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June 2005

By Michelle Apuzzio, MSPT

Brooke Army Medical Center’s new amputee center is giving options to wounded soldiers

Capt James Watt assists Juan Arredondo in relearning living skills

Capt James Watt, OT, officer in charge, Upper Extremity Amputee Section, assists Juan Arredondo in relearning living skills at BAMC's Amputee Center.

John Fergason never begins a patient's treatment by telling him which activities to give up. As the head prosthetist at the new amputee center at Brooke Army Medical Center (BAMC), he guides injured military personnel through their options but lets them discover their self-imposed limits. After all, expectations for amputees are much different than they were a decade or so ago.

Take running, for example. "Not that there's anything magical about running, but it's a milestone—an important milestone for some people," says Fergason. "Other folks say, 'Golly, I don't need to run. I just want to walk around uninhibited and not worry about falling or getting so tired that [I] can't go on.' But other people say, 'If I can't run, I can't go back to what I want to do.'"

As the US Army's single Level I trauma center and the only American Burn Association treatment center in the Department of Defense, BAMC has been handling some of the most complex injuries since the San Antonio facility was established prior to World War II.

Over the years, technology and survival rates have improved, with a 91% wound-survival rate in soldiers serving in the Middle East, compared to a 76% wound-survival rate in soldiers serving in the Vietnam War a generation ago. The majority of injuries still occur to those serving in combat units, which are all male. Yet the depth of the battlefield has changed, and Col Robert Granville, MD, director, Amputee Services, is treating more personnel from combat service and support units. "[Since the Iraq conflict] is an insurgency ... logistics convoys are being attacked, military police patrols are being attacked. We are seeing, unfortunately, a number of women with equally severe wounds," says Granville, an orthopedic surgeon.

Most soldiers are treated briefly at Landstuhl Regional Medical Center in Germany before they are transferred to a facility in the United States. BAMC will send a transport team directly to Europe to pick up burn patients. However, other patients are transported via the Air Force Critical Care Air Transport teams to Walter Reed Army Medical Center in Washington, DC, before a second air transport brings them to BAMC.

Wounds are rarely closed when patients arrive at BAMC, notes Granville. Many are badly contaminated and require multiple debridements before they can be closed. In addition, the majority of patients have associated injuries.

HISTORICAL STEPS
With a long history of treating severe extremity injuries and burns, BAMC was a natural setting to open a dedicated amputee center earlier this year. The plan to do so had been in place since the September 11, 2001, attacks at the World Trade Center in New York and at the Pentagon, and was further necessitated when Walter Reed—which has its own amputee center—reached a maximum census.

The 29,000-square-foot center at BAMC, designed to accommodate 15 inpatients and 30 outpatients, was renovated at a relatively low cost—less than $250,000—with expenses divided almost equally between equipment purchases and building modifications.

Keeping with the mentality of its young, highly active patients, the rehabilitation gym at BAMC is geared toward athletics with a running track, elliptical trainers, a long lane for agility drills, and a climbing wall. Some of the cardiovascular and weight-lifting equipment is specifically designed to accommodate amputees, but the gym also has machines identical to those in regular fitness centers to help these patients transition to life outside of BAMC.

A gait laboratory provides the high-tech component where clinicians can analyze a patient's movement for proper prosthetic fit and perform research studies. And the upper-extremity rehab area has a computer program that allows patients to control a myoelectric prosthesis, game tables like foosball, and a complete efficiency apartment with no adaptations in its layout for real-world simulation.

Although inpatients are still housed on the general orthopedic floor, a section of the unit is specifically for amputees. "We try to get amputees together early on. No one can understand what someone's going through better than someone who has already gone through it," says Granville.

The camaraderie continues in the rehab gym, notes Capt Shane Koppenhaver, MPT, OCS, officer-in-charge, Amputee Section of Physical Therapy. "What's nice for these guys is that they come back here and everybody in here is an amputee, and I think it really helps them start to feel comfortable with things. They get to ask questions of other amputee patients who are further along in their rehab," he says.

As soon as patients are functional in basic activities of daily living (ADLs), they transition to outpatient status with approximately 4 hours of therapy each day. The junior enlisted stay in nearby barracks, which are equipped with six Americans with Disabilities Act-approved rooms, if needed. Married junior enlisted, as well as senior enlisted, personnel and officers live in a guesthouse or one of three privately funded housing units, which can accommodate family members.

DETERMINING TREATMENT
At BAMC, treatment is determined by functional level rather than having a clock expire when the patient goes over a preset number of days, weeks, or visits. That allows amputees, covered by government coffers, to receive hundreds of visits and use that time to progress beyond the primary goals of prosthetic care and ADLs.

The bar is often much higher, in terms of functional outcomes, at BAMC, though. Military amputee care is different than traditional amputee care, explains Koppenhaver, with the former being more sports medicine than just amputee rehab, primarily because of his patients' age group. "The typical amputee is an older diabetic or vascular amputee, and if you can get them walking without a cane, that's a pretty high level. But these guys—it's a totally different ballpark," says Koppenhaver.

And that means that some of them even want to return to active duty. "It forces us to be very creative and push the envelope with traditional amputee rehab," he says.

Whether a soldier can return to the role he once filled in active duty is a question answered on an individual basis, but BAMC takes steps to ensure a smooth return if that is the case. "A lot of times, we will not assign these folks to our medical holding company, but will only attach them so that they remain associated with their parent unit," says Granville. "If we assign them to our medical holding company when they're ready to return to duty, then they just go back into the manpower pool and can show up at a unit that has no knowledge of them and no attachment to them, and it makes it more difficult for them to overcome the doubts that would be natural for a command to have [regarding] whether someone with an amputation could pull their weight."

