Chapter 9
REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE
Colonel Paul W Brown, MC, USA (Ret.)
As an enlisted soldier in combat in World War II, I first learned how essential motivation is to the individual’s survival--and to his sanity. As a young medical officer during the Korean War, I began to wonder why some severely wounded men recovered so well, while others with the same or lesser injuries did not. The patient’s attitude about healing and recovery seemed to have as much influence on his hospital course as any of the treatments administered. During the subsequent decade of peacetime orthopedic practice, I observed over and over that the patient’s motivation, regardless of the severity or nature of his ailment, could direct the course of recovery and even make the difference between healing and permanent disability. With the Vietnam War came my opportunity, as a senior military orthopedist, to apply what experience had taught me about the rehabilitation of combat-wounded amputees.
This chapter on rehabilitation is as much philosophical as historical. While it shows how ideas about using patient motivation as a rehabilitative device were developed and applied to Vietnam casualties at Fitzsimons General Hospital in Denver, Colorado, it also inevitably spills over into matters political, sociological, and emotional. It falls short of completely defining the goals and limits of early rehabilitation of the severely wounded soldiers because it is limited to the story of some of these soldiers in one hospital during a portion of one war. Nevertheless, perhaps from their experiences can be learned some lessons useful for the future.
HISTORICAL BACKGROUND
When the number of beds and physicians is limited and the influx of acutely wounded constant, transfers become inevitable once a hospital is full. During World War II, the accepted approach to this problem was to treat the seriously wounded casualty in a military hospital up to a certain point and then either to transfer him to a veterans’ hospital or to discharge him to civilian life. Thus, if the casualty had not obtained “maximum hospital benefits” within a certain period, the length of which fluctuated according to the pressure for hospital beds, he was transferred to a “long-term care facility,” generally a veterans’ hospital. An arbitrary period of time rather than the degree of recovery was the determining factor in the decision to discharge or transfer a patient. This approach, which reserved military hospital beds for more acute rather than protracted care, was, from the administrative viewpoint, both useful and practical. But it could adversely affect rehabilitation, and its effectiveness from an overall medical point of view was debatable.
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In the five years after World War II and before the outbreak of the Korean War, the field of rehabilitative medicine progressed to the point of achieving some respectable status as a medical specialty. But most physiatric methods applied to the Korean War casualty were devoted to kinesiology, gait patterns, and occupational therapy, with only rudimentary attempts at vocational rehabilitation. Although a definite advance, these rehabilitation efforts tended to fragment patient care. Physical medicine was administered to the patient in special departments and areas, and the ward surgeons and nurses were, to a degree, excluded from the process. In some military hospitals--Letterman General Hospital in San Francisco for one--a good deal of jockeying for control of the patient developed among the chiefs of the departments of physical medicine and the various surgical services.
During the Korean War, the number of casualties was considerably lower than in World War II, but fewer military hospital beds and physicians were available for them. When a return to duty or discharge to civilian life could not be effected within a prescribed time, the pressure to transfer patients to veterans’ hospitals was even greater than it had been during World War II. By the early 1950s more Veterans Administration hospitals were in operation than at the end of World War II. And the prescribed time before transfer was even shorter than it had been in World War II, since using the new Veterans Administration hospitals seemed politically and fiscally sounder than enlarging existing military hospitals.
In both World War II and the Korean conflict, the government management of the amputees was direct and simplistic. During the time period allowed for hospitalization in Army facilities, the amputation was to be completed, the stump healed and fitted with a prosthesis, and the amputee shown the rudiments of gait before his discharge to civilian life with some type of disability award. If the stump could not be healed or fitted within a “reasonable” time, the amputee was transferred to a veterans’ hospital. This uncomplicated approach made sense militarily. Because it was standardized and uniform, it also permitted the political system to disentangle itself quickly from uncomfortable reminders of the price of war.
