AAMC Reporter: October 2005

Soldiers' Multiple Wounds Present Learning Opportunities

By Whitney L.J. Howell

When the young soldier arrived at the Minnesota Veterans Affairs Hospital late last year, he had a severe brain injury, a significant loss of eyesight, and many other impairments. At first, he could only lie in bed. He was virtually immobile, unable to communicate, and dependent on nurses and family members to help him with daily grooming and dressing.

But after about seven months of therapy, the wounded veteran was able to leave Minnesota for a craniectomy at Walter Reed Army Medical Center (WRAMC) in Washington, D.C. By then, he was already using a wheelchair and walking about 150 feet with assistance.

"We had a physical therapist, an occupational therapist, a speech therapist, and a visual specialist working with this young man," says Barbara Sigford, M.D., Ph.D., national director of physical medicine and rehabilitation for the U.S. Department of Veterans Affairs, and chair of the physical medicine and rehabilitation department at the Minnesota hospital, which treated the patient. "When he left, he could communicate, his visual impairments had improved significantly, and he could dress and groom himself. From where he started, he was doing quite well."

With military conflicts raging in both Iraq and Afghanistan, the Veterans Affairs system will treat 950,000 more patients in 2006 than it did in 2001, according to White House estimates. Improved field medicine and body armor mean a soldier who lives through an initial trauma has about a 98 percent chance of survival—much higher than ever, says Michael Kussman, M.D., principal deputy undersecretary for health in the Veterans Health Administration.

Increased Complexities

But the wounded soldiers are coming back with multiple wounds that are often far more complex than those suffered by survivors of previous military actions. The increased complexities led VA officials in April to convert four brain-injury centers in Richmond, Va.; Tampa; Minneapolis, and Palo Alto, Calif., into polytrauma centers equipped to treat people with two or more kinds of wounds.

Across the country, the VA operates 157 hospitals and more than 800 community-based outpatient clinics. Although Congress has not yet finalized VA funding for fiscal year 2006, the Senate has proposed $30.9 billion for VA medical care, which would be an increase of 10.7 percent.

Medical schools often work closely with VA hospitals to give wounded soldiers and veterans the most up-to-date, high-level care available. In fact, the AAMC has affiliation agreements with a total of 113 VA facilities nationwide, including 98 short-term, acute-care facilities. Sixty-two VA facilities are full members of the Council of Teaching Hospitals. The partnerships offer special benefits to medical students and residents as they learn about battlefield trauma and develop closer working relationships with attending physicians. The University of Minnesota Medical School provides such hands-on practice.

"It offers students and residents a new educational experience," Sigford says. "We have them rotate with us and take care of patients as part of their education. They learn a lot about new injuries and diagnoses they might not see in other rotations."

Although treating wounded soldiers can be more complex than caring for other patients, students and residents can do everything their level of clinical competency permits to assist soldiers and veterans. During a surgical rotation, for example, residents might see patients who need multiple amputations, and students could meet patients exhibiting a complicated spectrum of disorders.

Psychosocial Issues

Students and residents also learn about related psychosocial issues, such as frustration and depression, and discover the importance of having patients' families involved throughout treatment and rehabilitation. Maintaining open communication is not only helpful in the recovery process, medical personnel have learned, but it is essential for marked improvement.

But successful rehabilitation has its challenges, Sigford notes. One of the biggest is infectious disease. Although field treatment has improved, it is still quick and dirty, leaving many wounds insufficiently cleansed during initial triage. That can make subsequent treatment more difficult when, for instance, soldiers stop at the American military base in Landstuhl, Germany, on their way to Walter Reed, which is often their first hospital in the United States. Lingering contamination, of course, can lead to complications.

Working with amputees who also have brain injuries can be especially taxing. Not only must physicians choose a well-fitting prosthetic device, but they also must also be sure patients have the necessary cognitive skills to accept the device and use it properly, Sigford adds.

Probably the most important and demanding aspect of treatment is creating the proper psychosocial network for recovering soldiers. Many soldiers in VA hospitals have been away from home for weeks or months, Sigford says, and many need help in switching their focus from life and death to recovery and rehabilitation.

"We need to help the family with transitions and help them feel comfortable," she says. "We have social workers and case managers who can guide the family and provide support and counseling."

The scene at Walter Reed Army Medical Center is similar to the one at Minnesota's VA Hospital. Although WRAMC or the National Naval Medical Center in Bethesda, Md., is generally the first stop for wounded soldiers in the early stages of recovery, Walter Reed also operates a rehabilitation center. According to Col. Jeff Gambel, M.D., chief of WRAMC's Physical Medicine and Rehabilitation Ambulatory Patient Care Clinic, the Walter Reed center has received approximately 1,200 to 1,300 soldiers injured since the hostilities began in Afghanistan and Iraq.

While body armor can shield vital organs from damage, bullets and fragments from explosive devices can still penetrate the face, neck, and limbs. Such multiple wounds confront WRAMC doctors every day.

But challenges that soon will confront many patients will far outweigh the difficulties that doctors face in treating them, Gambel says. Patients often must relearn routine acts of daily life that most people take for granted, and the more complex the injury, the more arduous the task. For some, the ultimate goal may be simply being able to bathe themselves, but others may hope to return to advanced physical activities, such as rappelling or sky-diving.

"We affectionately call Walter Reed a cocoon because it protects the wounded service members," Gambel says. "The challenge is for them to move from that protective support to their own lives, wherever that may be."

Bob Bahr, a physical therapist at Walter Reed Army Medical Center, adjusting a computerized prosthetic leg for Army 1st Lt. Melissa Stockwell

Motivation from Others

To help soldiers and veterans regain the optimal level of strength and mobility, WRAMC provides access to a physical and occupational therapy gym where patients can improve their abilities and get motivation from seeing others who are further along in rehabilitation, Gambel says. The soldiers develop a support network and encourage one another to continue therapy and push themselves to improve.

In addition, many amputees work with physical therapists in a swimming pool to improve their range of motion. Others may take weekly trips to the firing range or participate in water sports. The idea, Gambel notes, is to keep the soldiers motivated with enjoyable activities while bolstering their ability to return to everyday life as much as possible.

But the transition from the medical center to a more "normal" routine can be strenuous both for soldiers and their families. To ease the process, WRAMC provides access to psychologists, social workers, chaplains, doctors, and therapists, as well as to marriage and couples counseling.Many family members have difficulty understanding and accepting a soldier's new disabilities, Gambel says, so physicians are diligent about including them in the rehabilitation process.

Such services do not stop once a soldier leaves WRAMC or any other VA facility, says Robert Petzel, M.D., network director for the Minnesota Veterans Integrated Service Network, because the VA system has a commitment to serve all veterans regardless of age.

"These soldiers have care for the rest of their lives," Petzel said. "Their ongoing rehabilitation could go on for years, and they will always be in contact with us for their physical, emotional, and mental health."

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