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The Walter Reed Experience: Current Issues in the Care of the Traumatic Amputee

LTC Paul F. Pasquina, MD,
CPT Kevin F. Fitzpatrick, MD

ABSTRACT

Military operations in Iraq and Afghanistan have resulted in a significant increase in the number of traumatic amputees receiving care in the military medical system. Combat casualties with amputations present unique medical, surgical, and rehabilitation challenges. Multiple factors such as the complexity of soft tissue trauma and number and nature of comorbid conditions greatly influence the outcomes of individual patients. Optimal treatment strategies in caring for the combat amputee should be shaped by analyzing the effects of interventions on outcomes. Outcome measures play an important role in caring for these patients and improving the processes by which they are provided care. Existing outcome measurement tools are limited in their application in the assessment of this unique patient population; therefore, the application of multiple tools is required.

Recent experience at Walter Reed Army Medical Center in caring for combat casualties related to Operations Iraqi and Enduring Freedom has provided a unique insight into the complexities of caring for the traumatic combat amputee. Advances in forward surgical and medical care, coupled with improved body armor and evacuation techniques, have contributed to injured soldiers surviving wounds they might not have survived in earlier military conflicts. In addition, a larger percentage of combat casualties are receiving major limb amputation. The severity of these wounds, however, has posed significant medical, surgical, and rehabilitation challenges. The United States military is committed to providing the highest quality of care to its combat casualties and recognizes the importance of outcome measures to improve its practice to help injured soldiers return to their highest level of physical, psychological, and emotional function.

UNIQUENESS OF THE COMBAT CASUALTY

Combat casualties injured overseas receive immediate lifesaving medical care by trained combat medics and forward medical and surgical teams. They are then rapidly evacuated to higher levels of care in fixed military medical facilities. Advanced medical and surgical care is staged throughout the evacuation process in a highly structured and organized fashion. Soldiers, sailors, airmen, and marines with severe limb trauma require multiple and frequent surgical "washouts" throughout this process. It is often weeks before they are ready for their definitive amputation surgery and skin closure. The majority of U.S. military amputees are currently being treated at Walter Reed Army Medical Center in Washington, D.C. Walter Reed has developed a well-organized, comprehensive program in caring for its amputee population, with services ranging from highly specialized surgical care to vocational counseling, peer visitation, and recreational therapy. Holistic care is achieved through an interdisciplinary team approach.

The United States government, along with numerous public and private organizations, has continued to show unlimited support in providing state-of-the-art care for its injured soldiers. This tremendous support has allowed combat amputees to be fitted and trained with the latest and most high-tech prosthetic components on the market. Unfortunately, there is very little scientific evidence that one prosthetic component is superior to another. Because of this, patients and providers must use expert opinion, patient satisfaction, and gait and functional assessments to determine which prosthetic components are best to meet individualized goals and objectives. The high volume of amputees currently being seen at Walter Reed presents an excellent opportunity to perform valuable outcome assessments, which should contribute greatly to the field of prosthetics and amputee care. Although this remains a high priority to the providers at Walter Reed, achieving this goal is not without significant challenges.

Unique challenges in caring for the combat amputee exist at every level of medical, surgical, and rehabilitation intervention. Wounds resulting from blasts or explosions have a significantly high infection rate and are associated with extensive soft tissue damage and complex scar lines. Furthermore, combat casualties often present with a high prevalence of confounding comorbidities, such as multiple fractures, traumatic brain and spinal cord injury, visual and hearing impairment, and complex psychosocial issues. Although it is widely accepted that these factors greatly influence medical, surgical, and rehabilitation outcomes, demonstrating this in a statistical fashion in such individualized patients is a significant challenge.

Implementation of outcome measures to assess quality of life or return to previous premorbid activity level is also limited in this patient population, given the unique characteristics of military personnel. Individuals who enter the military are typically young, with excellent premorbid health. Their high expectations to return to premorbid activity levels continue to appropriately challenge healthcare providers and engineers to improve prosthetic designs as well as therapeutic intervention and training. Additionally, the need to develop new outcome measures that examine higher levels of function is highlighted, as opposed to those typically used for the older diabetic or dysvascular amputee. Finally, many soldiers enter the military with unclear long-term career goals, seeking educational grants and career experience to help formulate their future aspirations. After injury, a certain amount of time is expected for physical healing, achieving independent function and psychological adjustment before full integration back into the community and work force. Vocational rehabilitation counselors are valuable in this process; however, we have found it difficult to establish a systematic way to track long-term outcomes in this population. Work is currently being conducted to partner with the Department of Veterans Affairs to establish an effective system.

