Rehabilitation of Combat Trauma - AMOPSamops.org/.../Rehabilitation-of-Combat-Trauma-by-JT... ·...
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4/19/15 Scholz, AMOPS-San Diego, 2015 1 Rehabilitation of Combat Trauma JT Scholz, DO, Ph.D. Walter Reed National Military Medical Center, Bethesda, MD
Transcript of Rehabilitation of Combat Trauma - AMOPSamops.org/.../Rehabilitation-of-Combat-Trauma-by-JT... ·...
4/19/15 Scholz, AMOPS-San Diego, 2015 1
Rehabilitation of Combat Trauma
JT Scholz, DO, Ph.D.
Walter Reed National Military Medical Center,
Bethesda, MD
Disclosures
l I have Nothing to disclose, I am here on my own dime, and that and $1.00, will get me a cup of coffee.
l The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government
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Learning Objectives
l Learner will: – Understand the multi-discipline nature of recovery – Understand the steps involved in Combat Trauma Care (CTC)
and rehabilitation – Define and understand the what physiatry is and the role in MTF – Define the role that pain management plays in the role of
rehabilitation – List our allied medical personalell involved in rehabilation of the
CTC Patient. – List the acute, sub acute and long term needs of a CTC patient. – Define the responsibility/roles for care: VA vs. MTF vs. Civilian – Be able to outline the process of combat trauma care CTC) from
injury to completion of care.
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General Direction today. l Combat trauma l Definition l Who is involved
– People – Specialties – Process
l Timeline of care – MTF, VA, Civ. – Return to duty
l Questions
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Overview: Combat wounded l Combat wounded – Complex medical care. – Multidiscipline
l Field evacuation, to regional, and definitive MTF
l Trauma (TACS), ortho/gen Surg/plastics, Med, Rehab (PMR).
l PMR-Rehab is multi-discipline by definition – Ortho, Plastics, PMR, PT, OT, Bev health,
Social support, Military. – Next steps.
l VA, RTD, Civ. l During higher flow, vs. lower flow.
– Teams, SOP in place support – SOPs, turnover, different standard of care.
Ortho
PTOT
PM & R SW
VA
Plastics
GSurgPsych
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Vocabulary
l PMR, Physical medicine and Rehabilitation, physiatry (phezz-eye-it-tree)
l Multi-discipline: driving the direction of care – All members must have equal input – Must have sense of value of their input
l MNA—Non Medical Attendant l MEB—Military Evaluation Board l Command interest—The solider is a resource..
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Combat Trauma
l GSW, IED, MVA, l Multi-trauma l Ortho l Burns l Internal Damage l TBI l Psychological l Combo’s of the above…
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Current situations: Same problems as previous wars… l Gunshot wounds , landmines, bombs etc.. l Bigger guns, IEDs, Chemical??
– Better aim, closer – Remote trigger – Suicide vest
l Getting closer… – City fighting vs. open field – Results...
l Worse outcomes.
Protect thy solder
l Better Amour – Slide of amour for beginning of Vietnam – Recent wars – New wars – Current
l Better Vehicles – Stryker, Armored Humvee, – Vs. Jeep?
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Decreased time to treatment.
l Armor l Rapid evacuation l Early medical attention l Better Medical protocols l Increased survival rate of multi-trauma
service members
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Result…
l Service member (SM) alive, but bodies very damaged
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Combat Trauma injured SM
l Very complex Patient – Complex wounds – Co-morbidities
– Vision loss – Spinal cord Injury – Traumatic Brain injury – Fractures – Severe Neurological or Vascular injury – Behav. Health/SW
l Support System variability l Premorbid conditions
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How to provide care?
l Optimal Care = well functioning and coordinated multidisciplinary teams.
l Clearly stated scope and responsibilities l Each member is recognized
– Valuable role – Equal importance – Voices heard
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Teams of specialist
l TBI Clinics l Amputee Clinics
– Prosthetics Clinics – Wheel Chair Clinics
l Multi-trauma Rounds l Pain-Psych Team l Complex Wound Care
– Special tam – Coordination with Nursing
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Other considerations . . .
l Medicine l Surgery l Ortho/TACS/Hand l PCLS l OT/PT/SLP l Plastics l Urology l Other
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Chaos, vs. concert
l Physiatrist as conductor – Primary care provider for the wounded SM – Coordination and recommending the
interventions l Systems l Specialist l MTFs vs. VA
l Holistic l Education & communication
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Education
l Stake holders – Patient – Family
l Spouse l Parents l Children
l Medical services – “…mine is most important” vs. – What is best for patient
l Now vs. later
l Where can SM get the best service? l Other considerations…
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The rehab team l Physiatry & others.
