The group had had stopped kayaking and were on the shore when the man slipped. “He was scouting the area and he slipped and fell into that rock crevice,"
A Brief Case Summary
A 65-year-old Lithuanian man became trapped in a rock crevice while on a group kayaking expedition in southwest Tasmania in November 2024. The group of ten had stopped kayaking and was on the shore of the Franklin River. Valdas Bieliauskas, a seasoned adventurer and kayaker, slipped into the Franklin River while scouting an area near the rapids around 2:30 p.m. on November 21. He was submerged chest-deep in the 10°C rapids and his left leg became entrapped between large boulders. He and his friends were unable to free his leg, so they activated EMS using a satellite phone. Multiple rescue attempts were made throughout the day and into the night, involving two helicopters, 500 kg of gear, and 57 winches. The rescue team attempted to create space between the rocks using equipment such as spreaders and airbags. They also attempted to create a pulley system to reposition Valdas and haul him out. All of these attempts were unsuccessful. A medical team stayed with Valdas overnight to monitor his condition and treat his pain while he remained submerged waist-deep in the rapids. As the kayaker became increasingly hypothermic overnight with limited means of rewarming in the moving current, the medical team determined that he was in a life-or-limb situation. The rescue team communicated to Valdas, with the assistance of his friend, Dr. Arvydas Rudokas, a Lithuanian speaking medical doctor, that a leg amputation was the best remaining option.
The initial physician on the rescue team, Dr. Nick Scott, accidentally slipped and fractured his wrist in the same area where Valdas had fallen, requiring another physician, Dr. Jorian Kippax, to be flown in. He was tasked with performing an underwater limb amputation with a Gigli saw. Like much of the rescue team, he battled with this decision but knew it was the best choice. After Valdas was sedated with ketamine, it took Dr. Kippax less than two minutes to amputate the leg.
After he was extricated from the river, Valdas was found to be unresponsive and pulseless. He was presumed to be in hypothermic cardiac arrest, requiring mechanical cardiopulmonary resuscitation while being flown to the Royal Hobart Hospital. After spending four days in intensive care, where he was rewarmed with extracorporeal membrane oxygenation (ECMO), he awoke and made a remarkable recovery. He returned to Lithuania in January 2025 and is now continuing his recovery by learning to walk with a prosthesis. He plans to return to the Franklin River in 2026 to complete the original paddling trip.
Case Highlights and Clinical Pearls
A Cold Start
Defined as a core temperature of <35°C, hypothermia is categorized by severity based on temperature and clinical features to aid detection in resource-limited settings. The management of accidental hypothermia resulting from cold exposure mainly focuses on rewarming and preventing further heat loss. In the out-of-hospital setting, minimizing movement of a patient with moderate or severe hypothermia is particularly important to prevent fatal cardiac arrythmias. Patients should be rapidly, and carefully, extricated, but rewarming should not delay extrication.
In this case, insulating and rewarming Valdas was nearly impossible, given he was submerged in cold water. Immersion in 1-2° C water can lower core temperature as fast as 5-10°C per minute. Cardiac arrest can occur in just 30 minutes in <15° C water. Although Valdas had the insulation of a thick wetsuit and life jacket, he was submerged chest-deep in 10°C water. Valdas’ friends rotated in shifts, bringing him food and warm drinks every thirty minutes. Their efforts likely slowed the onset of hypothermia; however, with the convection of the rushing water, eventual progression into severe hypothermia was inevitable. The rescuers noted that he was “doing remarkably well”, remaining stoic and participating actively in his care for the majority of this ordeal. Over time, he became much less conversational, and it became clear that he was progressing from mild to moderate, and eventually, severe hypothermia.
Breaking Free
Field amputation is a rarely performed prehospital intervention. Indications for performing a prehospital amputation include: an immediate threat to life due to scene safety; risk of death from medical deterioration if rapid extrication by other means is not possible; a nonsurvivable or severely mutilated limb with minimal attachment that delays extrication or evacuation; and a deceased patient obstructing access to potentially viable casualties.
Like any procedure, field amputation begins with optimizing oxygenation, ventilation, hemostasis, analgesia, and securing vascular access, if possible. The medical team appropriately chose ketamine for procedural sedation, as it provides analgesia and sedation, without respiratory depression. A proximal tourniquet should be applied to minimize major bleeding and the limb should be amputated as distally as possible in a guillotine fashion – cutting through the bone using a sliding blade. All layers of skin should be first incised using shears or a similar tool, and hemostats may be applied to occlude large vessels. A Gigli saw—a lightweight surgical instrument consisting of a flexible, toothed wire—can be used, if available, to divide the bone smoothly. Some sources report that a hacksaw, reciprocating saw, or Holmatro device can be used, though they are not recommended as first-line, given risks such as additional blood loss or accidentally extending the cut beyond the minimally intended area.
