June 2003 Bulletin

AAOS leaders extol troops, military surgeons

Orthopaedists extol military surgeons, nurses; offer support, gratitude to soldiers

By Carolyn Rogers

A privilege that many celebrities, politicians and journalists had been denied was granted to a grateful delegation of orthopaedic surgeons on April 26, 2003—a visit with U.S. soldiers recovering from injuries sustained in Operation Iraqi Freedom (OIF).

The opportunity arose while the surgeons were attending the National Orthopaedic Leadership Conference (NOLC) in Washington, D.C. A trip to Walter Reed Army Medical Center (WRAMC) earlier in the week inspired Lt. Col. Dean C. Taylor, MD, to facilitate the visit.

"I stopped by Walter Reed to see an injured soldier, the captain of the lacrosse team at West Point," explains Dr. Taylor, an orthopaedic surgeon at Keller Army Hospital in West Point, N.Y., and the Society of Military Orthopaedic Surgeons’ representative to the Board of Councilors. "He’d had bilateral amputations in his lower extremities, but he’s doing pretty well. It’s impressive to see. The next day it struck me that the orthopaedic leadership of the United States was in the same town as a significant number of the soldiers wounded in Iraq. It made sense to get them together."

Opportunity to offer support, recognition

Dr. Taylor floated the idea to Academy leaders, who responded with great enthusiasm.

"We were eager not only to offer our support and gratitude to our war-injured soldiers, but also to recognize the hard work and dedication of military physicians and nurses," said Academy President James H. Herndon, MD.

Dr. Taylor promptly put a call in to Col. David C. Polly, Jr., MD, chief of the department of orthopaedic surgery and rehabilitation at Walter Reed, who graciously agreed to host the impromptu visit. Arrangements were quickly made for the delegation to visit Walter Reed on Saturday morning, April 26. In addition to Dr. Taylor, the delegation included Academy President James H. Herndon, MD; Jack Henry, MD; Jim A. Goulet, MD; Andrew M. Wong, MD: Craig P. Smith, MD; E. Michael Okin, MD; Andrew Schmidt, MD; John McPhail, MD; John Kelly, MD; William Nash, MD; Todd B. Orvald, MD; Bradley Nelson, MD; Paul C. Matson, MD; Robert W. Bucholz, MD Stuart A. Hirsch, MD; and Lynanne Foster, MD.

National Association of Orthopaedic Nurses (NAON) President Laurie A. Sienkiewicz, MSN, RN, and NAON President-elect Geri L. Tierney, MSN, RN, also joined the group for what Dr. Herndon later called an "inspiring and emotional visit."

Changing nature of war injuries

Dr. Polly kicked off the morning with an overview of the role of military medicine in Iraq as well as briefing on Walter Reed’s overall war effort.

The role of military medicine is different in every war, Dr. Polly explained, in part because "the nature of war injuries is different in every war."

Although the majority of the wounds sustained by soldiers in Iraq have been battle injuries—such as fragmentation and gunshot wounds, landmine injuries and wounds sustained when vehicles were hit by rocket-propelled grenades—nearly 40 percent of the injuries were the result of accidents.

"The troops were moving across the country so quickly that many injuries resulted from accidents, such as hummers flipping over or running over soldiers’ legs while driving in convoys," he explains. "When you’re driving in a tactical situation like that—with the enemy shooting at you—you’re driving in ‘blackout’ conditions. This means you’re driving at high speeds, with no headlights and slit taillights. It’s very easy to start running into things—especially during sand storms."

Kevlar body armor saves lives

The type of injuries sustained in Iraq differed from previous wars in another way: 80 percent of all the life-threatening injuries to OIF soldiers were wounds to the extremities. Among non-fatal injuries, head and torso wounds were almost non-existent.

Why such a distinct injury pattern?

"The widespread use of Kevlar helmets and body armor vests significantly reduced head and torso injuries," Dr. Polly reports.

Most of the estimated 125,000 coalition ground troops in the region were required to wear Kevlar helmets and a 16-pound vest lined with Kevlar and ceramic plates, which is said to stop high-velocity 7.62 mm rifle bullets capable of piercing light armored vehicles.