For others, their goals are far from returning to the combat field. Koppenhaver had a patient who was about to become a father, and his goal was to walk without an assistive device so that he could carry his baby and transfer the infant into and out of the crib. He met that goal, says Koppenhaver.

BENEFITS OF A GOOD ATTITUDE
Beyond what therapy and hard work can accomplish, spirit and attitude play a key role in outcomes. Most soldiers injured in combat have some level of post-traumatic stress disorder, which requires the treatment team to work closely with behavioral health specialists.

While an amputation may seem like the end of the world to some, Koppenhaver remembers one man in his early 20s with extensive leg and knee injuries. His limb was salvaged by the medical team, but he had external fixators, was non-weight-bearing for months, and continued to have significant pain. Finally, he got sick of ambling on crutches without much functional movement in the limb. With the physician, he decided to have an above-the-knee amputation. Shortly, his entire outlook had changed. Much of his pain was gone, and he was walking without a cane within 1 month. "We hope that we can get them back to everything that they used to do and everything that they want to do. Sometimes they want to do things that they never have done," says Koppenhaver. "Several of them went on a ski trip, and a bunch of them had never skied before."

As part of his rehabilitation, Juan Arredondo works out in the Amputee Center's state-of-the-art gym. The youth and general fitness of the center's patients means that rehab is designed to return the soldiers to their highest physical level.

Much of this positive outlook comes from the soldier-patients' military training and mind-set. "They're highly motivated. They're disciplined. Their job is to get better. The active-duty folks are still active duty, so now their new assignment is rehabilitation, and they take it as seriously as they take any other assignment," Fergason says.

Along with an intense level of commitment to rehab, the patients have a good deal of fun as they work through the challenges of intense therapy. Koppenhaver notices many of them sticking around the gym after their twice-daily sessions are finished, socializing with others who are facing the same physical test, competing over therapy goals, and mentoring newer patients in the gym.

BETTER PROSTHESES, BETTER RESULTS
Although much of what they accomplish is due to their own strong will, what these patients can achieve functionally is partially a result of the advancements in prosthetics. According to Fergason, prosthetics have changed in terms of their construction and flexibility since the Vietnam War. And more recently, he is seeing microprocessors in artificial knees and advanced suspension methods that create a vacuum to keep the limb in place.

The microprocessors in prosthetic knees are helpful to control stability and prevent falls, especially when the user changes cadence while walking or maneuvering on stairs and ramps. The next generation of prosthetics will take it a step further, adding power to the joint so that a knee or foot can generate force rather than just react to what is placed on it.

Advances are not only being seen in lower extremity prosthetics. "We're also seeing advances in the upper extremities, such as prosthetic hands that look more lifelike, are much faster, and have more capability," says Fergason. Myoelectric prostheses, which the patient controls by activating muscles in the residual limb, contain motors that flex and extend the elbow, rotate the wrist, and open and close the hand. Programmable microprocessor circuits allow the clinician to easily fine-tune controls according to the patient's need, including changes that occur when a patient's strength improves. For prosthetic devices that require battery power, there is a lithium-ion system available that is easier to charge and lighter than the older nickel-cadmium versions.

One of Fergason's biggest challenges is getting the right fit when the patient plans to return to a high activity level. That type of usage requires a nearly perfect interface between the skin and the artificial limb, so Fergason uses sockets that adjust to the constant shape changes of a residual limb.

Much of this technology is available to the general public, but the key difference between BAMC amputee care and what the average citizen might encounter is the amount of resources dedicated to assembling the amputee treatment team, which consists of an orthopedic surgeon, physical medicine and rehabilitation physician, PT, OT, prosthetist, social worker, psychologist, chaplain, and Veterans Affairs representative (the latter for discharge planning). The clinicians, who exclusively treat amputees, hold a weekly clinic in which they discuss most of the patients together. But Koppenhaver says he is able to interface daily with any of those team members should questions arise.

When Fergason was contemplating his recent career move from a university setting, he sensed the pride among BAMC staff as they worked toward a common goal of doing everything in their power to return the soldiers to their full potential. "There is a real team here like I've never experienced in my life," he says. "That was very enticing to me, and a chance to work with young men and women who are this motivated, who have devastating orthopedic injuries and burn injuries, yet still have incredible motivation."

Working with motivated patients was only one of the lures for Fergason. "The chance to use technology and base what I do for somebody not on cost but on what is best for them is a highly unique situation for a clinician like myself to practice in," he adds.

Although clinicians at BAMC realize that it is not feasible for civilians to spend as much time in rehab as military personnel, Granville believes that their patients' functional outcomes and therapy model will change the paradigm for young amputees. "I think the expectation will be that the young traumatic amputee can go back to doing whatever they have the heart to achieve," he said.

Fergason also points to a general attitude shift in the public concerning their health care, citing his perception that the average patient is more educated thanks to the amount of advocacy and information available. "Patients have become self-advocates and are educated to the point where they're the consumers of services rather than the patients," he says. "And clinicians, I think, in general, are trying to vest patients or clients more in their own care, because we have all found that if someone is more in charge of their own care, they're more apt to move forward quicker and more thoroughly."

Michelle Apuzzio, MSPT, is a contributing writer for Rehab Management.

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