Amputations and Saving the Part

Why this matters

A fingertip lost to a mower blade, a sheet metal brake or a fan is the injury where the people at the scene have the most influence on what happens next, in two ways. They decide whether the person loses dangerous amounts of blood in the first minutes, and they decide whether a surgeon ever gets the chance to reattach the part. Reattachment is not always possible, and the surgeon makes that call. What the crew controls is whether the part arrives clean, cool and with the patient, instead of in a pocket, in a glove, frozen in a cooler or still lying in the grass.

This is not training, and the guidance below is the lay first aid taught by the American Red Cross and the American Heart Association; a hands-on course is what makes a responder.

The order is fixed: person, then part

Stop the machine first. Shut off the engine, open the disconnect, unplug the tool. Do not reach toward a blade, belt or die to recover anything until it is stopped and cannot restart. Pull the spark plug wire on a mower or trimmer, or remove the key, before anyone goes near the blade or chute.

Then the bleeding. An amputation can bleed heavily or surprisingly little, because cut vessels sometimes clamp down. Either way, bleeding control comes before anyone looks for the part.

• Gloves on if they are within reach; do not delay pressure to find them.
• Firm, direct pressure on the stump with gauze or the cleanest cloth available, and keep it there.
• For a limb, if pressure does not control bleeding that is spurting or pooling, apply a tourniquet above the wound. See related: Severe Bleeding and the Tourniquet, and How to Apply a Tourniquet and Pack a Wound.
• Cover the stump with a dressing and keep pressure on it.

Call 911. Any amputation is a 911 call, including a fingertip. Have someone else call while you hold pressure. Tell the dispatcher the body part, that you have the part or are looking for it, and how the bleeding is doing.

Then the part. Only once the bleeding is under control and someone else can hold pressure does anyone go looking for the amputated part.

Packaging the part: the layers, inside to outside

The goal is to keep the tissue clean, moist and cool without freezing it or soaking it. Each layer has a job.

   outside
   +-------------------------------------+
   |  container: ice and a little water  |
   |  +-------------------------------+  |
   |  |  sealed plastic bag (air out) |  |
   |  |  +-------------------------+  |  |
   |  |  | moist gauze, wrung out  |  |  |
   |  |  |  +-------------------+  |  |  |
   |  |  |  |  amputated part   |  |  |  |
   |  |  |  +-------------------+  |  |  |
   |  |  +-------------------------+  |  |
   |  +-------------------------------+  |
   +-------------------------------------+
   label the bag: name, part, time of injury

• Rinse only if dirty. If the part has grass, soil or debris on it, rinse it gently with clean water. Do not scrub, and do not use soap, alcohol or peroxide on it.
• Moist, not wet. Wrap it in sterile gauze moistened with sterile saline or clean water, then wring the gauze so it is damp, not dripping. A part sitting in liquid becomes waterlogged, which makes reattachment harder.
• Sealed bag. Put the wrapped part in a clean plastic bag, push the air out and seal it. Double-bag if you can.
• Cold, never in contact with ice. Set the sealed bag in a container of ice with a little water. The ice touches the bag, never the tissue. Direct ice or dry ice freezes tissue and destroys it.
• Label it with the person's name, the part and the time of the injury, and it goes with the patient in the ambulance. If the part is found after the ambulance leaves, package it the same way and get it to the hospital they were taken to, telling the dispatcher it is coming.

Cooling slows the damage and widens the window for reattachment; a part left warm loses that window much faster. The surgeon decides whether the window is still open. Your job is not to know the number of hours; it is to make sure the part was cooled correctly from the first minutes.

Partial amputations

If the part is still attached by a strip of skin or tissue, do not cut it off. Leave it attached, lay it back in its normal position as well as you can without forcing it, cover the whole area with moist gauze and support it with a splint or padding so it cannot twist. That connection may carry blood flow or nerves that matter. Control bleeding the same way, and call 911.

What not to do

• Do not put the part directly on ice, in a freezer or in dry ice.
• Do not submerge the part in water or any liquid.
• Do not wrap the part in a dry paper towel or shop rag and put it in a pocket; it dries and warms.
• Do not let the injured person carry their own part, and do not send the part in a different vehicle from the patient unless it was found late.
• Do not try to put the part back on.
• Do not give the person anything to eat or drink. They may go to surgery.