But most medical officers during World War II and the Korean War were frustrated by the fact that they could contribute only a small bit to the patient’s recovery before they were required to ship him out to another installation. Although tactical and logistical considerations had rendered this approach to patient care unavoidable for most overseas hospitals, every physician in the chain of evacuation felt that he had done an incomplete job for the individual patient. The surgeon’s frustrations were compounded by the knowledge that he would rarely ever learn of the ultimate outcome of his cases.
During the period from the end of the Korean War until the casualties from Vietnam first reached embarrassing numbers--roughly from 1953 until 1967--the specialty of rehabilitation medicine began to mature. Leaders and innovators in the field were asking the question, “Where does treatment cease and rehabilitation start?” The true significance of this basically rhetorical question lay in the implication that treatment and rehabilitation were indistinguishable parts of one another and should not be considered separately. In other words, rehabilitation should start immediately as a part of the therapeutic endeavor.
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EVACUATIONPOLICIES AND THE PATIENT IN THE VIETNAM WAR
The growing conviction that rehabilitation could not be separated from treatment increased concern about evacuation policies that moved the patient from facility to facility, undermining the continuity of care that was increasingly seen as vital to prompt, successful rehabilitation. Furthermore, a transient commitment to the patient, the normal consequence of a lack of continuity of care, quite naturally fostered a depersonalization of the patient-doctor contact, a situation that frustrated the physician intellectually and sometimes, because of his compassionate concern, emotionally. The patient, however, experienced more than mere frustration; he inevitably felt afraid and abandoned. With each move to a new hospital scene, he became more reluctant to commit himself fully to a new doctor-patient relationship. No sooner was he familiar with a team of physicians and nurses and a hospital environment than the whole scene and all the characters in it (save the principal one--the patient) were changed to another. In the course of this change the patient was categorized and often referred to by the nature of his injury, not as an individual; he was labeled a “fracture, compound, comminuted of the femur” rather than “John Smith, who has a fractured femur.” In the initial phases of treatment, early in the chain of evacuation, he could handle this well enough, but with each successive change, the trauma increased. The patient saw quite well that each move delayed his recovery rather than expedited it, and he felt strongly that he was a pawn in a system. The threat of another move depressed motivation; it tended to make patients more passive in their own rehabilitation. Moreover, the shifting around often created an attitude of skepticism and cynicism about their government’s concern for them, since multiple transfers were obviously for the benefit not of the patient but of the administrative process.
Holding and treating patients for a month or more in hospitals in Japan in the course of their evacuation from Vietnam probably made a good deal of economic sense in terms of utilization of our facilities in Japan. It may also have simplified transportation problems, but it most definitely interfered with the continuity of care of the patient. Although these hospitals provided excellent and devoted care, some of the benefit of the early and effective rehabilitation measures usually started there was negated by the interruption of the process resulting from evacuation to the United States and exposure to a new medical scene. For many, therefore, the care was neither continuous nor orderly but fragmented and frequently changed. Ideally, injuries permitting, the patient should be evacuated as rapidly and as safely as possible to a general hospital in the United States and kept there throughout all of his remaining treatment and rehabilitation.
In spite of the recognized disadvantages that resulted from the evacuation policies followed in the early years of the war, the most profound change in evacuation policies during the Vietnam War came only as a result of the Tet offensive of February 1968. The sudden influx of large numbers of casualties forced the abandonment of the policy that had permitted casualties from Vietnam to spend weeks to months in hospitals in Vietnam, in the Philippines, or in Japan before their evacuation to the United States. Hospitals in Southeast Asia and Japan were quickly filled, making it necessary to send patients directly from Vietnam to the United States, where a much
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higher proportion of patients with openwounds, open stumps, and fresh, unhealed fractures werebeing received. As a result, in less than a year the orthopedic censusat Fitzsimons GeneralHospital more than tripled to over 900 patients.
Early evacuation of patients had its drawbacks, however. Some were rushed into the evacuation chain before their medical condition could safely permit the extended trip. Occasionally, patients were damaged, and some experienced severe discomfort that might have been avoided had their evacuation been deferred for even a few days. The most serious complications were seen in those with respiratory difficulties or blood loss problems. Overall, however, considering the great pressure for acute care beds in Vietnam, screening for early evacuation was handled efficiently and compassionately.
