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Process of Care for Battle Casualties at the Walter Reed Army Medical Center: Part III. Physical Medicine and Rehabilitation Service

Posted on: Sunday, 26 March 2006, 03:03 CST

By Pasquina, Paul F; Gambel, Jeffrey; Foster, Leslie S; Kim, Ann; Doukas, William C

The Physical Medicine and Rehabilitation Service provides a critical role in the assessment, management, and disposition of the newly injured combatant. This role has been well demonstrated during Operation Enduring Freedom and Operation Iraqi Freedom. Military physiatrists are uniquely suited to support military service members as they maximize their function and either return to duty or transition to civilian life.

Introduction

The Physical Medicine and Rehabilitation (PMR) Service plays a critical role in the assessment, management, and disposition of the injured combatant. This role was well demonstrated during Operations Enduring and Iraqi Freedom. Having the PMR Service within the same department as orthopedics, physical therapy, and occupational therapy greatly enhances the communication and flexibility to provide optimal medical and rehabilitative care for those injured combatants with musculoskeletal injuries.

Inpatient Consults

All combat casualties who are admitted to Walter Reed Army Medical Center (WRAMC) receive several automatic referrals, including an evaluation from the PMR Service. PMR consultation to the primary admitting service helps to focus each patient's rehabilitation plan at the earliest possible moment. PMR consultations also help to identify other comorbidities such as peripheral neuropathies, fractures, and mild traumatic brain injuries that might not yet have been identified during the initial acute phase of inpatient treatment. In addition to providing comprehensive rehabilitative care plans, it is customary for PMR consultations to provide recommendations for pain management, bowel and bladder management, and strategies for avoiding complications of immobility such as deep venous thrombosis, skin breakdown, or contracture formation. These consultations also ensure coordination with social work services and allied health professionals for appropriate disposition, which can include transition to an inpatient rehabilitation service.

The primary goal of the PMR consultation is to ensure the holistic management of the patient and that all strategies for restoring optimal function are being considered.

Inpatient Rehabilitation

WRAMC has the sole inpatient rehabilitation unit within the Department of Defense. Although the average daily census of this service is customarily between 8 and 12 beds, the number of inpatient PMR beds can be increased given command approval, space availability, and appropriate staffing. During wartime, priority for admissions is appropriately given to injured active duty service members who require inpatient rehabilitation. Guidelines for admission are similar to those criteria used by civilian inpatient rehabilitation units and include:

1. The patient has a condition that is amenable to inpatient rehabilitation interventions.

2. The patient is motivated and is able to participate in a minimum of 3 hours of therapy (physical, occupational, speech, psychological, or recreational) per day.

3. The patient has the capacity to learn and show carryover from day to day to meet identified functional goals.

The inpatient rehabilitation unit at WRAMC has special challenges when caring for combat casualties. Injured service members who need inpatient rehabilitation often present with complex injuries and multiple comorbidities that require creative solutions to progress in rehabilitation. For example, a right transtibial amputation may be ready for prosthetics training and ambulation. However, a non- weight-bearing fracture on the contralateral limb may prohibit this from occurring. Other examples, which illustrate the complex challenges facing rehabilitation specialists in caring for the injured combatant, include blind multiple limb amputees, patients who have spinal cord injuries or concomitant peripheral nerve injuries, or multitrauma victims also suffering from post-traumatic stress disorder. Because of the specialized facility requirement and need for protracted rehabilitation in the treatment of high spinal cord injury or severely impaired head injury patients, the WRAMC inpatient rehabilitation unit will generally establish more rapid transfer of these patients to a highly specialized facility closest to the patient's home.

