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Incoming U.S. Casualties:Goals of WRAMC
LTC Paul F. Pasquina, MDLTC Jeff Gambel, MD
COL (Ret) Charles Scoville, PT Deployment
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Goal:
• Provide the highest quality of care to our soldiers, who are willing to put their life in harms way.
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Goal:
• Provide the highest quality of care to our soldiers, who are willing to put their life in harms way.
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Care: ComprehensiveShort Term / Long Term
• Evacuation• Surgical • Medical• Nursing• Co morbidities• Therapy• Psychological• Social support
• Pain Management• Nutrition• Prosthetics• Education• Equipment• Community reintegration• Vocational rehabilitation• Return to duty
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Highest Quality• Expert Opinions• Education
– Physician– Nursing– Therapist– Prosthetist– Patients– Family members
• Resources• Research
• TeamworkMultidisciplinary
• CooperationMultiple MTFs
• PartnershipMilitary VA
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Overview
• Epidemiological aspects• Health care system• Unique aspects of combat amputees• Facility resources available• Research opportunities/ideas
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Total Army Visits 1998-Present
• Total 1,870 unique patients with amputation related diagnosis and/or amputation procedure
• AD Army, Army Temporary Disability Retirement List (TDRL), Army Permanent Disability Retirement List (PDRL)
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FY 03 Patients (80)
0
2
4
6
8
10
12
14
16
18
20
Oct-02
Nov-02
Dec-02
Jan-03
Feb-03
Mar-03
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Allied ForceOIFOEFEnduring FreedomUnaffiliated
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Army:Major limbamputees
1051689Grand Total
22Hand & Wrist
11AKA & Fingers
11Bilat BKA & Thru Knee
11Thumb & other injuries
1019Finger(s) & other injuries
11AE, BE
77Toe(s) & other injuries
25520Finger(s)
11Toe
33Thumb
211Thru Knee
11L BKA; thumb
33Foot
15312BKA
514Bilateral BKA
22Bilateral BE
422BE
11AKA, BKA, AE
12111AKA
88AE
TOTALOEFIRAQLocation of Injury
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Average Daily Census WRAMC patients with amputation
• March 5• April 5• May 5• June 2• July 8• August 10• September 9• October 10• Current 13
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3. Arrival in CONUS to WRAMCMedical/Surgical treatment untilinjured extremity is stabilizedInitial Prosthetic FittingInitial rehab training by therapy team
4. Return to Home Station MTF or local VAInjured limb stableSoft tissue envelopeFinal Prosthetic FittingRehab/vocational/sport training
1. Injury in war zoneInitial forward treatment
2. Evac thru chain thru LRMCTo WRAMC Amputee Center
5. Follow up at WRAMCor at the local VA orCivilian facilityfor final prosthetic fitting
Medical Evacuation
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Soldier desires WRAMC Follow up(3,6,9,12 month) or assessment for RTN to Duty
Amputee Arrivals to WRAMC
Triage in Ortho Cast Room (Ortho/Surgery/Medicine)
PM&R/Amputee Svc Medicine GenSurg Svc SICU/MICU Ortho Svc NeuroSurg Svc
PM&R consult within 24hrs- Insure PT/OT/Prosth/Psych/Pain/Social Wk/CaseManagement started- Coordinate transfer to Amputee Svcwhen appropriate (goal 72 hrs)
Amputee Inpt Svc (PM&R)-Comprehensive care-Multidisciplinary meetings-MEB decisions-Track with case management
Amputee ClinicPM&R Clinic every Wed morning to monitor:-medical problems-Prosthetic fitting-Therapy-Disposition (MEB/PEB/RTN Dut)
Duty VA System Tricare NetworkVA System/TRICARE For Life Long Management
Mologne HouseFollow up with PM&R Svcnext morning
PM&R Clinic walk-in appt-address medical/rehab problems-Initiate consults
Inpatient (yes/no)
Yes
No
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Unique Aspects of Today’s Combat Amputee
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Advances in Technology• Forward surgical/resuscitation
capabilities• Advanced evacuation
capabilities• Body Armor
– Preservation of vital organs– Increased extremity injuries
• Advanced surgical techniques– Convert injury to clean surgical
wound– Save as much viable tissue as
possible (preserve joints)• Advances in antibiotic tx
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Average Length Of Stay
*During Viet Nam the average time from Injury to reaching the amputee center at Valley Forge was 4 Weeks
CSH 1.8 Days
LARMC/ROTA 5.2 Days
CONUS MEDCEN 41.7 Days
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Wartime Amputations: Lessons Learned
• Open circular amputation (OCA) of battlefield casualties at lowest possible length for later revisions– Permits wide drainage- no primary
closure– Prevents infection
