I had no training with the FAST1. It was a new device. The med shed had given me two of them, told me they were IO (intraosseous) kits, and I had tossed them in my trauma bag, where they had stayed for the last 8 months until now. I removed the contents of the package and laid them on my patient’s anesthetized chest.
I handed the package to one of the corpsman. “Here. Read these instructions to me.” I prepped the site and held the group of needles over the chest as instructed. “…apply firm even pressure”, THUNK!, “…holy shit!” The IO needle launched like a spear gun into the man’s sternum.
I connected my IV line to his chest then piggy backed a couple of 500ml bags: one with ketamine to keep him under, and the other with a gram or so of Ancef because this was surgery at its dirtiest. Next, my surgical team (shown), consisting of myself (18D), an 18C SF engineer, an SF warrant officer, a 68W combat medic (in the poncho), and two Navy corpsman prepped the leg for removal.
We were on the clock
With a marker, I drew a horizontal v-shaped cut line on my side of the leg. I was attempting to execute a shark bite technique where I cut the bone farther up than the tissue in order to have muscle and skin to cover the stump. I handed the marker to my assistant surgeon, my 18C, and he made his mark. “Scalpel”, I instructed a corpsman.
I touched the blade to the skin. “WhoaAAAAAA!” The old man moaned. Everyone froze. He didn’t move or retract but he did yell at the top of his lungs. I had learned that nightmares, specifically sex nightmares, were a side effect of ketamine. I didn’t know if he was in pain or dreaming.
I looked at my warrant, who I had trained to be my mud hut anesthesiologist. “Hand me that syringe of lidocaine.” I finished my cut and handed the knife to the 18C. He started his cut. “NO! STOP!” It was too late.
He cut the man’s skin in a clean straight line, top to bottom. This was a huge problem. I had cut a “shark bite” on the opposite side. Now I had a vertical cut roughly at the apex of my cut, about 4 inches proximal (higher) than the end of my incision.
The apex of my cut is where the bone was to be amputated. The remaining tissue was supposed to cover the amputation. Because of the vertical incision, I would not have enough tissue to cover the stump. I was at a loss for what to do, but we were in the middle of the surgery. I wasn’t going to give up on the procedure or my patient.
I chose to continue with amputation. I’d figure something out when we got to that stage. I took the scalpel and continued to cut through muscle, burning and ligating vessels as I came to them, till I was to the tibia and fibula bones. I took the Gigli saw and prepared to cut into through the bone.
It was then that I realized that handles had not been sent with the saw, nor had I requested them. I tried securing the ends with grenade pins. This didn’t work. You might ask why, but most of you are probably wondering what happened to the grenades: not important to this story. I monkey gripped the ends of the saw with my gloved hands and commenced to cutting. Smoke and a fine mist of bone rose from the cut.
Social Distortion was playing angrily in the background, “…children are taught to hate…” “Water.” A corpsman squeezed saline from an IV bag onto the cut site. I continued to saw. SNAP. “Ok, we’re through.” There was a sense of relief. We had cut off a man’s leg. It was laying on the litter in front of me, like a movie prop. I had effectively tourniqueted the leg and ligated vessels.
The man was alive, stable, and not in pain
The respite was over as quickly as it began. I still had the stump to deal with. I looked at the end of the man’s leg, the bones exposed, mosquito clamps tangling from arteries and veins like ornaments. All eyes were on me. What am I going to do!?
I gripped what was left of the leg with both hands and milked the skin and muscle to the end of the stump to see what I had to work with. It wasn’t even close to enough to cover the amputation. I stood there holding the leg in my hand, waiting for an answer to materialize. My 18C broke the silence, “What about that?” “What?” “That”, he pointed to the recently detached leg laying lifeless on the end of the litter. “Well…let’s try it.”
I handed the stump to a corpsman and instructed another one to hold the amputated leg. “Scalpel.” I cut the most viable skin off the calf and carefully removed it from the leg. I held the skin stretched tight between my blood-slicked, gloved hands and turned to size it against the stump…too tight.
The skin slipped from my hands and went airborne. For the longest fraction of a second in recorded history, I reached, grasped, and fumbled for the skin, but to no avail. The air was sucked out of the tiny dirty room as everyone present collectively gasped when the skin landed at my feet.
“Five second rule!”
I announced as I quickly picked the tissue off the floor. “Hand me that bowl. Fill it with betadine.” I washed the skin in the antiseptic fluid. “This looks exactly like teriyaki chicken.” I don’t know if my humor was helping anyone, but it was all I had at this point.
We rinsed the skin in saline and, with less tension this time, sized the flap against the stump. “Hold this here. Suture.” I anchored the stump and the skin together with a quick stitch, inserted a Penrose drain, and commenced to baseball stitching. Holy shit, this was going to work. I trimmed the skin to the stump and let everyone in the room throw a few sutures, like we were signing a mural we had all worked on.
It was some ugly art, but it was done. “Hey, we should give that leg to the dog!” My Marines from 2/8 had been watching the whole ordeal over my shoulder through the window behind me.
I had been too focused to notice the commentary until now. I stopped the congratulations. “Ok let’s clean up. I want the patient moved to the porch, and anything with blood on it taken care of.” I pulled my 18C aside and whispered, “don’t let the Yuts get the leg.”