A worked case: the mower chute

A lawn crew of three is on a commercial property. At 10:42 am, the crew member running a walk-behind mower stops forward motion but leaves the engine running, and reaches into the discharge chute to clear a clog of wet grass. The blade takes the tip of his right middle finger at about the first knuckle.

10:42. The crew lead hears him shout and sees him holding his hand. The first thing the lead does is reach the mower and kill the engine, then pull the spark plug wire. The blade has stopped and cannot restart.

10:43. The second crew member grabs the first aid kit from the truck. The lead has the injured man sit on the curb, gloves on, and presses gauze firmly on the fingertip. Bleeding soaks the first pad; the lead adds a second pad on top without lifting the first and keeps pressing. A fingertip does not take a tourniquet, and firm pressure is controlling it.

10:44. The second crew member calls 911 on speaker: a fingertip amputation, the address of the property and the entrance they are nearest, bleeding being held with pressure, and that the part is still in the grass by the mower.

10:46. The bleeding has slowed to an ooze. The lead hands pressure over to the second crew member and goes to find the part. It is in the cut grass about four feet from the chute. He picks it up with a gloved hand.

10:48. The part has grass clippings stuck to it. He rinses it gently with water from a clean, unopened bottle from the truck cooler. He moistens gauze with the same water, wrings it out, wraps the part, puts it in a zip bag from the kit, pushes the air out and seals it, then puts that bag inside a second bag. He writes the name, "R middle fingertip" and "10:42" on the outer bag with a marker.

10:50. The truck cooler has ice and water in it, with drinks. He empties the drinks, sets the sealed bag in the ice water so the bag, not the tissue, is in contact with the ice, and closes the lid.

10:56. The ambulance arrives, 14 minutes after the injury. The lead tells the paramedics the time of injury, that it was a mower blade, that the bleeding was controlled with pressure and two pads, and hands them the cooler. The part rides with the patient.

What made the difference. Two moments. At 10:42, killing the engine and pulling the plug before anyone reached near the chute, because the same clog-clearing reflex has taken a second finger from the person who comes to help. At 10:50, the cooler: a part dropped straight into ice in an open bag would have been frozen tissue by the time it reached a surgeon, and a part left in the gauze on the truck seat would have spent the next hour warm.

What would change this answer. If the injury had been to a forearm or hand rather than a fingertip, with bleeding spurting through the first pad, a tourniquet goes on at once and the search for the part waits until a second person can take over. If there had been only one other person on the crew, that person holds pressure and talks to the dispatcher, and the part waits until help arrives; the person always comes first.

After the event: the 24-hour report

Under 29 CFR 1904.39, an employer must report any work-related amputation to OSHA within 24 hours of learning about it, whether or not the person is hospitalized. In the case above, the injury at 10:42 means the report is due by 10:42 the next morning. That is the federal rule; states running their own OSHA plans set their own reporting process, sometimes with a shorter deadline, so check yours. The OSHA definition counts the loss of a fingertip, with or without bone loss. See related: Accident and Incident Reporting SOP.

The mower goes out of service until it has been checked, and the crew's procedure changes: engine off, plug wire pulled and a stick, not a hand, to clear a chute. The same lesson applies to a sheet metal brake, a fan, a belt drive and a snow blower.

How to verify you got this right

Open the first aid kit on one truck and check that it can actually package a part: sterile gauze, a bottle of saline or clean water, two sealable plastic bags, and a marker. Ask each crew member, without notice, what goes on the outer bag and what the ice touches. Three answers you want: name, part and time; the bag, never the tissue; and the part rides with the patient.

References

• American Red Cross First Aid/CPR/AED guidance on amputations and severe bleeding
• American Heart Association and American Red Cross Guidelines for First Aid
• 29 CFR 1904.39, OSHA reporting of fatalities, hospitalizations, amputations and loss of an eye
• See related: Severe Bleeding and the Tourniquet
• See related: The First-Aid Kit for a Service Van