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Open Circular Amputation
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Skin Traction Device
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Infections• Dirty wounds require frequent returns to the OR for
washouts as well as revisions.• Infection Control: all incoming hospitalized wounded
swabbed (nares, axilla, and groin) to rule out MRSA• Acinetobacter baumanii, some sensitive and some
resistant to abx• WRAMC experience
– 37 patients with Acinetobacter out of 442 medical evacuees screened
• Others: 18 with MSSA, 6 with MRSA, 5 with Staph– 3 identified cases of nosocomial spread of MDRO
Acinetobacter
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Complex Surgical Problems• Amputee surgical
procedures staged over lengthy evacuation chain at different treatment facilities
• Multiple, complex injuries– Multiple amputations,
bone fractures– Wound healing
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Complex Surgical Decision Making
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Optimizing Length / Function
• Team decisions– Viability of tissue– Viability of nerves– Progress in therapy– Prosthetic options
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Complex Rehabilitation Problems
• Co morbidities:– Brain Injury– Facial Trauma– Spinal Cord Injury– Peripheral Nerve Injury– Fractures– Internal Organ Damage– Pain Management– Poor wound closure
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• Immediate post-op prosthetic use often not possible:– Hemodynamic stability– Weight bearing status – Wound healing– Limb maturation
Prosthetic Fitting
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Vacuum Assisted Closure
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Plastic Surgery
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Unique Psycho-Social Needs• Adjustment to loss at young age
– Limb– Other bodily functions– Friends– Separation from unit
• Duty status– AD, NG, Reserves– Duty station vs. Home– MEB/PEB– Perceptions of VA
• Social support system• Premorbid socio-economic status• Political beliefs• Religious beliefs
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Photo presented to WRAMC from D. Bowman
Unique Pre-morbid Activity Level
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Resources Available at WRAMC
• Surgeons – All subspecialties
• Physical Medicine & Rehabilitation
• Anesthesia and Pain Management Initiative
• Nursing• Physical Therapy• Occupational Therapy
• Prosthetics• Psychiatric Consultation • Social Work• Peer Support• Dietetics• Public Affairs Office• Gait Lab• Database• Command Support
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“..they cope with grievous combat injuries, mostly unknown in civilian hospitals. The best military hospitals arguably stand shoulder to shoulder with top academic centers in terms of training and research. ”
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“Our fine young sons and daughters of America who’ve given so much to our country are getting the best care possible for their injuries...”
American Academy of Orthopaedic Surgeons President James H. Herndon, MD.
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Physical Therapy
• Prosthetic Donning/Doffing
• Basic Mobility Skills• Strength Training• Gait Training• Balance Training• Co morbidity Rehab• Advanced Skill Training
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Advanced Activities
Return to Duty
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Occupational Therapy
• Prosthetic Donning/Doffing
• Myoelectric training– Myoboy
• Gross motor skills• Fine motor skills• Activities of Daily Living• Community Reintegration
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Apartment
• Kitchen• Bedroom• Laundry• Office
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Prosthetic Fitting
• Pre-Surgical Consultation
• Leading Edge Technology
• CAD/CAM• Meet functional
goals
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GAIT LABU.S. Army Amputee Care
Program
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Research Opportunities
• Surgical techniques• Infection rates• Pain management
– Stump pain– Phantom Pain
• Wound management• Role of telemedicine
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Research Opportunities• Psycho-social
– Rapid community reintegration
– PTSD• Therapy Techniques• Prosthetic Technical
Advances– New components– Meet demands for return to duty– Develop guidelines for prosthetic prescriptions
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Research Opportunities• Develop Clinical Pathways• Outcomes Measures (validity/reliability)
– Mobility– Functional– Quality of Life– Advanced Activities– Gait Parameters
• Long-term Studies– Prevention of OA (knee, hip, shoulder)– Back Pain– Cardiac (O2 consumption)
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