Gigli Saw (Olek Remesz, WikiMedia)
In this case, submersion under water made performing the procedure especially challenging. Due to poor visibility, Dr. Kippax performed the amputation with bare hands for tactile feedback while he himself was partially submerged in spread eagle position. Rachet straps were implemented as torniquets out of concern that the hook and loop fastener of a conventional tourniquet – such as a Combat Application Tourniquet (CAT) – would not function underwater. Dr. Kippax cut through thigh musculature and began dividing the femur using a Gigli saw, which broke partway through the procedure. Despite this, he was able to cut through the rest of the femur and complete the amputation.
Afterdrop, Rescue Collapse, and Resurrection
After he was freed, Valdas likely suffered from "afterdrop” and rescue collapse. In afterdrop, core cooling continues even after removal from the cold environment. This occurs as cold peripheral blood returns to the core during rewarming, and through conductive heat transfer from warmer central tissues to colder extremities. The resulting drop in core temperature can precipitate cardiac instability, and rescue collapse during extrication or transfer often manifests as sudden cardiac arrest. Sudden movement and exercising patients should be avoided as this is known to cause rescue collapse even in those who are conscious. For this same reason, gentle and horizontal transport is recommended.
A key distinction in managing a pulseless hypothermic patient is the prolonged duration of CPR, which should continue until the patient is “warm and dead,” defined as having a core temperature >32°C. Severely hypothermic patients may qualify for venous-arterial ECMO, which supports organ perfusion but can also be used to warm the patient quickly.
Indications for hypothermia transfer to extracorporeal life support (ECLS) center include ventricular dysrhythmias, systolic BP <90 mmHg, and hypothermic patients already in cardiac arrest. Compared to other etiologies of cardiac arrest, survivability is much higher in hypothermic cardiac arrest.
After extrication, Valdas was found to be apneic and pulseless. Positional change during the extraction from vertical to horizontal may have triggered his collapse. He was winched from the crevice and placed on a mechanical CPR device before being airlifted to a tertiary care center.
A Job Well Done
Throughout this case, rescuers demonstrated exceptional preparedness and adaptability, anticipating potential outcomes and planning corresponding next steps. Friends and rescuers helped slow the progression of hypothermia through simple but effective interventions, buying valuable time to determine a means of extrication. Valdas’ determination and composure under extreme physical and psychological stress were remarkable. The team remained vigilant during the critical period following extrication, enabling immediate intervention when he lost pulses. They arrived well-prepared, equipped not only with appropriate gear but also with specialized tools such as a Gigli saw. Owing to the skill and coordination of the rescue team, Valdas ultimately survived—and was able to return home to his friends and family.
Lithuanian tourist pack rafting on Franklin River still fighting for life in Tasmanian hospital
By Henry Belot, The Guardian
Sun 24 Nov 2024
Police involved in the rescue of a rafter from the Franklin River in Tasmania described the situation as ‘the worst case scenario of the worst case scenario’. ‘He was wedged like an hourglass’: rescuers describe 20-hour ordeal ending with amputation of rafter’s leg.
A 69-year-old Lithuanian man has been praised for his “extraordinary resilience” after emergency service workers were forced to amputate his leg during a 20-hour rescue operation in remote south-west Tasmania. The man, who remained in a critical condition in Royal Hobart hospital on Sunday evening, had been travelling with a group of 11 tourists on a multi-day rafting trip on the remote Franklin River. He slipped on a rock while walking beside the river and became trapped, partially submerged, in a crevice for close to 20 hours.
Mitch Parkinson, an intensive care flight paramedic with Ambulance Tasmania, was among the first people on the scene. He said it was “the most challenging case that I have ever taken part in. This was an exceptionally strong and resilient man and he maintained that throughout the night,” Parkinson said. “Our efforts were to keep him warm as best as possible, to keep him fed and watered as much as we could.”
Meanwhile, rescuers continued in their attempts to free him. One of the two surf lifesavers who worked to free the man, Ace Petrie, said when he first reached the man, he was submerged from chest down in fast moving water. “He had a little bit of broken English,” Petrie said. “When we tried to pull his leg out, he would say ‘oh, my leg is broken’. Apart from that, we couldn’t take his mind off the situation and talk to him about his family. That was really hard.
“He was wedged like an hourglass. He had his knee trapped in rocks in a deep section of that rapid. There were a number of hazards that we had to work around to gain access to the patient.” The man, seen here trapped between rocks, whose leg needed to be amputated to complete the rescue. The water level dropped as the operation continued, but not nearly as much as emergency services personnel hoped for.
Petrie said he did everything he possibly could to free the man. This included using ropes and pulleys. Eventually, the team used airbags and hydraulic tools to try to shift the submerged rocks that were pinning him. “These machines have a capacity of 50 tonnes, but we were not budging these rocks at all,” Petrie said. “This went on for about 10-12 hours of different scenarios.”
Constable Callum Herbert from Tasmania police said: “This rescue was the worst case scenario of the worst case scenario. “He could not be physically removed and every available angle to try and manipulate him out, and every resource possible was used before the amputation,” Herman said.