As the numbers and ratios of these “early evacuees” increased, so, too, did the impression that their rehabilitation progressed both more smoothly and more rapidly than that of evacuees retained longer in Southeast Asia. The soldier who arrived in the United States only a week or two after wounding was treated by one team throughout most of his healing process without the multiple and sometimes prolonged interruptions imposed by transfer to other hospitals. The question was not quality of care--the caliber of orthopedic treatment in overseas hospitals was equal to that in the United States--but consistency of care, since philosophies and methods differed from one hospital staff to another. The patient who started his healing process under one system and was then transferred to another had to shift gears; momentum, enthusiasm, and motivation were lost, irrespective of the relative merits of the different systems.
CARE IN CONUS HOSPITALS
The mission of the general hospital in the United States was never clearly defined in terms of medical responsibility to the Vietnam casualty. A certain amount of planning and administrative effort was put into transforming general hospitals into “specialized treatment centers,” which concentrated on particular types of wounds and to which orthopedic surgeons with known competence in the relevant fields were then assigned. The concept was sound but was never applied effectively beyond the assignment of one or two appropriately trained surgeons to each center. Generally, further support, either by assigning ancillary personnel or by providing special equipment or facilities, was never given. As a result, these centers were successful in direct proportion to their chiefs’ abilities to innovate, to scrounge equipment, and to hijack needed specialist personnel from other assignments. The efforts expended to make these centers effective detracted significantly from energies that would have been better applied to their primary mission.
The appropriateness of continuing orthopedic and surgical residencies at named general hospitals throughout the war was a topic frequently and heatedly debated among the chiefs of these programs. The experience in wound management and reconstructive surgery that young surgeons received in caring for Vietnam wounded greatly enriched their training programs and attracted many capable young medical officers who might otherwise never have been recruited or retained in the Medical Corps. But residency training requirements in the form of children’s orthopedic
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training, basic science studies, and numerousteaching sessions took the resident away frompressing duties involving care of the combat casualty. Despite theresidency problems, theoverall gain for the Army and for the individual patient was greatenough to justify continuationof the residencies.
The patient was not assured of continuity of care even after he arrived back in the United States. The length of hospitalization and the “maximum medical benefits” of the individual casualty fluctuated according to administrative policy, whim, physical considerations, staffing patterns, and bed availability. The doctrines of World War II and Korea might be applied: if a patient could not be “made well” within a specific period of time, his treatment should be interrupted and he should be separated from the service and transferred to a Veterans Administration hospital. When these general policies were indiscriminately applied to individual patients, both continuity and quality of care usually suffered. Some felt expendable, abandoned, or culled, probably with reason.
Fortunately, most general hospital commanders were physicians before they were commanders. As a result, they had the motivation and courage to resist or subvert policies that threatened detriment to their patients. Many medical officers and hospital commanders found ways to delay transfer of patients to Veterans Administration hospitals until they had finished their treatment and rehabilitation. Only after hospital beds became scarce did The Surgeon General’s Office begin pushing these officers to have patients with an anticipated prolonged hospital stay discharged from the military and into a veterans’ hospital.
The Veterans Administration hospital chosen for the casualty was often the one closest to his home, which was not necessarily the facility best equipped to care for him. Ironically, many wounded soldiers were sent to veterans’ hospitals with no capability for managing their particular treatment or rehabilitative needs just when The Surgeon General was promoting the doctrine of the “whole man” approach to medical practice and the assessment of disability. A sound concept, it was generally overridden by administrative priorities when military hospital beds were scarce and was more assiduously applied to the attainment of disability ratings for retiring personnel than in treating the war wounded.