It is also well recognized that the collection of goodoutcome data takes a significant amount of time and infrastructure support. Without information technology assistance, developing and maintaining a database that meets the security and privacy standards needed for healthcare information is virtually impossible. Additionally, as in many institutions, healthcare providers are faced with more clinical work and less time to undertake quality research projects. This is further complicated in the military healthcare system, in which providers are often also faced with frequent deployments.

CURRENT OUTCOME MEASURES

MILITARY-SPECIFIC MEASURES

The Army Surgeon General's Office has historically maintained a database of injuries and evacuations from military conflicts. This valuable information has provided military planners with essential guidelines when developing medical support plans for military operations. It has also guided military medical training to ensure medical support is available for soldiers on the battlefield as well as their loved ones all over the world. These reports, however, are primarily managerial in nature to help ensure that appropriate resources are available to all facets of military activity and to provide for training and equipment needed in a fluid environment to provide optimal functioning across the continuum of military of operations. Among the data collected in this database are types of injuries, average lengths of stay at the various military medical facilities from in-theater locations to stateside medical centers, and demographic information about injured patients.

SURGICAL OUTCOMES

Surgical outcomes at Walter Reed are tracked in a manner similar to other medical institutions. Information such as surgical procedures performed, lengths of stay, and complication rates, are routinely followed. There remain, however, many challenges when evaluating surgical outcomes in the amputee population. For example, decisions such as whether to attempt limb preservation versus amputation remain a topic of debate among medical and surgical experts. Issues such as short- and long-term outcomes and complication risks make this decision more complicated, especially when there is strong evidence of the higher functions currently being achieved by today's active amputee.

There is currently a lack of rigorous research addressing limb preservation versus amputation for this population of patients, and studies are therefore needed to assist in this decision-making process. As a highlight to the complexity of this issue, several patients have opted for elective amputation after prolonged attempts at limb preservation. Some patients, after going through multiple surgical procedures and up to 12 months of intensive rehabilitation, continue to have significant mobility and functional limitations with their preserved limb. Their frustrations are compounded as they witness amputees arriving at Walter Reed who undergo prosthetic fitting and training and are back to running and sports in sometimes less than 6 months. Although these experiences have been helpful in formulating their decision for the elective amputation, all have reported that they are happy they were the ones making the informed decision as opposed to the surgeon on the battlefield. Without hard data, military surgeons are compelled to continue to make every possible effort to preserve limbs.

Additionally, significant controversy exists in the area of optimal functional outcomes at different levels of amputation. In particular, substantial debate continues about which is more functional: a knee-disarticulation versus a transfemoral amputation, or a Syme's amputation versus transtibial. For example, a knee disarticulation or a Syme's amputation may have the benefits of added residual limb length and improved socket suspension, but these levels present significant drawbacks in terms of options for prosthetic components, cosmetic outcomes, and patient acceptance. Although arguments on both sides have sound reasoning, hard data are lacking to support individual claims. More relevant outcome data are needed in this patient population to assist in guiding these often difficult surgical decisions.

MEDICAL OUTCOMES

Caring for multitrauma injuries, as seen in the combat amputee, requires aggressive monitoring and management of all organ systems and includes the provision of needed nutritional support. In this patient population, it is especially important to track and treat infections and maintain adequate infection control policies and procedures. Additionally, effective pain management policies must be established with institutionally recognized and taught assessment tools such as the Visual Analog Scale or 0–10 verbal scores for pain. It is also critical to be vigilant in preventing, identifying, and treating secondary medical complications such as deep venous thrombosis, pulmonary embolus, and heterotopic ossi- fication. Outcome studies specific to this patient population, however, are needed to help monitor the effectiveness of prevention and treatment strategies.

Another special consideration for this patient population is the impact of mental health conditions on functional outcomes. Military soldiers face challenging psychosocial stressors, especially those who have been exposed to combatrelated experiences. These stressors are magnified further by factors such as protracted separation from their friends and family and exposure to foreign environments. These issues, coupled with one's loss of limb, may significantly complicate the process of adjustment and acceptance of a new physical impairment. Tracking the incidence of such mental health disorders as posttraumatic stress disorder, anxiety, and depression has been a major concern of military psychiatrists as well as preventive medicine specialists. Military experts have found it helpful to develop unique outcome screening tools to identify and track these diseases. A study by Hoge et al.¹ reports the results of the implementation of such a tool unique for this patient population.

