Extremity amputation: how to face challenging problems in a precarious environment

Indications for amputation in natural disasters are not the same compared to our daily practice. They must be determined by those with great surgical experience and good knowledge of military or disaster surgical doctrine. Unfortunately, nowadays few surgeons have this experience. In fact, some volunteer surgeons may be interested in providing care for civilian victims of war or disaster in developing countries. However, there are significant differences between the type and the management of cases seen in this context versus those seen at home. The problems of amputations cannot be solved schematically. Amputation will depend on several factors: the form of warfare or disaster, the conditions for surgery, the skill of the surgical team and the experience of the surgeon, and the length or duration of the mission.

Here is a schematic showing the three main situations: civilian practice, war practice and disaster context. These three different situations require different strategies for treating the wounded and for making amputation decisions.

In the case of a natural disaster, there are many wounded civilians, they arrive at the medical facility late and there is usually only one surgeon and a single, limited medical facility to provide all treatment. He must make quick, wise choices, economising limited blood supplies and the use of surgical procedures. The decision to proceed with limb salvage or amputation for patients with severely injured limbs will be a source of continued debate. Amputation, radical and irreversible intervention, is a frequent and essential procedure in the disaster context and one of the standard means to successful treatment of limb wounds.

We propose to reflect on the following questions: why to amputate, how to perform amputation under these conditions and how to pass on a doctrine to the voluntary surgeons who lack experience in a disaster context.