The inpatient rehabilitation unit is colocated with the Inpatient Orthopaedic Service. Given the large volume of soldiers with extremity injuries, this facilitates the transfers of patients within the hospital while improving communication between physicians, nurses, therapists, and other health care professionals. The inpatient rehabilitation unit has many dedicated and caring military and civilian nurses trained in medical-surgical nursing; however, cross-training in rehabilitation is also required. Therefore, an ongoing educational process must exist to ensure the highest level of care. Critical to the functioning of the inpatient rehabilitation unit is the active participation of a multidisciplinary team. The core members of this team include PMR, physical and occupational therapy, social work, nursing, and psychiatry.

Having the rehabilitation unit located within the echelon V facility ensures the highest quality of care for these patients with complex injuries. First, it ensures continuity of care as these patients are transferred to the rehabilitation unit from multiple medical specialties (orthopaedics, vascular surgery, general surgery, neurosurgery, internal medicine, etc.). second, if during the rehabilitation phase of recovery a patient develops a medical or surgical complication, immediate multispecialty evaluation and comanagement is available. It is the PMR specialist's responsibility to serve as the inpatient's primary care physician, facilitating communication between specialties, providing attention to detail in monitoring daily progress, and ensuring the execution of the optimal treatment plan.

The inpatient rehabilitation team must have a close working relationship with the Department of Veterans Affairs in order to transfer patients to these facilities when warranted. In addition, the PMR specialist must have an extensive working knowledge of the military disability system, to include training in writing medical evaluation boards, counseling patients on the physical evaluation board process, as well as writing physical profiles. Most patients admitted to the inpatient rehabilitation unit require complex disposition decisions and extensive administrative processing. It is the PMR specialist who must ensure that all necessary requirements are completed to promote that optimal long-term care is provided for the patient, whether the patient is returned to duty or transitioned to a Department of Veterans Affairs facility.

Figure 1. Echelon V care of the combat amputee.

Caring for the Amputee

Experience during Operations Enduring and Iraqi Freedom has further highlighted the special and complex needs of combat amputees. These patients present unique challenges because of the nature of their wounds as well as the extent of their comorbidities. Complex decisions as to the need and optimal length of residual limb revisions, wound management, pain management, timing for prosthetic fitting and weight bearing, types of therapy, appropriate prosthetic components, etc., require a multidisciplinary team approach. To help facilitate this approach and achieve optimal care for these patients, it is best to create an independent amputee service. At WRAMC, this service falls within the Department of Orthopedics and Rehabilitation, with PMR staff serving as the supervising attending physician. The amputee service is designed similarly to the Inpatient Rehabilitation Service, with representation by a multidisciplinary team. Critical members of this team include those stated above in the inpatient rehabilitation team with the addition of orthopedists and certified prosthetists. A flow diagram of the echelon V care of the combat amputee is presented in Figure 1.

Electrodiagnostic Evaluations

The PMR specialist is also skilled in performing electrodiagnostic testing to include nerve conduction studies and needle electromyography. It is common for combat casualties to sustain multiple extremity wounds jeopardizing the peripheral nervous system. A complete and accurate assessment of the peripheral nervous system is needed to make better medical, surgical, and rehabilitative decisions. It is often difficult to make accurate clinical assessments of the peripheral nervous system in combat casualties given the extensive nature of the wounds, particularly in blast injuries. In these situations, electrodiagnostic testing can be very helpful. Determination of a central versus peripheral nerve lesion as well as root versus plexus injury is possible in the hands of a skilled electrodiagnostician. Finally, results from electrodiagnostic testing provide input on predicting prognosis.

Performing electrodiagnostic examinations on the combat casualty is often challenging given the extent of soft tissue injury that has occurred. In addition, the presence of swelling and/or an external fixation device further increases the difficulty in performing these procedures and interpreting their results. It is therefore imperative for the PMR specialist to have experience in \this patient population.

Ambulatory Casualties

Although much attention is paid to the multitrauma victim, a greater number of soldiers return from theater with non-life- threatening medical problems. A significant amount of these problems involve the musculoskeletal system, especially the neck, back, shoulder, and knee. The majority of these injuries can be attributed to acute macro-trauma or repetitive microtrauma. A significant portion of these patients, however, present with the exacerbation of a preexistent condition that was aggravated by the extraordinary bio- psycho-social demands and stress of combat.

