. Splint the partially severed leg to prevent further damage as much as possible. Keep ALS coming so the pt can get fluids to keep the BP up and to treat the pt further than I can. I would call for a helicopter for transport to the trauma center.
Jeffrey Flaker Jeffrey Flaker Sunday, July 27, 2014 1:36:30 PM Control the bleed with a tourniquet just above the wound or above the knee (which ever is more practical). Secondary since PT has an airway and is A&O, put pt on 02 @15lpm to try to delay shock. Splint the partially severed leg to prevent further damage as much as possible. Monitor vitals every 5 mins. Keep ALS coming so the pt can get fluids to keep the BP up and to treat the pt further than I can. I would call for a helicopter for transport to the trauma center.
Josh Buck Josh Buck Sunday, July 27, 2014 1:44:23 PM What are your treatment priorities? Control life-threats. In this case the major bleed. Direct pressure has failed by bystanders so immediately apply a tourniquet to control the bleed. Consider c-spine. Depending on local protocols you may or may not backboard and c-collar this patient, however a backboard may be the best way to move this patient. Have a deputy attempt to stabilize distal limb to prevent further injury or damage. Treat for shock as best you can while continuing rapid assessment, mainly drying patient off to keep heat in. Manage and maintain airway, apply oxygen at 15 LPM, check lung sounds for aspiration. Have suction ready to maintain airway in case of vomiting or to clear inhaled water. Check CMS in all extremities except injured leg as well as femoral or carotid pulses. If the patient has femoral or carotid pulses but no radial pulses, the patients BP is below 80 systolic. Based on the information from the primary assessment make a transport decision. In this case, I would start helicopter for transport to trauma facility. Move the patient from his boat to our boat and bring to shore and prepare for ALS arrival. I would get a set of vitals and try to obtain a patient history while starting large bore IV's for rapid fluid replacement and maintain a controlled hypotension. Place heart monitor. Depending on provider impression have defib pads placed and ready. In secondary assessment do a complete head to toe looking for and treating any other injuries and verifying that previous treatments are still effective. Reassess vitals every 5 minutes. When ALS arrives provide with a brief report for hand off. What additional equipment do you need to package the patient? Backboard is probably the best bet to transport patient. Depending on protocols you may or may not take full spinal precautions but the backboard is going to be the best way to transport to shore regardless. You can splint the extremity to the board and leave the decision up to ALS or the helicopter if they want to transport with the backboard in place. Also place dry blankets on top of the patient to prevent heat loss, facilitate drying of the patient and keep the patient warm while transporting to shore. Which hospital should the patient be transported to? Trauma facility via helicopter.
Josh Buck Josh Buck Sunday, July 27, 2014 1:53:13 PM A tourniquet should always be placed on the femur or humerus as close to the trunk as possible.
James R Olejarczyk James R Olejarczyk Sunday, July 27, 2014 2:15:50 PM Trendelenburg/shock position, apply tourniquet, place medical helicopter on standby. Have officer get a set of vitals if they're trained to do such. C-spine precautions. Have officer notify ALS of any updated information. Get the pt. to the nearest part of the shoreline and have the incoming ALS rig meet you there. If time allows, ALS should begin transport to the nearest hospital that is 25 minutes away. Update helicopter as to whether you would like them to meet at the nearby ER to continue to transport the hopefully stabilized pt. to the better trauma center, or if the nearby ER can handle the trauma. Whichever is best for the pt. is what you must do. Don't be lazy and have the chopper come to the area of such a busy place. Get the pt. to whomever can provide the best level of care in the smallest amount of time. Choppers can always stand-down if needed.
Mari Warner Mari Warner Sunday, July 27, 2014 2:26:32 PM Tourniquet, shock position, maintain airway (pt will probably lose consciousness. Have an NPA ready. Start 2 large bore IV lines. Bolus LR as fast as it will run in through both lines. Warm blanket. Transport fast. Go to nearest hospital for stabilization. If this is a critical access hospital only, have a helicopter on the way.
Jay Remy Jay Remy Sunday, July 27, 2014 2:57:25 PM BSI, Scene safety. ABC's. O2 via/NR 15lpm Clean the site from debris, Apply direct pressure to control bleeding. Consider A tourniquet if bleeding is unmanageable, cover it with sterile dressing wrap around with kling. If amputation place the separated body part in a plastic bag and place on ice. Start 2 large bore IV/ Normal Saline. Treat for shock, Cardiac Monitor txp Asap to the nearest level 1 trauma center. Enroute I would consider analgesics for pain management. Morphine sulfate in 2-mg increments titrated to pain relief every 5 minutes up tp 10 mg. or fentanyl in 25-50 mcg dose, followed by 35 mcg doses, titrated to relieve pain. Check vitals & interventions during txp as often as possible.
