Patient Care Team Includes
Surgery
Physical Medicine and Rehabilitation
Regional Anesthesia and Pain Management
Nursing
Physical Therapy
Occupational Therapy
Prosthetics and Orthotics
Psychiatric Consultation and Liaison Service
Social Work Dieticians
Public Affairs Office
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Gait Lab
Ministry and Pastoral Care
Peer Visitation (Amputee Coalition)
VA Counseling
Vocational Rehabilitation and Employment Services
VA Research Community
Red Cross
Patient
Patient's Family
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During previous military conflicts, soldiers
who underwent amputation typically received
immediate life-saving medical treatment
and limb stabilization in a military medical
facility. Once they were stable, the trend was
to medically discharge them and transfer
them to the Veterans Health Administration
for rehabilitation and prosthetic care. After
Operation Desert Storm, however, we realized
that an amputation was not necessarily a careerending
injury, especially with the evolution of
new prosthetic devices that enabled soldiers to
run, jump, and function at a much higher level
than they could in the past.
Now, after Operation Enduring Freedom
and Operation Iraqi Freedom, the military’s
philosophy of healthcare has evolved into a
proactive team-based approach to amputee
rehabilitation. This means that a team of
healthcare professionals work together with the
patient to meet his or her surgical, prosthetic,
rehabilitation, training, emotional, spiritual,
financial, and continuing medical needs. To
accomplish this, in December 2001, WRAMC
established the Amputee Patient Care Center,
which provides a full spectrum of high-tech care
for soldiers who sustain traumatic amputations
on the battlefield. The healthcare team at the
Center is dedicated to the rehabilitation and
restoration of these amputees with the end
goal of giving them the option to remain on or
return to active duty and complete their military
careers.
The subspecialties involved in this
rehabilitation team include the Physical
Medicine and Rehabilitation (PM&R) Service,
the orthopaedic team, prosthetics, physical
therapy (PT), occupational therapy (OT), nutrition
care, psychiatry, the Social Work Service, the
ministry and pastoral care group and the nursing
staff, including the nurse case manager and the
rehab nursing staff. Throughout the amputee’s
hospitalization, this team keeps patients and
their families actively involved in the decisionmaking
process to help them develop and
achieve attainable goals.
The Orthopaedic Service
WRAMC orthopaedic surgeons
have the education and experience
necessary to surgically treat upper- and
lower-extremity injuries that result
from the trauma of war and eventually
lead to a limb amputation. The high
kinetic energy delivered by modern
munitions, such as landmines and other
blast-producing weapons, results in
extensive soft-tissue damage that is
far different from the injuries sustained
in conventional civilian trauma. The
necessary surgical procedures are
staged throughout the evacuation
process, and the patient and his or
her family participate in the decisionmaking
process concerning the level
of amputation and other aspects
of surgery. After final closure of the
amputation and the patient’s limb is
stabilized, the orthopaedic team turns
the patient over to the management
of the PM&R physician, although the
orthopaedic surgeon remains an active
member of the team and is available
for further wound care and revisions as
needed.
The Physical Medicine& Rehabilitation Service
With the patient’s input at the forefront,
the PM&R physician manages the
rehabilitation team, and the members
of the team each contribute their own
expertise with the goal of helping
the patient attain the highest level
of independence possible. Pain
management, for example, is one of the
primary areas of concern coordinated
by the PM&R physician. WRAMC is
currently the only institution in the
Department of Defense offering
regional anesthesia through the
continuous infusion of local anesthetics
by catheter for peripheral nerve blocks.
This leading-edge technology alleviates
pain and associated anxiety, helping the
patient sleep and participate in physical
therapy, occupational therapy, and
prosthesis fitting.
Prosthetic Service
Whenever possible, prosthetists,
PTs, and OTs work together,
communicating continuously during
the pre-amputation and immediate
post-amputation planning and care of
the patient. Fortunately, military medical
centers have all of these healthcare
professionals available under one roof.
The prosthetist is a crucial member
of the rehab team, and he or she
discusses prosthetic options and the
optimal length of the patient’s residual
limb with the surgeons before they
perform the amputation or final limb
revision. When the patient is ready
for a prosthesis, a prosthetist at
WRAMC uses leading-edge CAD/CAM
(computer-aided design and machining)
equipment to digitally and unobtrusively
measure the patient’s residual limb
with a laser device. Once these
measurements are taken and used
to develop a computer model of the
patient’s residual limb, the machinery
can fabricate the patient’s socket.
Once the socket is ready, state-of-theart
components for both upper- and
lower-limb prostheses can be added to
help patients return to a higher level of
function.
The Physical Therapy Service
This team is highly dedicated to helping
these patients return to the highest level
of activity they wish to achieve. Many
of these amputees are young soldiers
who are on par with high-level athletes,
and they desire to return to sports and
running if possible. The PTs direct rehab
towards achieving these goals using an
extensive program of aquatic and gym
therapies.