Increasing the pressure upon physicians dealing with Vietnam casualties in CONUS hospitals was the grim fact that many casualties who would not have survived their wounds in previous wars were now reaching the United States alive. Their survival, the result of using improved medical techniques, helicopter evacuation, and antibiotics, brought hospitals a proportionately higher number of bilateral amputees and men with massive combined injuries than any other conflict. These patients would experience a protracted hospitalization and significantly greater rehabilitative problems. Although the public conscience--and the consciences of the physicians caring for Vietnam casualties--could quite easily cope with the occasional mangled soldier, as the numbers of these patients grew and facilities and staffing became more strained, attention was focused more sharply on their requirements. When the war in Vietnam began to heat up in 1966 and 1967 and ever greater numbers of casualties reached the United States, public discomfort grew, and physicians increasingly challenged the quality of their approach to their problems. Orthopedic surgeons involved in the care of Vietnam wounded in CONUS hospitals also wondered whether purely fiscal and economic considerations were
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dictating too much of the hospitalization policy within the UnitedStates. Only a few surgeonsbecame political activists--to the detriment of their professionalobligations--and only a fewnarrowly defined their medical commitment to its purely technicalaspects. But many wereincreasingly concerned about how well our government was fulfilling itsresponsibilities to itswar wounded, believing that the wealthiest nation in the world owedideal care to men who hadbeen rather indiscriminately selected to fight for a questionable cause.
REHABILITATION THE CHALLENGE
Converging in the spring of 1968 to effect a significant change in the overall medical management of our patients were a growing discontent with the war, a burgeoning number of casualties, and a changing attitude toward the rehabilitation of the seriously injured soldier. The specialty of rehabilitation had continued to mature during the quieter early years of the Vietnam War from 1961 through 1967, and its concept had been expanded. Social workers, vocational counselors, government agencies, business, and industry all became more involved with the transition of the wounded and disabled soldier to the status of a wage-earning civilian. Physicians were increasingly realizing that the surgical challenge extended farther than the bodily healing of damaged patients. But the rising numbers of casualties and the political and moral frustrations resulting from the Tet offensive in 1968 forced a confrontation with the question of how far the rehabilitative process should be taken. When did medical treatment cease? What was our obligation to the casualty as a patient, as a man, and as a political creditor?
Motivation became a major tool in the rehabilitation of the orthopedic patient. In their attempts to learn how it could best be used, surgeons gathered to discuss psychological abstractions openly and attempted to apply them systematically. For orthopedic residents, eager to learn the technicalities of operative techniques of their newly chosen specialty, the devotion of time and energy to such discussions was particularly unusual. Fortunately, although motivation is an abstract quality, difficult to describe, even more difficult to recognize, and impossible to computerize or categorize or write policies on, almost everyone recognized what it was. Ward nurses, paramedical personnel, physical therapists, and occupational therapists enthusiastically accepted the concept and proved to be innovative in discovering, engendering, and stimulating patient motivation. But how these medical people discharged their responsibilities to the amputee varied greatly, since it was influenced by their own definition of responsibility, by their medical philosophy, and, especially in the Vietnam War, by the politics and morality of the time.
Successful rehabilitation and good medical management were frequently thwarted by the leave granted the wounded soldier to return home as soon after his return to the United States as his physical condition allowed. While valid for compassionate reasons, it interrupted treatment, often for thirty days or more. The poorly adjusted casualty tended to become even more so at home, where he was often pampered, spoiled, and lulled into a state of lethargy and dependency--all of which worked against our attempts to motivate and rehabilitate. A preferable approach involved giving shorter periods of leave more frequently and coordinating
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them with a rehabilitation program, butattempts to do so were often defeated by parental andpolitical pressures.
Patient motivation was most successfully exploited to achieve rehabilitation in dealing with the amputee, but the motivational techniques developed with him were used with various degrees of success with other types of casualties. The patient with the shattered femur or mangled hand posed greater reconstructive challenges to the surgeon, and his hospitalization, frequently protracted as it was by multiple operations, problems of infection, and nerve and bone loss, was often longer than that of the amputee. Nevertheless, the amputee’s loss was more visible to him, to his family, and to society. With the exception of the brain-damaged, the cord-injured, or the castrated patient, the amputee’s body image was more altered and his emotional stress was greater than for most other war wounded. His conspicuous loss made it possible for him to display his disability and to use it to foster his dependence. Thus, the poorly motivated amputee tended, or at least was tempted, to become a professional cripple--physically, emotionally, and sociologically.