Although no one has an exact count, military experts say that dozens, possibly hundreds of soldiers owe their lives or their escape from injury to the Kevlar body armor.

Asymmetric warfare

Military medical personnel in Iraq also had to adjust to the reality of "asymmetric warfare," in which unconventional weapons and tactics are used to gain advantage over stronger opponents.

Unlike previous wars with more traditional lines of battle, coalition soldiers in Iraq could be attacked and wounded almost anywhere at any time, as is still happening in cities with persisting elements opposed to U.S. efforts. As a result, "the line of treatment was not as clean as in the past," Dr. Polly says.

NAON President Laura Sienkiewicz, RN (far left)
and NAON President-elect Geri Tierney, RN
(second from right) visited with orthopaedic nurses
at Walter Reed Army Medical Center

Forward surgical units

The rapid advance of coalition troops through Iraq also had an impact on the way wounded soldiers were treated.

"Forward surgical units in Iraq weren’t as fixed as in the past," Dr, Polly explains. "The forward surgical teams (FSTs) worked as close to the front as possible, but they weren’t classic, fixed MASH (Mobile Army Surgical Hospital) units."

To meet these new demands, the military deployed six Forward Resuscitative Surgical Systems (FRSS) in Iraq. The units operated within 20 miles of the frontlines, with one unit leapfrogging ahead of another as the frontlines shifted.

The FRSS is a highly mobile, rapidly deployable trauma surgical unit designed to provide emergency surgical interventions. Each FRSS consists of a forward surgical team, medical supplies and equipment that would be found in a typical emergency room, and a two-tent shelter that takes just one hour to set up and one hour to break down.

Advances in battlefield medicine save lives, limbs

As the Academy’s popular Legacy of Heroes multimedia project points out, medical advances tend to accelerate during times of war. The sheer numbers of wounded provide the opportunity, and often the necessity, to attempt bold new surgical techniques. Many of the soldiers wounded in Iraq will go on to live productive, independent lives thanks to the scientific advances that came out of World Wars I, II and later conflicts.

Some of those advances include:

Walter Reed gears up for war effort

As war in Iraq became imminent, the department of orthopaedic surgery and rehabilitation at Walter Reed shifted its resources away from routine medical care and geared up for war casualties.

For example, their total joint surgeon Lt. Col. John S. Xenos, MD, temporarily stopped doing total joints in early April. "Dr. Xenos is an excellent extremity surgeon, as well," Dr. Polly explains. "He elected to stop doing total joints for a while in order to care for war casualties and optimize use of resources at Walter Reed."

WRAMC actually began receiving casualties before the war had even started. "Many injuries occurred while soldiers were setting up tents and unloading equipment," he says. "We were still receiving casualties from Afghanistan, as well."

Battlefield to Walter Reed in 7-10 days

The average time between injury on the OIF battlefield and a soldier’s arrival at Walter Reed was seven to 10 days.

"Wounded service members were moved from the FSTs to the combat support hospital, then on to Landstuhl Regional Medical Center in Germany," Dr. Polly says. If necessary, patients were then flown to Andrews Air Force Base in Maryland, where they were transferred by ambulance either to Walter Reed or to the National Naval Medical Center in Bethesda, Md.

"Many soldiers received definitive care at Landstuhl," he adds. "There were seven orthopaedic surgeons there, including Lt. Col. Joachim Tenuta, MD, and Maj. David B. Carmack, MD. They were able to fix a lot of the casualties before sending them on to us."

Incoming wounded

The doctors at Walter Reed obtained information on incoming patients through official military channels, but "we’d watch CNN for updates as well," Dr. Polly admits. "Their intelligence was pretty good."

In some cases, the doctors at Walter Reed were able to review the patients’ x-rays many hours prior to their arrival at the medical center.

"Landstuhl has a digitized radiography imaging system," Dr. Polly explains. "For complex cases, images were sent in advance via secure e-mail from Germany; in other cases the images arrived on a CD with the patient."

When patients arrived, typically around 11 p.m., they were immediately taken to the cast room, which served as the triage area. Wounded soldiers were classified as either "ambulatory" or "litter." Ambulatory cases were moved to the ward and litter cases were transferred to the intensive care unit.