Radio signal was so poor in the region that the Maritime Safety Authority needed to dispatch a jet from Canberra, which acted as an intermediary between the rescue staff on the ground and helicopters in the region. “The focus of the entire evening was ensuring that [amputation] was the absolute last resort,” Parkinson said. “There was an understanding that every conceivable single effort had been made. This was not a discussion or decision that was made lightly.”
Parkinson said the man’s Lithuanian friends helped to supply him with hot drinks and meals during the entire time he was stuck. One of the ten people who were rafting with the patient was a doctor in Lithuania, who was able to communicate with him as a translator. Through him, the trapped man was informed that amputation was the only option.
Petrie said those conducting the rescue, including himself, had put their own lives at risk during the rescue operation. “We do train for these type of scenarios, but this one was out of the box,” Petrie said. Emergency personnel have worked with diplomats to reach his family overseas, to keep them informed.
On Sunday evening the man remained in a critical condition in hospital.
Kayaker Trapped on Australian River Has Leg Amputated in 20-Hour Rescue
The police in the state of Tasmania said all other efforts to help the man, a foreign tourist in his 60s, failed before the decision was made to amputate.
By John Yoon, NY Times
Nov. 23, 2024
A kayaker’s leg was amputated on Saturday in a harrowing 20-hour effort to free him after he became trapped in rocks on a river in Australia, the police in the state of Tasmania said. The man, a foreign tourist in his 60s, was then flown to a hospital in the city of Hobart, where he is in critical condition, the authorities added.
The man, who has not been identified by the authorities, was on a group kayaking expedition in the Franklin River on Friday when his leg got stuck between rocks in a remote section of the rapids. Emergency teams responded when they received a distress signal from a smartwatch at 3:30 p.m. on Friday, the police said in a statement. When rescuers reached the remote location, they tried but failed to free the kayaker in the evening.
The kayaker spent the night partly submerged in the river; a medical team stayed with him throughout. In the morning, another attempt to free him failed as his condition deteriorated, the police said. After consulting with the man, the medical team amputated his leg using specialized equipment, the police said.
“This rescue was an extremely challenging and technical operation,” Doug Oosterloo, the acting assistant commissioner of the Tasmania Police, said in a statement. “Every effort was made to extract the man before the difficult decision to amputate his leg.” The police said they were in the process of contacting the man’s family.
Man’s leg amputated in near 20-hour effort to free him from rocks in Tasmania’s Franklin River
International visitor aged in his 60s fighting for life in hospital after accident on rafting trip on Friday
Australian Associated Press
Sat 23 Nov 2024
A man has had his leg amputated and is fighting for life after a complex 20-hour rescue in south-west Tasmania, after he fell into a rock crevice during a rafting trip with friends. The international visitor, aged in his 60s, was pack rafting along the Franklin River when he slipped and became trapped between rocks in rapids on Friday afternoon, acting assistant police commissioner Doug Oosterloo said. His smartwatch made a call for assistance about an hour later and triggered an emergence response, providing rescuers with his location.
The man was partly submerged in water and workers unsuccessfully tried to extract him several times on Friday evening and Saturday morning. A medical team stayed with him throughout the ordeal and determined his condition was deteriorating. “This was a life and death situation and the decision was made in consultation with the patient to amputate his leg to be able to remove him from the rock crevice,” Oosterloo said. “He is described as being in a critical condition but it is quite clear from the medical advice that had he remained in the location where he was, and trapped in the rock crevice he would not have survived.”
Oosterloo said it was a challenging rescue for everyone involved and said workers did well to get the man out. The man was sedated while his left leg was amputated above the knee. Ambulance Tasmania’s Charles Wendell-Smith said his colleagues described the man as resilient and positive throughout the rescue attempts. “Very positively focused and optimistic to be rescued and get out of the situation that he was in,” he said. One ambulance worker slipped at the site and suffered a wrist injury.
“The scene was an incredibly challenging location in the remote and austere environment of the south-west of Tasmania on the Franklin River,” Wendell-Smith said. “Not only were they in the elements throughout the night with limited communications, but they were in a precarious location with lots of hazards and risks around them.”
The man was trapped for about 20 hours in total and had been travelling in a group of 11 international visitors, who Oosterloo said were well prepared and well resourced for the multi-day rafting trip.
“The beauty of Tasmania’s wilderness is what attracts people to this state but that wilderness is also some of the most challenging and rugged terrain in the world,” he said. “Even if you are well prepared, even if you do take all necessary precautions, things can go wrong. “It’s a really timely reminder to people to make sure you take all those precautions in the interest of your own safety.”
Authorities have not identified the man publicly or revealed his nationality as they have been unable to contact his family overseas. Those travelling with him are being airlifted away from the area and police are waiting to speak to them to find out exactly what happened. “Our understanding is that he was scouting the area,” Oosterloo said. “They’d stopped kayaking. They were on the shore. He was scouting the area and he slipped and fell into that rock crevice.”