Understanding the individual patient was necessary to successful use of motivation in his rehabilitation, whatever his injury. Although the fact that a wound of the psyche coexisted with the somatic wound helped explain differing reactions to the same type of injury, whether the psychic trauma proved to be significant and lasting depended on many things, among them the circumstances of the injury, the patient’s personality, and the nature of the wound itself. Wounds that caused persistent and severe pain noticeably affected the patient’s personality and attitude, but pain and impaired function were not the only factors governing a patient’s reaction to his injury. Some wounds have traditionally borne a particular stigma not necessarily proportional to their overall seriousness, and the fear that they have inspired also adversely affected the patient’s motivation. Because different men react so differently to pain, fear, and wounding, surgeons encountered varied and often unpredictable reactions in amputees from the Vietnam War. The rehabilitation team discovered, however, that subjective responses to wounds could become tools for motivation.
Those who proved capable of managing much of their own rehabilitation displayed many diverse qualities, some obvious--among them courage, philosophic acceptance, and aggressiveness--and others more subtle including sublimation, transference, and overcompensation. The sum total of these reactions, whatever the particular mechanism, was adaptation. Those who adapted well needed only medical technical skills and logistical aid to attain their rehabilitation. The patient who was psychically devastated by his wound, regardless of its nature, might remain so for long periods or even permanently. These men, a minority of the total, appeared to have no reserves or inner strength and responded listlessly, or not at all, to our attempts to rehabilitate them. They seemed drained of will and the resolve to improve and almost to welcome a permanent state of disability. They manifested their psychic wounding in many different ways, some by chronic depression, some by apathy and listlessness, and some by antisocial behavior. Unsophisticated in the science of psychiatry, surgeons classified these reactions as neuroses, a term which, even though passé, still proved useful in overall management of these patients. For the majority of casualties who fell between the two extremes, recognition that the psychic aspects of some wounds required special attention proved useful in facilitating and accelerating the recovery process.
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As is so often true in the practice of medicine of any specialty, communication and education proved to be most valuable tools, since the patient often had many needless misapprehensions about his injury. In these instances, a thorough explanation of the wound and its significance quelled the anxieties and depression that had inhibited his contribution to his recovery. Some fears were based on misconceptions of future surgical procedures, since terms such as “debridement,” “scar revision,” “internal fixation,” and “delayed closure” had no real meaning for many, who were inclined to imagine the worst. The amputee was both fearful and ignorant about the various types of amputations and prosthetics and their implications for future functional capacity. Most patients were reluctant to admit their ignorance or were inhibited by the disparity in rank between themselves and their surgeons. Thus, although most patients quickly acquired a practical education in some of these matters through their own observations, experience, and conversations with other patients, much of what they learned was based on superstition, misunderstanding, and gossip. We deemed it important to establish rapport and to start patient education shortly after the patient entered in the hospital. Ward officers were encouraged to start the process in the initial interview with the patient and to continue it on ward rounds.
The approach to education, straightforward and basically simple, had three objectives. The first was identification and analysis of the problem with the patient. The aim was a realistic look by the patient and doctor together at the injury and the anatomy of the injured part and an explanation of the healing process. The second was an examination of the significance of the injury to the patient’s body and to his future. This, although usually simple, could be complex because of what the patient had already been told and the prejudices and fears that had already become entrenched. In spinal cord or pelvis injuries, the probabilities concerning the patient’s future sexual capacity had to be addressed. When there were disfiguring wounds, a forecast of future appearance was necessary. Amputees required education about their prosthetic and functional potential as well as discussion on how they would be received by families and society. The third was an indoctrination into the rehabilitation process. The patient was shown how he could make a quicker, more comfortable, and more satisfactory recovery if he contributed actively to his own progress. The difference between active and passive participation was made clear. The various types of rehabilitation programs, both obligatory and voluntary, in which he would be participating were explained as were the interests and identities of the people conducting these programs. Great emphasis was placed on progress and on planning for the future.
