Mrs. P, aged 63 years, is an energetic and right-hand-dominant grandmother who enjoys woodworking and frequently uses table saws and other mechanical tools. Two years ago, she was cutting wood with a miter saw in her basement when she looked down on the ground after “feeling something” and saw her hand and part of her arm lying on the floor.

Instantly, she crawled upstairs, looked outside, saw someone, and called out for help. A stranger walking by came to her assistance. While applying direct pressure to Mrs. P’s residual limb, the good samaritan called 911. 

The paramedics arrived quickly, wrapped the limb in nonadherent sterile gauze dressing, and continued to apply pressure to control the bleeding. An IV solution of sterile saline was initiated as well. 

Mrs. P arrived in the trauma bay less than one hour after sustaining her injury. The medics did not bring the amputated limb to the emergency department (ED). A next-door neighbor placed the limb in a plastic bag before following the medics to the ED and giving the amputated limb to the trauma staff (Figures 1 and 2). The limb was then irrigated with sterile saline, wrapped in saline-soaked sterile gauze, placed in a plastic bag, and put in a tub of ice.

Figure 1. X-rays show the amputated appendage after arrival in the trauma bay

Figure 2. The patient’s truncated forearm

1. History

Mrs. P’s medical history was positive for hypertension, but she had stopped taking her medication because of the high cost. She had an otherwise unremarkable medical and surgical history. She denied drinking alcohol or taking illicit drugs, and her toxicology screen was negative. 
Mrs. P’s history was positive for tobacco use (one pack day for more than 30 years). The patient also reported that she drank several cups of coffee per day and ate chocolate almost daily. 

On examination, Mrs. P was alert and oriented but slightly lethargic due to pain medication administered in the ED. Her vital signs were stable but slightly hypertensive. Her lungs were clear, and her heart rate, heart rhythm and ECG were normal. Serum lab tests and urinalysis were normal. 

The amputated hand was appropriately preserved, and at the one-hour mark, the fingertips were just slightly dusky. Both distal and proximal edges of the amputated arm were ragged with exposed bone.

2. Treatment 

Treatment in the trauma bay consisted primarily of ruling out any other injuries, inserting a Foley catheter, updating Mrs. P’s tetanus immunization, and administering IV antibiotics and aspirin. A hand surgeon outlined two possible treatment options and described the risks and benefits of both. 

The first option was a revision amputation that would be completed mid-forearm. Mrs. P would eventually need a prosthesis, which might be unaffordable given her limited budget. The second option was a replantation. This would require Mrs. P to consent to a long surgical procedure, make a firm commitment to change her dietary habits, immediately quit smoking, and agree to long-term intensive therapy sessions. 

Mrs. P was adamant in her decision: She wanted to try to save her arm, no matter the outcome, and she would do whatever was asked of her in return. 

3. Surgical Course

The patient was taken to the operating room (OR) to begin what became an eight-hour procedure. Surgery was prolonged in part due to two episodes of arterial thrombosis that were likely attributable to Mrs. P’s smoking. General anesthesia was initiated along with a brachial block. Standard prepping and draping procedures commenced. 

This article originally appeared on Clinical Advisor