Soldiers who are unable to continue with their combat mission because of a non-life-threatening injury are evacuated to the continental United States in a nonemergent status. The severity of injuries will dictate their triage status. Patients with less severe injuries may not arrive to an echelon V facility like WRAMC for several weeks or even months. Often these patients have already spent many days in transit before arriving at the echelon V facility. It is counterproductive to pursue an extensive medical evaluation of these patients upon their arrival in the middle of the night. It is much more effective and efficient to allow these ambulatory patients to get a good night's sleep, shower, and meal before their evaluation. It is therefore imperative to identify a housing facility in reasonable proximity to the echelon V facility that is handicap accessible. In addition, prior arrangements must be made to have clothing, shoes, and meals for these patients upon arrival since they typically arrive with only the clothes they had when they were evacuated from battlefield medical treatment facilities.

Ambulatory patients with musculoskeletal problems are instructed to report to the PMR clinic the morning after their arrival, where a complete evaluation may be performed to include obtaining appropriate further studies (radiographie, laboratory, electrodiagnostic) as well as arranging referrals to other medical specialties and health care professionals providing direct patient interventions. Prearrangements must be made with orthopedics, physical therapy, occupational therapy, psychology/psychiatry, and social work services to ensure easy patient flow, as these services will be most often needed. In addition, the evaluating PMR specialist must have a good understanding of the air evacuation system and the requirements of the Patient Administration Division, which is responsible for tracking patients, issuing their military orders, and making transportation arrangements for return to their home duty station or mobilization site.

Making disposition decisions on soldiers in today's modern Army is extremely complex. Not only do these soldiers present with challenging medical problems, but most also have unique social situations. This especially holds true for the National Guard and activated Reserve soldiers, who may have their family in one state, their unit in another, and the demobilization site at even a third. It is generally best to return each soldier back to his/her demobilization site as quickly as possible, provided appropriate medical and therapy facilities are accessible at these sites and are arranged before the soldier leaves the echelon V facility. It is also generally best for the PMR specialist to ensure that a complete and comprehensive diagnostic workup and appropriate treatment plan is established before allowing a soldier to leave the echelon V facility. Conflicts arise as these injured soldiers request convalescent leave to visit their loved ones, from whom they have been separated for a protracted period of time. To address this issue, it is helpful to have an established policy that ensures each soldier is treated fairly, but at the same time ensures accountability and tracking of these soldiers who may otherwise be lost to medical follow-up or who may compromise their medical recovery if they are not compliant with the established treatment program.

In general, echelon V hospital convalescent leave should not be granted to these soldiers unless the plan is for them to return for follow-up at that facility. In this situation, the hospital command may grant up to 30 days as indicated by the type of injury. All other soldiers should be returned to their demobilization site or duty station, where their rear unit may grant unit convalescent leave based on the needs of the unit as well as the availability of medical care at their place of convalescent leave. To facilitate proper disposition, it is imperative for the PMR specialist to document a clear and concise treatment plan on the air evacuation form (AF Form 3899) so the soldier's unit can ensure optimal care and accountability. All referrals to physical and occupational therapy should include a frequency and time limit, e.g., three times per week for 4 weeks.

Guarantor: COL William C. Doukas, MC USA

Contributors: LTC Paul F. Pasquina. MC USA; COL Jeffrey Gambel, MC USA; LTC Leslie S. Foster, MC USA; MAJ Ann Kim, MC USA: COL William C. Doukas, MC USA

Department of Orthopedics and Rehabilitation. Walter Reed Army Medical Center, Washington, DC 20307.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army or the Department of Defense. All authors are employees of the U.S. government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

This manuscript was received for review in October 2004 and was accepted for publication in April 2005.

Copyright Association of Military Surgeons of the United States Mar 2006

Source: Military Medicine

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