REHABILITATION OUTCOMES

Several well-established rehabilitation outcome measures are currently in use for the amputee population at Walter Reed Army Medical Center, including tools that measure mobility, quality of life, and general level of functioning.

Mobility outcomes are measured with a variety of tools: (1) the Amputee Mobility Predictor (AMP), administered either with or without a prosthesis, provides a tool for measuring ambulation potential.² This is performed at regular intervals once amputees have been fitted with a prosthesis. Our experience has found that once a patient is able to be fitted, they quickly reach a ceiling effect with this measure. (2) The 6-minute walk test provides an objective measure of mobility.³ This test is able to measure efficiency of gait, patient confidence in a prosthesis, and cardiovascular conditioning and allows for comparison of different prosthetic components (e.g., a hydraulic knee versus a microprocessor knee system). This test does not appear to display a ceiling effect in the acute phase of rehabilitation; however, more data are needed to evaluate its effectiveness for long-term follow up. (3) The Timed Up and Go test measures an amputee's ability to initiate ambulation.⁴ Although normal values have not been established, data are currently being collected for this particular cohort of young traumatic combat amputees. (4) The Sensory Organization Test (SOT) is a standardized measure of balance. It is administered at Walter Reed upon the patient reaching a level of modified independence with the prosthetic limb and again after a course of rehabilitation. The SOT rates the results of patients with amputations against age- and sex-matched patients in the able-bodied population. (5) Gait analysis provides further information useful in the rehabilitation of the amputee. Gait and motion analysis is particularly useful to help guide prosthetic component choices and as an educational tool for patients and the rehabilitation team. It has been effectively used to provide immediate feedback to the therapist, prosthetist, and patient to help guide prosthetic adjustments, therapeutic intervention, and education.

Currently at Walter Reed, information regarding quality of life and function is gathered through the implementation of the Standard Form 36 (SF-36)⁵ and Functional Independence Measure (FIM).⁶ These measures are administered at admission and discharge and provide valuable feedback on the effectiveness of our inpatient care process. They also act as excellent baseline information for future studies to examine long-term outcomes.

MILITARY-SPECIFIC REHABILITATION OUTCOME MEASURES

Several outcome measures specific to the military population have proven important in the care of the combat-injured amputee: (1) a Patient Satisfaction Survey has been developed for use in the amputee clinic at Walter Reed. Each patient is administered the 23-item survey upon his or her initial visit to the amputee clinic, and the feedback obtained is used to facilitate performance improvement in the care of the patient. This survey examines issues such as medical care and pain management through the evacuation process as well as at Walter Reed. Additionally, it provides relative value assessments of the effectiveness of our educational and support programs. (2) Statistics are also maintained regarding return to duty rate. A recent cultural shift in the military has helped to retain soldiers with amputations who desire to remain on active duty. It will be important to track these statistics and make comparisons to figures from previous military conflicts. Kishbaugh et al.⁷ reported a return to duty rate of 2.3% among amputees after the first Gulf War. Significantly higher rates are expected after the current conflict. (3) The Fire Arms Training System is a virtual-reality system designed for training soldiers on the use of firearms in a simulation of combat scenarios. This system has been used to allow amputees to train in military-specific skills.

Although several military-specific outcome tools are being developed, more are needed. For example, a sophisticated peer visitation network has been established at Walter Reed and has received high satisfaction scores by our amputee population, but how does this translate into short- and longterm outcomes? Additionally, it is well recognized that motivated patients recover more effectively, but difficulties with measuring motivation and the influence of activities or environment on motivation have limited the ease with which these effects can be measured. Finally, better outcome instruments are needed to evaluate higher level activities such as running and military-unique tasks. There is a need to incorporate sports medicine principles and return to play criteria to guide the rehabilitation of active amputees and provide for a safe return to higher level activities.

CONCLUSIONS

Recent experiences at Walter Reed Army Medical Center have provided a unique opportunity to examine and improve outcomes for traumatic amputees. Many factors contribute to make combat amputees unique from amputees traditionally seen at other medical institutions. Clearly, there is a need to improve the development and utilization of outcome measures specific to this population. By doing so, the opportunity exists to share the benefits of the experiences obtained at Walter Reed in an effort to improve outcomes for patients with amputations treated throughout the medical community.

Correspondence to: LTC Paul F. Pasquine, MD, Physical Medicine & Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Ave., Washington, DC 20307; e-mail: .

LTC PAUL F. PASQUINA, MD, is affiliated with Walter Reed Army Medical Center, Washington, DC.

CPT KEVIN F. FITZPATRICK, MD, is affiliated with Walter Reed Army Medical Center, Washington, DC.

References:

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