Taking a lesson from previous wars, Walter Reed keeps soldiers from the same units together in the same area of the hospital, Dr. Polly added.

Dr. Herndon thanked Dr. Polly for hosting
the AAOS delegation at Walter Reed by
presenting him with a "Patient Safety is
No Accident" lapel pin.

310 OIF patients treated at Walter Reed

As of press time, WRAMC had treated a total of 310 patients wounded in the war in Iraq, 130 of whom were battle casualties. Of the battle casualties, 93 were treated as inpatients and 37 as outpatients.

Following Dr. Polly’s briefing, orthopaedic resident Kenneth Taylor, MD, discussed several OIF patient cases with the group.

Being careful to protect the patients’ anonymity, Dr. Taylor detailed the treatment process for three patient cases. In two of the cases, the soldiers had stepped on landmines; one lost several toes and a portion of his forefoot; the other lost all his toes and sustained an injury to the heel area.

WRAMC has seen a lot of dirty wounds and extensive soft tissue injury, according to Dr. Polly. "We’ve performed numerous debridements for open fractures, amputations, and our hand surgeons are taking care of a number of hand, upper extremity and peripheral nerve injuries."

Following the briefing, the delegation moved on for a tour of the department, with NAON members stopping to chat with nurses as they made their way through the patient wards.

Meeting the soldiers

Prior to bringing visitors into patient rooms, or sharing any details of their cases, WRAMC secures releases from the patients, in accordance with Health Insurance Portability and Accountability Act’s privacy rule.

Two servicemen signed releases to meet the visiting surgeons that morning. However, upon entering the first soldier’s room, they found him talking to his parents on the phone, and chose not to disturb him.

Thankfully, the second soldier was available to greet the group when they arrived. Standing at the young man’s bedside, the leaders shook his hand and offered their thanks and support in what was described as a "very emotional" meeting. Dr. Herndon, in particular, was visibly moved by the encounter.

"Seeing these young men in their teens and early 20s losing limbs and wounded; it’s an emotional experience to say the least," he said.

For Dr. Herndon, it also brought back a flood of memories.

An earlier war

As an Army major during the Vietnam War, Dr. Herndon served as chief of the amputee service at Valley Forge General Hospital in Phoenixville, Penn., from 1971 to 1973.

"Seeing these young soldiers brought those days right back to me," he says. "I remember we used to dread the late afternoons; that was the time of day they’d fly in and leave us anywhere from four to six new amputees… It was tough."

Dr. Herndon was in good company at Valley Forge, however—previous Academy President Vernon T. Tolo, MD, worked alongside him at the amputee service for one year. "The two of us took care of 150 patients at a time in that hospital," Dr. Herndon recalls.

Dr. Herndon was "called to duty" again 30 years later, this time at Walter Reed where he served as a consultant to the Army just prior to the war in Afghanistan. With millions of landmines littering that country, WRAMC anticipated a lot of amputations and asked for Dr. Herndon’s help in establishing an amputee service.

"Fortunately, only a handful of soldiers were actually injured by landmines in Afghanistan," he says. "Most of the injuries were to Afghan civilians."

WRAMC employs new amputation techniques, technology

Of all the injuries sustained by OIF soldiers, approximately 15 percent required amputations.

Amputees at Walter Reed receive early psychological evaluation and support, Dr. Polly informed the group, and the latest techniques in amputee care are being employed to return the wounded soldiers to the highest level of function possible.

A discussion of various battlefield amputation techniques ensued, such as length preserving vs. "guillotine" or "open" techniques, and circular vs. spiral approaches.

Soldier to receive "Bionic" leg

WRAMC’s use of high-tech prosthetics also impressed the visiting surgeons. One OIF soldier recovering there will begin using a new "bionic" prosthetic leg within weeks.

Unlike a traditional prosthetic leg, which must be swung forward with each step using the wearer’s body weight, this prosthesis has microprocessor-controlled knees with hydraulic pneumatic controls that enable amputees to attain the closest possible approximation to their natural walk.

The leg—complete with microprocessor knee and force-sensing pylon—reads feedback data 50 times per second and evaluates it to determine the appropriate movement for the leg.

