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Captain David Rozelle is the first soldier to return to military service in Iraq with a prosthetic leg.

AAOS Now

Published 7/1/2007
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Judy Datz

AOFAS initiates new military visitation program

“Humbling” was the word many participants used to describe the day that 18 members of the American Orthopaedic Foot and Ankle Society (AOFAS) took part in a new educational initiative—a military visitation program at Walter Reed Army Medical Center (WRAMC) in Washington, D.C.

In the words of one attendee, the experience turned out to be “possibly the best one-day course I ever attended.”

The goal of this interactive seminar was to increase participants’ knowledge of traumatic war injuries to the lower extremity, the treatment rendered by military orthopaedic surgeons, and the military’s comprehensive state-of-the-art rehabilitation program for military soldiers. The program was chaired by three AOFAS members: Donald R. Bohay, MD; WRAMC’s LTC Scott Shawen, MD, and LCDR John Keeling, MD, of the National Naval Medical Center (NNMC). Faculty included NNMC’s LCDR John Forsberg, MD, and WRAMC’s MAJ David Rozelle and CPT Adam Groth, MD.

Bringing military and civilian surgeons together
The program was proposed by Lowell H. Gill, MD, at the 2006 AOFAS annual summer meeting. His idea was to “establish a visitation program with [WRAMC] for the exchange of ideas, communication among specialists, and a better appreciation of the sacrifices of our young soldiers.” Dr. Gill felt that the members of the AOFAS would benefit from “a renewed appreciation for what our soldiers do to help support our country and our freedom. We would also benefit from becoming acquainted with the military orthopaedic surgeons who dedicate themselves to the soldiers’ rehabilitation.”

After an initial fact-finding visit, the AOFAS Military Visitation Program was launched in April 2007. Participants could earn continuing medical education (CME) credits by taking advantage of the opportunity to do the following:

  • Increase their knowledge of high-energy traumatic injuries to the lower extremity
  • Understand and enhance their recommendations for prosthetic treatment
  • Update knowledge and skills in rehabilitation options for posttraumatic injuries

The educational sessions began with WRAMC’s CPT Amber Aragon, MD, who presented a Synopsis of morning reports—Trauma cases during the past week. She was followed by Drs. Shawen and Keeling, who focused on Foot and ankle reconstructive problems, unique cases and new cases presented to WRAMC/NNMC during the past week. Dr. Shawen also presented a summary of Humanitarian care in Afghanistan, and MAJ Rozelle provided a first-hand account and insight into the support given to soldiers who have undergone amputations and are currently in physical rehabilitation in his Amputee Center presentation.

Participants were able to tour the physical therapy, occupational therapy, and prosthesis labs before the afternoon session, which included presentations on the METALS database and other WRAMC trauma research by Dr. Groth and Cytokine wound research and other NNMC trauma research by Dr. Forsberg.

An immediate reaction
The participants’ reactions were immediate and heartfelt. Attendees enjoyed every aspect of the day, although for many the most important aspect was the case presentations with two injured Marines and their family members present.

According to Dr. Bohay, “The professional nature of those participating and the quality of the presentations were outstanding, but I think what set this apart was the presence of the patients and their families as we discussed their cases. The clinical history, photographs and X-rays were presented, and the patients discussed their injuries and demonstrated their progress. It was special because we saw these young men as not only patients with horrible injuries but survivors in a battle for our freedom and security.”

Learning how these young soldiers are coping with life-altering injuries, as well as building new lives for themselves, was inspiring to AOFAS members. As the military surgeons stated, “These young men and women are treated as injured athletes, not disabled people. Our goal is rehabilitation so that they can return to their active lifestyle of snow- and water-skiing, rock climbing, hiking, and backpacking. Our team includes people in all areas who are coaching these soldiers every step of the way.”

The military surgeons also expressed their appreciation. “The first thing that I thought about after the meeting was the genuine thoughtfulness and interest that the participants demonstrated throughout the entire meeting,” said Dr. Shawen. “We presented many difficult and challenging cases and felt that the group was interested in figuring out the best possible way to treat them, without judgment or criticism, because there is no perfect answer.

“The highlight of the day was the patient presentations,” he agreed. “This ran way over because of the interest demonstrated by the visiting doctors. They wanted to know much more than just what was done for each of the patients physically, but also how they have coped with every step of the way. As I thought about this, I wanted to make sure that future programs devoted more time to this part of the meeting as it seemed to be the most beneficial to overall learning and sent strong messages to each side: First, that doctors care about their patients, regardless if they are military or civilian, and second, that our service men and women are great people who have sacrificed a lot for this country.”

A combination of care and research
“It was a nice combination of all aspects of the care we provide and research that we are trying to perform so we can provide the best possible care to these injured young men and women,” said Dr. Keeling. “They are truly very motivated to get better and often make our jobs much easier because of their desire to excel in all ways.