Derrick Watford Derrick Watford Sunday, July 27, 2014 5:44:04 PM First thing is bsi and appears scene is safe have the officer place o2 on the pt nc r nr depending if there any breathing issue while he doing that u put a touq on sense direct pressure nt working once applied bandage wound best u can while stabilizing leg need controll c spine best
Larry Wells Larry Wells Sunday, July 27, 2014 5:44:37 PM Other are there to assist. Use them. Continue direct pressure to control bleeding. If it doesn't, constricting band or inflated B/P cuff to control bleeding. NO TQ. Treat for shock, blanket or towels. Splint right leg, pack wounds with extra towels and bandages. Put on backboard for better packaging of victim. Apply Oxygen 10 - 15 L via non-rebreather mask. Transport victim to the dock until ACLS ambulance or helicopter transport arrives. Contact the community hospital and advise of situation. Ask if they can handle and to get other resources in the loop. i.e. Trauma Center. If victim was wearing a skin suit wetsuit, leave on but cut it to the waist. Have victim lay on the wetsuit for warmth. Nothing by mouth to be given to victim. ACLS ambulance due to arrive within 5 minutes. Transfer victim on backboard from boat dock to ambulance access. Hand off care to ACLS crew with report. After they depart, sit down, and detox myself from this call. Restock my kit, return to Sheriff's marine patrol boat with a backboard from the ambulance.
Derrick Watford Derrick Watford Sunday, July 27, 2014 6:00:00 PM As possible keep pt warm an in shock position if ur a emt I start a Iv bilateral 14 with ns keep monitoring vitals and pt condition while having someone communicating with ur ALS unit let them decide if air support is a better option and set up a meeting point with them equip needed would be spinal immobilizing equip an Iv supplies if air support is over 10 out I would transport to nearest hospital to stabilize
Bill Utermark Bill Utermark Sunday, July 27, 2014 7:04:35 PM Before arriving at the patients side, call for Med Flight. You already have been told that there is significant trauma and almost amputated leg. This will save valuable time, Med Flight can always be cancelled. I agree with most of the other assessments and treatments. Apply tourniquet, depending on the extent of the wound clotting agents, treat for shock, immobilize the patient, apply O2. Load and go with ALS intercept in route to the landing zone keep the patient moving toward the Trauma Center.
Freddy Gann Freddy Gann Sunday, July 27, 2014 7:06:22 PM Apply a tourniquet, tightening just till bleeding is controlled, cheeking for a pulse in affected extremity, and treat for shock. Considering the ETA and the trauma center distance, I will put a bird in the air asap. This Pt in is need of a trauma center for certain. I will continue treatment with reassessment of my Pt. Every five minutes.
Chad Tillman Chad Tillman Monday, July 28, 2014 5:08:34 AM Immediately apply and time stamp tourniquet. Have deputy call for air medic to meet you at docks. Treat for shock and keep pt warm. Patient history should include how much, if any he has drank. Administer high flow O2. Determine which boat will get you to the docks the quickest and prepare for transport. Your ALS unit is now between 5-10 minutes out and will probably be at the dock when you arrive. Prepare a cushioned ride for patient with elevated lower extremities. While in transit, inspect leg for debris and irrigate w/clean water. Using empty ice bags, create watertight sleeve for leg to cover trauma, but leave tourniquet exposed.. Use tape to seal. Wrap leg in towel and ice it down. Continue to monitor vitals. If possible, create "T" in O2 line and and pressurize sealed bandage to generate makeshift hyperbaric chamber. When you reach the docks, if ALS is there, and no airmedic, transfer pt to ALS unit and begin fluid replacement as warranted. Continue to monitor leg temperature and color. If air support is within 5 minutes of arrival, await and transfer to air medic for transport to trauma center.
Brett Nathan Gillet Brett Nathan Gillet Monday, July 28, 2014 10:52:31 AM I see a lot of LBB decisions and I'm curious to know why. In my area this patient doesn't appear to meet criteria for it. Those who said spinal immob please explain so I understand better
Brett Nathan Gillet Brett Nathan Gillet Monday, July 28, 2014 10:53:36 AM What's the bag's intended purpose? Was confused on that one
Dyana Bishop Dyana Bishop Monday, July 28, 2014 2:44:09 PM MARCH Massive hemorrhage- co troll with CAT or some other tournament Air way- apply Oxygen an monitor respiratory effort. Watch for dry drowning Respiration Circulation- IV( NS) with secondary site secured by a port. Maintain blood pressure in the 90's. Hypothermia- wrap up the patient as.much as you can. Splint leg as best as you can. All the while beat fleeting to shore and calling for the bird.
Eden Yeh Eden Yeh Tuesday, July 29, 2014 1:54:51 AM wouldn't backboard be used for spinal injuries?
Brittany Smith Brittany Smith Tuesday, July 29, 2014 4:23:48 PM ems
Mark McCabe Mark McCabe Tuesday, July 29, 2014 11:19:32 PM My treatment priorities has a basic emt is to apply a tourniquet to the right leg to control the bleeding and the additional equipment I would use to package the patient would be a scoop stretcher which can be pulled apart and then slid underneath the patient. The first reason being it results in less moving around of the patient. The second reason is instead of using a backboard which may aggriavte the patient's serious right leg injury with the scoop stretcher pillows to help elevate the leg can still be utilized and board splints can be applied to both sides of the right leg injury. The third reason is once patient is packaged and bleeding controlled the scoop stretcher can be position on top of the als ambulance stretcher and pulled apart without further injuring the patient. The patient in this case has long has the vitals are stable should be taken by helicopter to the trauma center 90 minutes away where the damage done can be repaired correctly and save the person's life instead of using the community hospital and ship them out asap by the helicopter.

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