The Occupational Therapy Service
The Occupational Therapy Service has
state-of-the-art resources and strives to
provide patients with the best possible
care. The members of this service
focus their training on the following
areas to help patients become more
independent:
- Activities of daily living and
instrumental activities of daily
living. These activities include
basic personal hygiene, dressing,
feeding, and toileting, as well as more
complex tasks like writing, cooking,
manipulating objects, and driving.
- Upper-extremity residual-limb
management. OTs teach upperextremity
amputees skin care
techniques, how to maintain or
improve strength, and how to use
a myoelectric or body-powered
prosthesis.
- Community reintegration activities
to help amputees and their family
members navigate through their
environment.OTs help patients
identify and overcome physical,
emotional and mental obstacles they
face as new amputees. Adjusting to
these barriers is an important element
in improving the patients’ mental
health and outlook.
The Psychiatric Counseling
Liaison Service
This service provides preventive and
restorative psychiatric care as part of
the multidisciplinary team. All patients
returning from the Operation Enduring
Freedom and Operation Iraqi Freedom
theatres of operations are screened
upon arrival at WRAMC, and treatment
is administered as deemed necessary.
This treatment may consist of individual,
family or group therapy.
The Social Work Service
This service provides patients and
families with psychosocial assessment
and support. Its staff members serve as
liaisons for the transition of care from
the military medical system to a number
of different environments, including the
Veterans Health Administration, civilian
healthcare facilities, and family resource
organizations. These social workers are
also responsible for coordinating the
provision of durable medical equipment
for patients, such as wheelchairs,
walkers and crutches.
Ministry and Pastoral Care
Chaplains and ministers provide
comprehensive religious and spiritual
support to patients and their families
24/7 through assigned ward chaplains
and on-call staff who coordinate their
ministry with interdisciplinary teams.
Patients and their family members
are met upon arrival at WRAMC and
then have an initial formal meeting
with a chaplain on their ward within
24 hours. The chaplains then provide
daily follow-up with both patients and
family members. Religious, spiritual,
and moral support is offered for all
faith groups and individuals, and
worship opportunities are offered in
the chapel or brought to the patient on
the ward. Chaplains provide counseling
opportunities, prayer, sacraments, rites,
ordinances, religious literature, and a
constant spiritual presence until the
patient is discharged. Follow-up care
is offered and coordinated with the
patient’s home chaplains when desired
or necessary.
Nursing
The nursing staff manages and directs
most of the acute and rehabilitative care
provided, beginning with the patient’s
arrival until his or her discharge.
Because nurses are working with
the patients 24/7, they are able to
observe subtle physical, mental and
psychosocial changes in them and
initiate timely interventions. Nurses
also participate in multidisciplinary care
coordination and seek to address the
concerns of patients and their family
members.
Not all soldiers will choose to remain
at a medical center, and some will opt
to return home for rehabilitation and
eventual prosthetic fitting and training.
These individuals have the option of
transitioning over to the Veterans Health
Administration facility close to their
home, and we will make every effort
to ensure a smooth transition and
provide the same modern rehabilitation
and prosthetics available through
the military medical system. In some
instances, soldiers may seek their
follow-up rehabilitation and prosthetics
through a local facility via TRICARE,
a managed healthcare program for
active duty and retired members of the
uniformed services, their families and
survivors. Using the team approach,
this program brings together the
healthcare resources of the military
and supplements them with networks
of civilian healthcare professionals to
provide better access and high-quality
service to help the amputee achieve the
highest quality of life.
Amputee Coalition Provides Training
and Support to Military Medical Personnel |
The Amputee Coalition has been
participating with Walter Reed Army Medical Center
(WRAMC) and the Veterans Administration (VA) on
several projects designed to educate healthcare
professionals and the service men and women
they care for who have lost limbs through trauma in
conflicts abroad, accidents or disease.
In August 2002, approximately 100 military medical
personnel, including doctors, nurses, physical and
occupational therapists, and prosthetists, attended a
full-day seminar at the Uniformed Services University
of the Health Sciences (USUHS). Douglas Smith,
MD, Amputee Coalition’s medical director; John Michael, MEd,
CPO, FAAOP, FISPO; and Paddy Rossbach, RN, Amputee Coalition’s
president and CEO, presented “An Overview of Care
for Amputees.”
This seminar has been followed in 2003 and
2004 by programs designed to update WRAMC
nurses and VA healthcare providers in several
Veterans Integrated Service Networks (VISNs) on
current practices in amputee care. Pat Isenberg,
MS, Amputee Coalition’s chief operating officer and a master
trainer, has also conducted peer visitation training
programs at WRAMC to certify individuals to
conduct peer visits to injured military personnel.
Designing and developing Military inStep has
also been a large part of this ongoing partnership
to provide better information about limb loss to
injured service men and women.
— by Paddy Rossbach, RN, Amputee Coalition President/CEO |
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