Picture this: a man trapped, half-submerged in frigid, flowing river water for nearly a day, his life slowly fading away as hypothermia took its toll.
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All efforts to extract 66-year-old Lithuanian adventurer Valdas Bieliauskas had failed after his leg became trapped in a rock crevice while rafting on the Franklin River in Tasmania last November.
Dr Jorian Kippax was the Tasmanian doctor called in after amputation was determined to be the only way to save the man's life.
"Valdas' death was inevitable and evident probably in the next couple of hours," Dr Kippax said in an address to fellow medical professionals last week.
With tonnes of icy water flowing past him every second over such a prolonged period, Mr Bieliauskas' core temperature had plunged to a deathly 26.3 degrees.
"Amputation was the only viable option," Dr Kippax told the audience of fellow doctors at the Australian Orthopaedic Association's annual meeting in Hobart.
He said numerous setbacks had plagued the operation.
The doctor initially tasked with performing the amputation fell and broke his wrist.
Then, they discovered the tourniquet they hoped would stop the blood flow had a velcro grip that failed underwater.
And as they began the amputation, the saw that Dr Kippax chose to perform the procedure broke mid-operation.
The amputation itself was "profoundly unpleasant", he said.
"It felt like something from a bygone era."
A camera strap with a buckle was used as a makeshift tourniquet, and Mr Bieliauskas was given a large dose of ketamine horse tranquiliser to manage the pain after a general anaesthetic was deemed too risky.
The saw Dr Kippax chose was a Gigli saw - a flexible, serrated wire with two handles.
"It certainly works very efficiently, but it is quite fragile," he said.
With the leg submerged underwater, he was effectively blind as he began cutting just above the knee.
He immediately struggled with the confined workspace and the constant pressure of rapidly flowing water.
"And then to my horror, the [saw] wire just about immediately snapped and left the femur very much intact," Dr Kippax said.
He had no spare saw in his equipment, leaving him with no readily available tools to cut through Valdas' thick leg bone.
"I remember looking across at Rohan, the [intensive care] paramedic beside me.
"I was holding the two ends of the gigli saw, and his eyes got wider and the shoulders slumped."
Dr Kippax said he thought about using his Leatherman multi-tool, but the item was a distance away stored in a pack.
"So I looked at Rohan, and I said 'I'm just going to kick it'.
"I kicked it really hard and nothing happened.
"So I kicked it again, harder, and at that stage, the femur snapped, and suddenly he was free."
The amputation had taken just three minutes.
After nearly 24 hours in the water, Mr Bieliauskas was pulled up onto a ledge, placed on a stretcher and wrapped in warm blankets.
But even then, Dr Kippax doubted his patient would survive.
"At that point, his survival did look extremely bleak," he said.
"It was a near certainty that no matter what we did and how carefully we got him out of the water, that he would deteriorate.
"We anticipated that he would probably go into cardiac arrest shortly after we got him out."
His prediction turned out to be true - Mr Bieliauskas' heart soon stopped and the team began efforts to revive him, using CPR, and then a mechanical machine that kept his heart pumping automatically.
"He had no output for over 30 minutes, and as we know, the likelihood of survival following cardiac arrest trails off dramatically from 30 to 60 minutes, and just about nobody survives after 60 minutes."
By medical standards, Mr Bieliauskas was dead.
However, he was revived at the Royal Hobart Hospital after his 40-minute flight.
Dr Kippax credited the so-called hypothermia paradox for saving the man.
The extreme cold had lowered Mr Bieliauskas' oxygen demands so drastically that his brain was preserved.
The frigid river, which had tried to kill him, became Mr Bieliauskas' lifeboat in the end.
After spending several weeks recuperating in Tasmania, he returned home
As to what happened to the limb he left behind: Dr Kippax confirmed it was never recovered.
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