The Army’s first recipient of the "bionic leg", a soldier wounded in Operation Enduring Freedom, received the prosthetic at WRAMC a few months ago.

Dr. Herndon also took note of the new temporary prosthetic limbs that are being used for early ambulation. "When I was in the Army, we also fit temporary limbs early, but we made them out of plaster," he explains. "Now they’re custom-fit with high-tech materials."

Still, the most noticeable difference between caring for soldiers today and 30 years ago has nothing to do medical advances, he says. "The biggest difference is we didn’t have any women soldiers. Now we’re seeing both men and women among the war injured."

Soldiers’ morale remains high

The level of morale among the soldiers remains high. "Psychologically, they’re doing much better than in previous wars," Dr. Polly says. "The country’s support makes a huge difference."

One Special Forces soldier actually told him, "My only regret is that I can’t go back to finish the job."

"These men and women have incredible spirit and drive," Dr. Polly says. "They’ve been through a lot, but their positive attitudes make it an honor to care for them. It’s still hard work, but it’s an honor."

The activity at Walter Reed began to slow down in early May, but many soldiers still remain at the medical center, including 18 battle casualty patients.

"A lot of them have been sent back home to Fort Campbell, Fort Bragg, Fort Stewart and elsewhere, but some will be with us a while longer," he says. "The goal is to get them back to best level of functioning possible."

Orthopaedic resident Kenneth Taylor, MD
(left in uniform) briefed visitors on the treatment
process for several orthopaedic patient cases

Kudos to staff

Dr. Polly is quick to praise the dedicated military surgeons who’ve worked long hours to provide the service members with such a high level of care.

"Once you’ve served in the military or been in harm’s way, you know what those guys and gals are going through," he says. "There’s a different level of desire to help them out."

His staff has worked "yeoman’s hours" to make this happen, Dr. Polly says. "I have to mention my orthopaedic traumatologist, Lt. Col. Richard B. Islinger, MD, and Lt. Col. John S. Xenos, MD, who’ve done just a tremendous job. Also, the residency program director Lt. Col. Timothy R. Kuklo, MD.

"Our orthopaedic service chief, Lt. Col. William C. Doukas, MD, has really been the linchpin of the operation," he adds. "And there are many, many others, including the hand surgery team, Lt. Col. Gerald L. Farber, MD, and Col. Alan Smith, and all the residents and fellows.

Visit had "profound effect"

Witnessing the high level of care being given to soldiers today had a profound effect on the leadership of the Academy, Dr. Herndon says.

"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 from these dedicated orthopaedic surgeons," he says. "Taking care of very sick war-injured is hard work; the military physicians, surgeons, and nurses out there doing a fantastic job."

Dr. Polly says the visit had a positive impact on the surgeons at Walter Reed, as well. "It’s had a profound effect on the Walter Reed team to know how incredibly supportive the leadership of the Academy is of our soldiers and our efforts to help them."

Pfc. Lynch’s birthday party cuts visit short

One of the more high-profile service members being cared for at WRAMC is former prisoner of war Pfc. Jessica Lynch, who happened to be celebrating her 20th birthday on the day of the visit. To ensure the privacy of her celebration that afternoon, outside visitors were asked to leave before the festivities began.

The delegation concluded its visit in the main lobby, posing for photos with Dr. Polly among the flags and a painting of the hospital’s namesake, Maj. Walter Reed, MD. Dr. Polly excitedly shared the news that the Academy’s "Legacy of Heroes" traveling exhibit travel will make its way to WRAMC on July 9 and will be on display in that very lobby through July 23.

A memorable send-off

After many expressions of gratitude, Dr. Polly escorted the group to their waiting motorcoach, idling just outside the hospital’s main entrance. The day was gray and misty, so the visitors quickly bid their goodbyes and ducked into the warm bus for the trip back to the hotel. Dr. Polly remained standing outside in the cold drizzle, still clad in his white coat, respectfully waiting for his guests to depart.

As the bus lurched forward to leave, the colonel snapped to attention and rendered a crisp military salute, standing motionless as the tailights faded into the distance. Not everyone on the bus was lucky enough to witness the stirring gesture, but those who did won’t soon forget.

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