– It not always good to be king… l PT
– “…how to get there” l OT
– “…What to do when you get there” – Types
l TBI l Optometry l Hand l Driving l Brian training
l Prosthetics l Pain/Psych l DME
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Communication
l Clear roles and duties/responsibilities l Regular meetings l Direct communication l Ongoing education l Monthly Programmatic meeting
– With Directors share l Ideas to maximize efficiency and QOC
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Example amputee arrival
l Arrival at WRNMMC – Triage in Ortho/Surgery/Medicine/TACS
l Inpatient vs. out patient l IP: Service
– PMR consult in 24hrs – Transfer to PMR <72 hrs. – IP ward – Clinics – Return to Duty, vs. VA, Vs. Tricare Network
Outpatient
– Housing – Clinics
l PMR (unique) – Pain – Amputee – Wheel chair
l Recreation Sports
l VA/Tricare system – For life – Return to duty 4/19/15 Scholz, AMOPS-San Diego, 2015
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Pain Management l Initial control for pain fro injury
– PCA--Perioperative l Secondary control for pain due to surgery
– PCA convert Long Acting opioids at definitive surgery l Tertiary control for pain form therapy
– Short acting for breakthrough and pre medication prior to Therapy
l Other, – Anticonvulsants (Gabapentin, Oxycarbamazepine, Lamotrigine) – TCA (Nortriptyline, Amitriptyline, Desiprimine) – NSIAD (COX2) (given the anticoag) – Sleep aid/nightmares (Quetiapine fumarate)
Non-Pharmacological agents
l ICE/HEAT l Desensitization l Transcutaneous Electrical Nerve Stimulation (TENS)
l Acupuncture l OMT l Chiropractic l PT-body work l Recreation therapy
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Regional anesthesia team
l Peripheral infusion catheters – brachial/LS plexus – sciatic nerves
l Positive effect on pain control l Reduction of medication use l Increase in participation of therapy
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A word about opioid addiction
l Control for pain at time of cause, and for promotion to next level
l Opioids are for the right time, and the right injury
l Reinforce long acting over short, and revise often
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Pain Management The whole world is watching. l JCAHO, ACGME, sub specialties unto
selves. l Experience at WR requires a multimodal
approach. l Exercise to re-enforce learning
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Medical management: Multiple comorbidities and higher risk for secondary complication l Increased risk for DVT
– Intact limbs, and body because of long periods of being motionless. – Prophylaxis-Low molecular weight Heparin (enoxaparin), unless counter
indicated
l Heterotopic ossification (HO) – High energy injury, younger age, TBI, or other cause – Additional pain, skin Breakdown – Trouble with prosthetics, and joint ROM, Return to duty.
l HO Treatment – COX2, – HO and DVT in healthy populations:
l Low-grade fever l Medical vigilance is improve
Medical management: Continued…
l Comorbid Head injury – Posttraumatic seizure precautions – Levetriactam (Keppra) – Trained staff to handle these patients
l Blood loss – Epo—stimulate blood loss
Promotes healing Inc. energy during therapy
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TBI
Surgical Consideration:
l Combat wounds extensive, but challenging – Contaminated w/ dirt, bacterial and shrapnel
l Co-management with multiple surgical subspecialties – Ortho, Vascular, plastics, NS, TACS
l Limb salvage vs. Limb amputation – Patient/family preference, vs. Medical call – Patient satisfaction lower with LS vs. Amp.
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Amputation of limbs
l Upper Limb – Comorbid fractures, Plexus injuries, soft tissue
defects, graft healing time – Post operative period: ID myoelectric control sites
l Lower limb – CAD-CAM for socket fit and changes – Microprocessor Knees and Dynamic response feet – Enhance function but promote more rapid progress in
therapy
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High Tech therapy
l 3-D motion analysis gait laboratory l Experienced therapist l CARREN l Custom labs
– Assistive technology – 3d printers
l plastics l Ti.
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Computer Assisted Rehabilitation Environment (CAREN)
GME
l Ongoing military-specific curricula help military facilities stay current – Medicine, Surgical, and Rehabilitative
approaches to care. – Cutting edge moving medicine forward
l WRNMMC – Only PMR residency in the DOD – Vital & Active research programà
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Peer and Phych social support
l Professional psychological and peer support – VA – Red cross – Amputee Coalition of America – Local volunteers – Emotional support and valuable feedback
l PT progress – Physically and Mentally – Guidance through the military medical system
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Sport as therapy
l National Disabled Veterans – Winter Sports clinics
l ACA l Disabled Sports, et al l Therapy vs. Recreation
– Can be both
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Recreation sports.
Family support
l Family Assistance Center (FAC) l Support for the care givers
– Medical – Psychological
l NMA
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Discharge Planing
l Starts at day one… l SW, Nurse Case managers, l Coordinating continued care
– Different agencies – Discharge – Equipment purchases – Grants – Outpatient housing
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Military Medical Disability System
l Navigation, can be daunting l Service promotes communication and
standardization l Doctors’s need to be education and
experienced on MEB. l Physical Evaluation Board Liaison Officer
(PEBLO) and VA counselors – Pt. awareness of benefits
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Tailoring programs to fit the needs of the paitent l Optimal disposition of patients
Geographical challenges Patients duty station Home of record vs. nearest military vs. VA medical facility in proximity
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Coordination throughout TRICARE MIL. HC System Variability in standard
-variability in private -public sectors across the US
Partnerships with -DOD -VA -MTF
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Conclusion l Last 10-15 years cultural shift with in the military (and
society) l Individuals with major combat trauma and even limb loss
can remain active duty service l Medical/technoicalrehabiltative advances l Prosthetics design, and the service members forcing the
developer to innovated l WRNMMC is committed to allowing all wounded to
reach therein maximal function and return the to highest possible quality of life
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Special thank for
l Dr. Paul Pasquina (COL Ret) l Dr. Mathew Miller, (MAJ)
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Questions:
l JT Scholz, DO, Ph.D. l [email protected] l [email protected] l (301) 520.2684
References: l Shannon, S. (2002) Military Trauma Rehabilitation, Physical
Medicine and Rehabilitation Clinics of North America. Saunders Company, Phil. PA.
l Pasquina, Paul (2004) Optimizing care of combat amputees: Experience at Walter Reed Army Medical Center. Journal of rehabilitation Research and Development, Volume 41, Number 3a.
l Litz & Orsillo, Chapter 3 , The returning veteran of the Iraq war: background issues, and assessment guild line, Iraq war Clinical Guide. PTSD: National Center for PTSD. US Department of Vertern affairs.
l Collener et all , Roadmap for future amputee care research, Care of the combat amputee. Chapter 28,.
