Paul J. Girard, MD, joined Ms. Gambale for a press briefing covering various aspects of her care, including the education and information provided before she decided to pursue limb salvage and how lessons learned in a military environment can affect civilian practice.

AAOS Now

Published 5/1/2012
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Terry Stanton

Story Behind PSA Shows Value of Military Orthopaedics

Public service announcement highlights challenges facing surgeons and patients

On the evening of Feb. 12, 2011, Dominique Gambale and her husband, James, prepared for an early Valentine’s celebration. But happy times turned to horror when they left the restaurant. An out-of-control taxicab careened into the exiting crowd and struck about 25 people, including Ms. Gambale and her husband. She was pinned to a wall, her right leg crushed.

“I recall the impact—and flying through the air—and falling to the sidewalk. I’m told the ‘falling’ sensation was due to my collapsing onto the cement, when the cab driver backed away from the brick wall after pinning me. I heard James calling my name. Someone, a Marine vet, tied a tourniquet on my leg. I started chanting my children’s names. I went into shock.”

Ms. Gambale tells the story of her injury and recovery process—along with the story of how the wartime experience of the surgeon who cared for her “made sure that Dominique’s leg would get another chance”—on a website created as part of the Academy’s 2012 public service advertising (PSA) campaign.

A collaborative campaign
The story of this PSA illustrates how the AAOS and its partner societies—in this case, the Orthopaedic Trauma Association (OTA)—work to provide the public with information about the many ways that orthopaedic surgeons improve patients’ quality of life. This case, involving the stark choices that patients with mangled limbs face, also demonstrated the importance of shared decision making by the physician and the fully informed patient.

The headline summarizes the central message: “A Crash in California Almost Took Her Leg. A Bomb Blast in Iraq Helped Save It.” The narrative relates how, in the first hours after Ms. Gambale’s injury, amputation appeared unavoidable. But on the second day, Paul J. Girard, MD, the surgeon who took over her care, drew on his experience from treating blast injuries in Iraq to recognize that the limb was potentially salvageable.

“There seemed to be enough viable tissue with foot circulation to ‘go for it.’ I made the determination that our approach would be to try to save her leg—even though there were lots of uncertainties about just how much of a recovery she could hope for,” said Dr. Girard.

Early on, a positive outcome was far from certain, and Dr. Girard informed his patient that at any time infection or other complication might necessitate abandoning the salvage course.

During this still-uncertain time, the AAOS and OTA approached Dr. Girard and Ms. Gambale about participating in the PSA campaign, recalls Sandra Gordon, AAOS director of public relations. She had been in San Diego preparing for the Annual Meeting when Ms. Gambale was struck, and the incident received extensive local news coverage.

The right story
Ms. Gordon was aware that the OTA and its then-president, Andrew N. Pollak, MD, were hoping to showcase how what is learned during wars is helping civilians, but finding a way to transmit that message was elusive. “It’s tough, because you need the right story,” she said.


Dominique Gambale addressed the AAOS 2012 Annual Meeting during the Opening Ceremony.

“We talked about how a public service announcement or print ad has to have a public health message,” Ms. Gordon said. “It’s not a self-serving ad or a ‘go-see-your-orthopaedic-surgeon’ ad. It has to have information that is useful.”

She then contacted Dr. Girard to see if he and Ms. Gambale would be willing to participate.

Dr. Girard, who is quick to note that he had no role in proposing or shaping the campaign, recalls his initial reaction: “I didn’t yet know how this was all going to turn out for Dominique. It was around the time I was getting ready to do her bone graft surgery in May. At that point, I didn’t know that she was going to be infection-free, and I didn’t know if her bone grafting was going to work, and I didn’t know if she was going to walk.

“At first I was a bit unsure,” he continued. “To have the case pick you in the beginning and have everybody follow it was a little bit unnerving. My first thought was, ‘I hope this ends well for her.’ I wanted to be sure, though, that I knew what the motivation was. After I talked to leaders in the OTA whom I respected and who had a broader view, it made a lot of sense to me.”

