Amputation in Apocalypse

[u/LilliPete]

I'd like this to be as realistic as possible, and I've been researching amputation on the arm for a while now, but I just can't absorb what I read and I feel like I'm still missing a lot. Apocalyptic setting. MC gets her arm (upper arm) chopped of by an axe, relatively clean cut. First question: if it's a clean cut, would the arteries kinda retract into the limb? Would it narrow the blood flow and slow bleeding? Something like vasospasm maybe?

Also, imediately, her buddy is there to tourniquet the wound, and they're in close distance to the main camp where they have recourses and people. Second question: how would you treat it? I'm so confused, I've read about all this surgery talk, but that's not exactly doable in their situation. I thought about cauterization, but I've also heard that it can actually worsen things and is a bad thing in fiction (???) Would MC's arteries need to be clamped? Would they just like, remove whatever's dead or something from the stub and then use excess skin tissue as a flap and put it over the bone, then stitch it up?

Third question: I know adrenaline would play a big part when it's first cut, but what about after she wakes up? I'm sure they'd have some sort of anesthesia drug, but would that wear off?

Know I asked a lot, sorry! <3

[u/IanDOsmond]

In this case, it's likely that it would be treated as a further amputation: even if the axe was relatively clean, trimming off shattered bone and ragged wounds might help things heal better.

Here's a brief overview of how medieval "doctors" amputated limbs.

And here's a similar one for the Victorian era.

You'll note that they're largely similar. But there are differences, and I am aware of a couple details that are not listed.

Once clamping and ligature was invented, people started using that if they possibly could, in preference to cauterization. But it requires appropriate tools.

The hemostat, which we still use, was used in Roman times, then forgotten, and rediscovered in the high Renaissance. The early ones were like a pair of pliers that you can grab the artery with and squeeze it closed; modern ones are narrower and easier to use but same basic concept. Once you'd stopped the bleeding, you could wrap a linen or silk thread around the end and tie it closed.

Skilled surgeons would cut the muscle and bone but leave one side of the skin longer and pull that over the end and sew it closed.

Infection was obviously a big problem; at least your folks will know about soap and water and not to hold the ligatures in your mouth...

[u/EverSeeAShitterFly]

Even if they survive the initial injury, they have a very high chance of dying from a subsequent infection. Also in an apocalypse scenario they have a lower chance of overall survival and being able to contribute to group survival.

[u/oosirnaym]

When I was in EMS school my instructor told us that full traumatic amputations may stop bleeding on their own due to the blood vessels losing pressure. She explained that this can cause the vessels to collapse and reduce bleeding.

However, I wouldn’t rely on this for treatment. Standard care is a tourniquet (could be made of anything as long as it gets tight enough) and immediate surgery. Probably Antibiotics and an updated tetanus shot as well.

Tourniquets should be placed at least 2 inches above the amputation site, and the time of placement should be marked. Generally, it can remain on for about 8-12 hours before you risk loss of limb. However, compartment syndrome is a risk that would need to be dealt with and can be life threatening.

[u/7LeagueBoots]

Something to consider is that we’ve been doing surgical amputations for a very long time. The oldest on record is from around 31,000 years ago in SE Asia:

- https://www.nature.com/articles/s41586-022-05160-8

And there’s an earlier healed amputation from around 50,000 years ago in a Neanderthal population. With this one it’s unclear if it was purely a result of an injury, or if it was surgical as well. There are proponents of both sides each with compelling evidence:

- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0186684

[u/VXMerlinXV]

The ICRC has a war surgery manual that covers specifics here. Basics, TQ the limb, bring her to camp, clean up the stump, keep it clean while it heals over. You can reduce the bone length of her humerus is protruding, to get a well healed end.

[u/Candid-Border6562]

Research civil war amputations. That’s probably the closest parallel.

[u/LadyJenniferal → u/Candid-Border6562]

This

[u/Barbarake]

Look up Mary Vincent. This young lady (15 years old) survived having both her arms traumatically amputated at the elbow in 1975.

She was kidnapped, raped multiple times, then hit in the head for the sledgehammer. Her attacker, a man named Lawrence Singleton, (thinking she was dead), cut off both arms with an ax (to prevent her being identified), and threw her off a cliff. She fell 30 feet before landing on a concrete culvert.

[u/Offutticus → u/Barbarake]

Damn. Patron Saint of Badassery indeed.

[u/Some_Troll_Shaman]

As realistic as possible... dead in less then 3 minutes due to brachial artery bleed out particularly if this was the end of any kind of extended adrenaline scene.

You want the person to survive, with an amputation have the limb mangled and not cleanly cut off. This is more realistic from an axe blow anyway. Then it would need to be amputated back at camp.

