Although infrequent, there are patients who present themselves to surgeons and ask that a limb be amputated. Generally, such patients fall into one of three categories. The first is those suffering from “Body Integrity Identity Disorder” (BIID), a condition in which individuals feel that one of their limbs is foreign to the rest of their body, and must be re moved. The second category is Apotemnophilia, a fetishized desire to become an amputee to enhance sexual gratifica tion. Such drive for sexual gratification may lead to requests for amputation. Finally, the third category is delusional beliefs secondary to severe mental illness that may compel an individual to seek amputation, or even attempt self-amputation. We present a fourth type of patient: the Global War on Terrorism veteran with a severely injured arm demanding amputation to fit in with others who use prosthetic devices. In this instance, the cause of injury was a motor vehicle collision. We speculate that our case is not the only one and that a fourth category of patient demanding ampu tation is emerging. Further study is needed.
A premium is placed on patient autonomy in modern medicine, with providers encouraged to find a balance between patient choice and physician power [
A 28-year-old male was the unrestrained passenger of a single vehicle rollover collision in a rural area of the western United States. He was partially ejected from the vehicle and his non-dominant arm became trapped between its roof and the ground. Hydraulic extrication was required and the patient was flown to our facility, a Level I trauma center. Other than relatively minor lacerations and contusions to the rest of his body, the patient’s injuries were generally confined to his non-dominant arm: a degloving injury to the hand and distal arm; multiple complex fractures involving the humerus, radius and ulna; and significant soft tissue injury with irreparable nerve damage. Despite these significant injuries, the orthopedic service was confident that this extremity could be salvaged, with some intact sensation in the fingers and the ability to open and close his hand. The patient was told, however, to expect significant disability with this arm, including frozen joints. The inability for the patient to have an articulating arm was reportedly unacceptable to him. The patient demanded that the limb be amputated and refused surgery or any other intervention that was not directly tied to removal of this arm. A psychologist was called to assess his decision making capacity.
Patients demanding amputation are not unheard of in the literature and generally three major areas are described. Michael First coined the term “Body Integrity Identity Disorder” (BIID) in 2004 to describe individuals who experience a dissonance between their actual body state and their perceived body schema [
Interestingly, there is a growing literature suggesting that BIID is closely related to the neurological condition somatoparaphrenia, occasionally occurring after right parietal lobe insult [
Apotemnophilia is a condition whose name was coined in 1977 by Money et al. to describe the fetishism of becoming an amputee [
Finally, severe, untreated mental illness may account for a patient demanding amputation. In some cases, need for amputation is so profound, some individuals may act on the impulse and self-amputate. There is a rich literature of psychotic individuals who have cut off limbs, genitals and performed self-enucleation. Large et al. suggest that this concerning behavior may be associated with the first psychotic break associated with schizophrenia [
It was with this framework that we conducted an evaluation of the 28-year-old male with a severe arm injury. He reported being an active duty member of the United States Marine Corps. He stated that his job in the Marines was to be a “door kicker,” and had recently been promoted to E-6 (Staff Sergeant). He reported a tremendous amount of pride being a leader in his unit. He enlisted at age 18 and planned “to make a career in the military.” He denied a previous history of mental illness, stating he had never been under the care of a mental health professional. He reported serving three deployed tours of duty in the Global War on Terrorism. The patient denied severe symptoms of PTSD, but did endorse some intermittent irritability and insomnia while being deployed. While not meeting full criteria for Alcohol Use Disorder, he did endorse some symptoms of problem drinking. He was under the influence of alcohol at the time of his injury.
When asked about his decision to simply choose amputation and forego other treatments, the patient stated that his military career was over. He said that he did not want to face his “brothers-in-arms” with an injury that he was largely responsible for. He reported that he did not want to have to tell people how his debilitating injury was not “earned in combat,” but was because he was not wearing a seat belt. The patient said he was well aware of the developments in prosthetic devices and would be proud to be like other veterans with missing limbs.
We cautioned the patient about making life changing decisions during an acute surgical emergency and urged him to learn more about the process and consequences of having a prosthetic arm, including phantom pain and rehabilitation requirements. We ultimately deemed him as having intact decision making capacity regarding the care of his injured arm, but also reminded the primary team that they were not obligated to perform a procedure simply because the patient desired it. He was ultimately transferred into the VA medical system and was lost to follow up.
It is likely that this is not the only case of a member of the military making such a request after a career ending injury. It may be that a fourth category of patients demanding amputation is developing with injuries sustained on the battlefield. Further investigation is necessary.