Optimizing care for combat amputees: Experiences at Walter Reed Army Medical Center.

Optimizing medical care for the combat amputee is a complex task. To date, Walter Reed Army Medical Center (WRAMC) has cared for more than 100 patients who have sustained a major limb amputation during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Managing these individuals, along with the thousands of other patients, has been challenging for the medical and administrative staff at WRAMC, especially those within the Department of Orthopaedics and Rehabilitation. Technological advances in body armor, along with rapid evacuation and early medical attention, have increased the survival rate of combat amputees. Despite these advances, many members of the armed services continue to return with severe limb wounds. While experienced military physicians and surgeons do everything possible to salvage viable limbs, frequently amputation is necessary. Combat amputees represent a unique patient population, because of the complex nature of their wounds and the extent of their comorbidities. Comorbid conditions—loss of vision, spinal cord injury, traumatic brain injury, fractures, and severe nerve and vascular injures—present significant medical, surgical, and rehabilitative challenges. In addition, an increased risk exists for the development of secondary complications such as infection, heterotopic ossification, and venous thrombus, all of which require close monitoring and attention. Finally, each patient has distinctive psychosocial needs, greatly impacting on issues such as pain management, adjustment to disability, body image issues, movement through the military disability system, and reintegration into the community or back to active-duty service. Providing optimal care requires the development of a well-functioning and coordinated multidisciplinary team, where each member is recognized as having equal importance. Our experience at WRAMC has supported the creation of a dedicated Amputee Inpatient Service as well as a separate Outpatient Amputee Clinic, both under the management of Physical Medicine and Rehabilitation (PM&R). Following a rehabilitation model, the physiatrist functions as the primary care provider for the amputee, coordinating the recommendations and interventions of multiple medical and surgical subspecialists, therapists, nurses,