Captain David Rozelle is the first soldier to return to military service in Iraq with a prosthetic leg.
A marine sergeant and patient of LCDR Keeling, MD, is planning to return to Washington State to resume his hiking and backpacking activities despite his severe lower limb injuries.

“I particularly wanted the two Marines to talk with the group and share their treatment experiences with a group of experienced orthopaedic surgeons,” he continued. “Not only could they share their feelings, they could gather expert opinion and obtain some additional input into their treatment. Moreover, I think that case presentations like these are much more powerful when a face, a voice, and a name are added to the clinical photos and X-rays. Later, both Marines told me that it was a very rewarding and positive experience for them.

“Their families were also honored to be a part of the presentation and have been so supportive during the months of treatment. I have two daughters in high school and watching these young folk come into our care at Bethesda Naval Hospital and being part of the full range of human emotion that these families endure and eventually overcome hits very close to home,” admitted Dr. Keeling.

AAOS First Vice-President E. Anthony Rankin, MD, who also attended the presentations, expressed his admiration for the program. “This is an outstanding program and—much like the Extremity War Injury Symposia—it fosters cooperation and an exchange of information between civilian and military orthopaedic surgeons. It also provides an excellent opportunity for the military to showcase the excellent work they perform for our wounded soldiers.”

The start of something BIG
The AOFAS hopes that this program will continue to grow. As stated in the AAOS National Orthopaedic Leadership Conference, 82 percent of all war injuries in Iraq and Afghanistan involve extremities. In Iraq, the likelihood of surviving a battlefield wound is 90.5 percent. U.S. soldiers who survive are likely to have traumatic injuries that require specialized treatment and long-term care. More than one half of all veteran disability visits to physicians are orthopaedic-related.

“Our injured soldiers are receiving excellent care with an initial team approach of orthopaedic surgery, physical medicine and rehabilitation, regional anesthesia and pain management, nursing, physical therapy, occupational therapy, prosthetics and orthotics, and psychiatric consultation,” said Dr. Shawen. “This care and rehabilitation is followed by staff consults in social work, dietetics/nutrition, public affairs, gait lab, ministry and pastoral care, peer visitation, Veterans Administration counseling, vocational rehabilitation and employment, and the Red Cross Department of Labor.”

Quoting Benjamin Franklin, he added, “The Good particular Men may do separately, in relieving the sick, is small, compared with what they may do collectively.”

These soldiers cannot continue their recuperation in a vacuum, however; they need the support of all orthopaedic surgeons when they return home after their military care. As Dr. Keeling said, “I’m very grateful that the AAOS and the AOFAS have embraced these injured heroes and their families and are working with military orthopaedic surgeons to enhance the care we provide for these life-altering injuries.”

Taking the message home
To ensure that returning soldiers will be able to continue receiving the ongoing orthopaedic care they need, all orthopaedic surgeons are encouraged to accept Tricare/Champus insurance. As Dr. Bohay concluded, “Our military colleagues are dispensing state-of-the-art care with compassion in an environment that civilian surgeons never really experience. We can express our gratitude to them and support our troops at home by accepting the insurance plans these soldiers carry.”

“No matter how you feel about the war and the politics surrounding it, supporting our troops by providing care to military personnel and their families is something all of us should do as citizens and trained professionals,” agreed Dr. Gill.

The AAOS is also delivering another important message to members of Congress by calling for substantial increases in funding for musculoskeletal research programs under the Department of Defense (DoD) Orthopaedic Extremity Trauma Research Program (OETRP) (See “AAOS Fellow testifies on war injuries,” June AAOS Now). OETRP is a peer-reviewed program administered by the Medical Research and Material Command at the US Army Institute of Surgical Research in Fort Sam Houston, Texas, and has received $7.5 million in fiscal year (FY) 2006, and $6.8 million in FY 2007.

OETRP potentially has great benefits for both civilian and military orthopaedic care. Research projects are focusing on ways to improve healing of segmental bone defects and speed recovery from blast injuries; prevent wound infection; improve function of limbs that are saved; prevent abnormal bone re-growth (heterotopic ossification); improve irrigation and débridement technologies and guidelines; develop new advances in extremity injury care that would benefit both military and civilian global terrorism casualties; and improve amputee care.

Although participants in the AOFAS Military Visitation Program benefited from the educational program, the personal benefits were perhaps even more striking. They saw, first-hand, the courage of the soldiers, the skill and devotion of their medical caretakers, and the potential knowledge that civilian surgeons can bring back to use in their own treatment of amputee care.

To learn more about the AOFAS Military Visitation Program, please contact Judy Datz at jdatz@aofas.org or (847) 348-4379.

Judy Datz is communications manager for the American Orthopaedic Foot and Ankle Society.