“The intention was to highlight the challenges associated with limb salvage, and the magnitude of the problem that severe extremity injury poses for its victims,” said Dr. Pollak. “This problem is common in both military and civilian settings, and the lessons learned in military environments are informing civilian practice with regard to care for these injuries.”

Ms. Gambale recalls that Dr. Girard, who was joined in her care by plastic surgeon, Mayer Tenenhaus, MD, was careful to ensure that she was far enough along in her recovery and could think clearly enough to make a good decision about participating.

“I said, absolutely, that I was going to do anything I could to help,” she said. “He truly saved my leg. It was within hours that I could have lost it. He saved it with his expertise and military background. I wanted to give that recognition.”

The mother of two continued, “It allowed people to see what I and my family went through and what Dr. Girard did. I think it helps people understand that there is a whole dynamic behind when something so serious like this happens in your life. I think it has touched people. It told them you have to be strong to move forward, and surgeons out there can help and change your life.”

An intensive experience
Dr. Girard served in the Navy in the initial invasion of Iraq in 2003, stationed on the hospital ship USNS Comfort and performing surgery on wounded Marines and other Coalition warriors and civilians.

“As I approached Dominique’s problem, I realized that my time in the Navy gave me the understanding that there are options,” he said. “One of the options—and it is a viable option—was amputation, and I have military experience in performing those. I also knew that technically she had a reconstructible limb injury as far as the bony elements and the soft tissues.

“Even though it was a severe injury, it didn’t overwhelm me, because I had seen a lot like it—some not as bad and quite a few that were significantly worse—and we were able to save the limb if that was the goal. Being very busy, dealing with very severe injuries, you get comfortable with your own skills, and you learn a lot as you progress. You get a wide breadth of experience in a short time frame.

“Secondarily, you understand better how an injury like hers behaves in terms of soft tissue,” continued Dr. Girard, “and the need for frequent trips to the operating room to remove any nonviable tissue, with the goal of trying to minimize the risk of infection. We did that frequently in the Navy.”

Paul J. Girard, MD, joined Ms. Gambale for a press briefing covering various aspects of her care, including the education and information provided before she decided to pursue limb salvage and how lessons learned in a military environment can affect civilian practice.
When she read Dr. Girard’s comment about using knowledge he had acquired as a military surgeon in Iraq to try to save Ms. Gambale’s leg, she filed it away in her mind. A few months later, she raised the idea of featuring it in the PSA, which Dr. Pollak and other OTA leaders endorsed.

“At first I wasn’t aware how serious my injury was,” Ms. Gambale said. “When I first heard it compared to a war blast, I realized how serious it was. This has given me some insight into what surgeons do and what these war guys go through, which breaks my heart, because I know people have much worse injuries than I did. I have a huge appreciation for what they do for everyday people like me.”

An informed decision
Although the print PSA features an inspiring individual who had a fierce will to heal, the accompanying website explains that not only was the salvage of her limb not a certain outcome, but that saving a limb is not necessarily the ideal option for every patient.

Dr. Girard notes that Ms. Gambale and her husband received counseling over the decision on how to proceed, and she even met with a prosthetist. “She made a difficult decision,” he said. “She would have been up and around faster with amputation. She would have had fewer surgeries, and it’s arguable whether she would be able to do more or do less. I feel pretty strongly that I did everything I know to do to give her the tools to make the decision.

“I don’t think any part of the campaign endorses limb salvage surgery as the only way to deal with this type of problem,” Dr. Girard continued. “Of course, it couldn’t go into a lot of depth about what went into the decision making, because that’s not the goal. We were clear to Dominique that her limb was salvageable but would need a lot of orthopaedic and plastic surgery and then a lot of rehabilitation, and certainly with the end result being not normal but hopefully serviceable for her.”

