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32 JULY 2016 | EMSWORLD.com for more information. But even if you can't make it to New Orleans, there's plenty to learn from the Philadelphia train case and other field amputations. Team Considerations Philadelphia's team gets its medical supplies and medications through a local hospital and uses PPE from the PFD. It's unfunded, however, and lacks ongoing training. What training should it be getting? It's hard to know, because there's not much literature to draw from or experience, for most people, beyond small exercises. "We have no science to really help us determine that," says Manifold. "I think any of our protocols, at a minimum, should be dusted off, reviewed and practiced on an annual basis, if not more frequently—even every six months. It depends on the empha- sis and interest of the agencies involved." Who should be on the team? Start with physician expertise—an emergency medi- cine physician, EMS medical director and/or trauma surgeon. Local hospital, trauma and orthopedic specialists should be involved, and the perspectives of front-line providers should inform all plans. "We absolutely need input from the field providers who may be asked to do this—the leadership team will be responsible for the involvement of their personnel," says Mani- fold. "I'd also include as potential ancillary personnel the chaplaincy and critical inci- dent stress management folks," as these calls can be emotionally taxing. As far as equipment, there are simple handheld tools and surgical instruments that can disarticulate an extremity fairly easily. Appropriate saws include electric and manual surgical saws and a Gigli saw; reciprocating saws are available on most res- cue trucks. Hydrau- lic tools like a Hurst work effectively but can damage bone. Complement these with basic surgical equipment such as scalpel, pickups and spreader. Include tourniquets and hem- orrhage-control dressings; a way to gain vascular access (IV or IO); and airway management options. Don't forget suturing equipment and a way to secure tissue and transport any salvageable parts. Coordinate all this at the hospital level. Ketamine is an excellent anesthesia for these cases— "probably the safest and best medication to use," says Manifold. Etomidate can be a good option too, and analgesia (of course) and antibiotics are called for as well. With so little information on how often EMS performs field amputations, their out- comes and what impact team and equip- ment configurations might have, it sure would be nice if someone pulled together available cases and started trying to learn something from them. That's a near-term goal of Manifold's. In the meanwhile, departments should at the least proceed with crafting protocols and conducting training. "People often do a good job of sort of put- ting this kind of thing in place," Manifold says, "but we're not always good with the follow-through of exercising it and making sure folks at the ground level really know how to access it and perform it efficiently. It does no good if it takes us two hours to assemble our equipment and team and get them out to the scene." R E F E R E N C E S 1. Williams S. Doctors Amputate Man's Foot on Philadelphia Train Tracks. W VPI-T V, http://6abc.com/news/doctors- amputate-mans-foot-on-philadelphia-train-tracks/892350/. 2. Kampen KE, Krohmer JR, Jones JS, Dougherty JM, Bonness RK. In-feld extremity amputation: prevalence and protocols in emergency medical services. Prehosp Disaster Med, 1996 Jan–Mar; 11(1): 63–6. —John Erich, Senior Editor Orthopedic surgeon Joe Alderete, MD, a leading expert on field amputations, will help conduct the amputation lab at EMS World Expo. Pr eparing f or the Pope Papal visit was unchartered territory W hen EM S person nel learned in 2013 that Pope Francis had scheduled a visit to Philadelphia on his 10-day global tour in 2015, the command structure began plan- ning for the event—or, rather, speculating. How many people would attend the highly anticipated Vatican-sponsored outdoor mass? "The papal visit was unchartered ter- ritory," admitted Crawford Mechem, MD, EMS medical director for the Philadelphia Fire Department, in his Gathering of Eagles presentation earlier this year, "Pontificating in Civitas Autem Fraternitatis Caritatem: Philadelphia Preps for a Peripatetic Papal Pass-Through." Crowds for previous masses around the world had reached nearly six million. "A papal event isn't comparable to other events, so the crowd estimate was our most difficult challenge," Mechem says. Initially the crowd estimate was three million. As the event drew closer, that dropped to one million. "It was the best number we could come up with," says Mechem. "There was little science to it." Based on that size crowd, Mechem began estimating the number of anticipated patients, while also planning staffing and first-aid tent and resource deployment. Papal visit activities would stretch from the Philadelphia Museum of Art to Indepen- dence Mall. A five-square-mile "traffic box" would close to private traffic. Among the unique challenges, mass attendees—includ- ing the elderly and infirm—would need to walk a good part of the way to the site. How many visitors would turn into patients? How sick would they be? "In our primary planning for the event, we placed first-aid stations throughout the area and deployed foot patrols consisting of EMTs, paramedics and small all-terrain vehicles to navigate the crowd," Mechem