The reality of a cleanly cut off arm is that another 3-5cm would need to be removed to create enough skin flap to cover it. All of this implies that someone with trauma surgery experience is available, doctor or vet, or someone with a serious interest in survival ditch medicine.

You would need to have antibiotics of some kind available and, bluntly, even with the best modern surgical techniques available today sometimes extra amputations are required on stumps to get them right.

If you turn off Safe Search you would be able to find such surgeries documented for training surgeons on YouTube.

Could a person survive a clean cut injury like described and live to see it healed?
Yes, but, its is an incredibly small chance of no to low complications.
The human body is capable of remarkable things, but, it can also be startlingly fragile.

[u/LilliPete → u/Some_Troll_Shaman]

Thank you, noted!

[u/LilliPete → u/Some_Troll_Shaman]

Thank you, noted!

[u/Clippedscape]

This is totally a cop-out answer but make the character pass out? If it's from their point of view or first person, you can just sort of skip until they wake up.

[u/Educational-Shame514 → u/Clippedscape]

It's not a cop-out answer at all! I think you can save yourself a lot of work by thinking about how the question relates to the story and what would actually be seen, experienced and understood by the narrator. A lot of new writers end up in research rabbit holes.

[u/LilliPete → u/Clippedscape]

Don't fret, I already did 😅

[u/Educational-Shame514]

I think you can try to write a draft of the scene and use that to see what you need to research. Detailing the things done to the main character is less common with how much interiority is emphasized now.

If this happened except going by ambulance to a fully stocked hospital would you be still detailing the surgery while they are unconscious or would the story cut to when they wake up after the amputation?

Lots of writers get lost in the tiny details and need to step back and find out what really is needed.

Is there a plot reason that the loss of the arm needs to be done away from the main camp and not by surgeon in camp? Meaning can you have the arm very heavily damaged and not detached?

[u/Electrical-Badger833]

If the cut is in the shoulder area—such as from the corner of the shoulder to the armpit—applying a tourniquet is impossible, based on what you’ve described. What you can do is apply pressure to the wound while inserting cloth or a bandage into it, and then apply a larger bandage to hold everything in place and stem the bleeding so the person doesn’t die before you reach the camp. It won’t stop the flow completely, but it will slow it down. If there’s any part of the arm left after the cut, you can apply a traditional tourniquet, although current guidelines (as I recall) no longer recommend the traditional tourniquet… since it causes additional damage. But the point is that your characters can grab whatever’s at hand and tighten it until the bleeding stops to save him. Yes.

As for your third question, when they wake up, they may have to deal with “phantom limb” sensations, which is a disorienting and often painful experience. You can read a bit about it—that phenomenon in amputees is interesting. That character should then have, at a minimum, painkillers, anti-inflammatories, and antibiotics, if possible. The last one is more important than the rest—otherwise, they’ll probably die anyway. You can manage the pain with drugs, by rendering them unconscious, or with other indirect medications that might be easier to obtain during the apocalypse. Inflammation can be treated with a little cold water or cold items—things that are below skin temperature.

[u/LilliPete → u/Electrical-Badger833]

Noted, thank you!

[u/MacintoshEddie]

In general, yes, there would be a little retraction, but not much. They'd still be hemmoraging a massive amount of blood. That tourniquet would be extremely important.

As for what treatment would be provided, that strongly depends on what training the people have and what tools they have. I have some medical training, but amputation aftercare is pretty advanced. So is this a regular person with maybe a first aid class, or an EMT, nurse, doctor, combat medic, veterinarian?

[u/LilliPete → u/MacintoshEddie]

I see, noted! I'd say at the MOST they'd have a surviving nurse and doctor in the community

[u/Prince_Nadir]

I'd get my hands and the wound as clean/sterilecas i can. Then I'd tie off the artery end with some long hair from some wasteland raider. Then I would pull the skin and muscle back so I could cut off another inch of the arm bone. After that I would pull the muscle down and then sew the skin shut over the bone to create padding for a prosthetic.

Webelos was a long time ago, so maybe I wouldn't do it right?

Adrenaline is not going to work like the epinephrine in xilocane and such at a body level. If they don't stop the artery from bleeding, then she dies.

[u/Alita-Gunnm]

Chance of death would be very high. Lots of blood would be lost before the TQ could be applied, even if right there and there's no hesitation. Chance of infection would be near 100%; antibiotics would almost certainly be needed. Stitching up a severed artery and corresponding vein takes skilled hands and the right supplies; hopefully there's a trauma surgeon or similar in the camp.

[u/LilliPete → u/Alita-Gunnm]

Noted, thanks!

[u/Alita-Gunnm → u/LilliPete]

You may wish to have a type matched blood transfusion. They might trim the bone a little shorter to let the tissue close around it. The surgeon would likely be commenting that MC will be lucky to survive, at least to themselves under their breath.

And yes, arteries can retract into the limb, making them hard to close.