“Someone else might have made a different decision,” said Ms. Gambale, an avid athlete who is determined to get back on the tennis court. “If I’d had an amputation and prosthesis, I would have moved on, but it would have been a different life.”

“In my opinion,” said Jeffrey M. Smith, MD, the chair of the OTA Public Relations Committee, “this is a fantastic example of how challenging these decisions are and how important it is for orthopaedic surgeons to assist our patients both in making the decision and in carrying out the plan.”

Dr. Pollak agrees. “The goals of the campaign were to raise public awareness that extremity trauma is a significant problem that affects many people with potentially severe long-term consequences. When it occurs, treatment needs to be individualized, and it can be prolonged. Each patient needs to make informed decisions about his or her own care in the context of discussions about the various treatment options and the relative risks and benefits of each.”

Supporting additional research
Dr. Pollack hopes the campaign will not only inform the public about how military medicine benefits the civilian population, but also lead to further advancements. “The lessons learned about these injuries from the Iraq and Afghanistan conflicts have begun to drive many of our thought processes with regard to treatment,” he said. “Nonetheless, good evidence necessary to drive protocol development and appropriate use criteria is lacking. We desperately need more research funding in the area of extremity injury to produce the evidence that has the potential to improve the quality of care we offer our patients.”

Dr. Girard adds: “Despite the tragedies of these conflicts, many surgeons, other physicians, and healthcare providers are gaining a lot of experience in dealing with very severe injuries under less-than-ideal circumstances. One of the few positive things about the conflict is that these providers are going to bring that experience back home.”

“I have a new appreciation for the entire medical field,” Ms. Gambale said. “I know surgeons do this every day, but I felt like we developed such a close relationship, and I can only imagine how that must affect them if things don’t go right.”

She says she has heard words of encouragement and admiration in response to the campaign from family, friends, other patients, and people who recognize her around town. “I heard my picture is on a bus somewhere,” she said. “Everyday people come up to me and tell me I have inspired them. That feels wonderful. I’m hoping I can take this and turn it around and help others.”

She continues to see a physical therapist, and her focus is on improving the mechanics of her leg and ankle and moving laterally. “It can be a mental battle, but I am staying positive. Last year my main focus was to get this leg to walk. I just need to keep moving forward.”

Just how successful she’s been was evident at the 2012 AAOS Annual Meeting in San Francisco, when she appeared onstage during the Opening Ceremonies—wearing high heels and walking without a limp.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Additional Resources:
Dominique’s website

2012 AAOS PSA Campaign

Extremity Injury Research:
AAOS Extremity War Injuries Symposia

Limb Salvage v. Amputation:
Lower limb amputees fare better than limb-salvage patients in military population

Returning to duty after open tibial fractures

AAOS On-Line Service Academy News - Section C

The Mangled Limb: Salvage Versus Amputation

References:

  1. MacKenzie EJ, Bosse MJ, Castillo RC, et al: Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am 2004;86-A(8):1636-1645.
  2. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002;347(24):1924-1931.
  3. MacKenzie EJ, Bosse MJ, Pollak AN, et al: Long-term persistence of disability following severe lower-limb trauma: Results of a seven-year follow-up. J Bone Joint Surg Am 2005;87(8):1801-1809.
  4. MacKenzie EJ, Jones AS, Bosse MJ, et al: Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007;89(8):1685-1692.
  5. Castillo RC, Mackenzie EJ, Bosse MJ; LEAP Study Group: Orthopaedic trauma clinical research: Is 2-year follow-up necessary? Results from a longitudinal study of severe lower extremity trauma. J Trauma 2011;71(6):1726-1731.
  6. Wenke JC, Milutinovich AB, Pollak AN: Congressionally directed research will improve outcomes through funding opportunities for orthopaedics. J Am Acad Orthop Surg 2011;19(Suppl 1):S40-43.