The third phase was continued throughout the patient’s hospitalization. Patients with similar wounds or problems who were making good progress were often enlisted as teachers and stimulators. All members of the rehabilitation team--ward nurses, corpsmen, technicians, physical and occupational therapists--contributed, often with effectiveness and enthusiasm that outstripped that of a physician’s. Wives, girl friends, and parents were also helpful if they did not smother the patient with sympathy and protection. Unfortunately, the families of the more passive patients, those who most needed stimulation, were those most inclined to be overprotective. With some of these patients, their families emerged as adversaries to the rehabilitation program and in some instances caused it to fail.
Some patients preferred discussing their injuries privately with the physician, but others were more open and expressive when part of a group discussion. Amputees
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tended to congregate because of their commonproblems and their assignment to amputee wards,to form their own exclusive fraternity from which medical personnelwere largely excluded. Inday rooms, at the Red Cross, and in local bars, groups tended to springup spontaneously withinthe amputee society, among patients in traction confined for most oftheir hours to one ward orcubicle, or among men in physical therapy. The same was true for handsurgery patients. Somepatients of diverse wounds, but with common vocational interests, werebrought togetherthrough vocational rehabilitation sessions. In some, race, background,or hobbies was thecommon ground. The commissioned officer patient was sometimes includedin groups andsometimes excluded from spontaneous and social groups, but nodiscrimination was made on thebasis of rank where groups were formed by the staff. The officerpatient who was assigned to agroup sometimes excluded himself or was rejected by the group. He couldbecome a difficultpatient to rehabilitate. With these few, the bar at the hospitalofficers’ club was often his ally,though seldom his friend.
Since much of the conversation in the informal groups was based on surmise and gossip and might reinforce misinformation, the creation of structured group discussions led by someone knowledgeable on the topics was attempted. These group sessions were useful in improving both education and communication between patients and staff. Some patients attended groups but seemed not to participate, although they might report later that they had achieved a better understanding of their injuries and treatment by their presence at such sessions. Others were willing to ask questions while in the group on topics which they were reticent to discuss alone with their physicians.
These group encounters were not regarded as “group therapy” sessions but rather as a means to better understanding. Members of the psychiatry staff seldom participated, nor was there need for their participation. Psychiatric attention was, of course, occasionally needed by an individual patient, but little relationship could be seen between the nature of the patient’s wounds and the appearance of any overt psychic abnormality. Since orthopedic surgeons were usually understaffed and they often had difficulty merely in keeping up with the surgical schedule, ward rounds, and the orthopedic training program, they tended not to become much involved with the psychodynamics of the rehabilitation process. Yet many orthopedic surgeons perceived, if only dimly, that there was more to orthopedic surgery than the surgery itself.
MOTIVATION AND REHABILITATION PROGRAM
Until the mid-1960s, the approach to wartime amputee care had changed little from that of World Wars I and II and the Korean War: heal the stump, fit it with a prosthesis, train the patient in its use, and discharge him to civilian life. Although advances in prosthetics and orthotics contributed to better function and the addition of vocational counseling and driver education to some degree rendered the adjustment to civilian life easier, progress in programs to help amputees live as normal lives as possible had not been significant. All management programs had been directed toward what was lost, not toward what had been retained. Only when the number of amputees began climbing rapidly in 1967 were ways explored to expand their total rehabilitation, using patient motivation as the key.
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In its basic form, motivation is a manifestation of a desire for gratification. Sometimes that desire is obvious enough--doing something because it’s fun, it feels good, or it wins admiration and recognition. Probably more often the desire is much more complex, obscure, or subconscious. Because of the complexity of human emotion and behavior, orthopedists have been uncomfortable in speaking, writing, or dealing with these mechanisms and have tended to retreat from that poorly defined field to the more familiar and comfortable terrain of the operating room, laboratory, and clinic. But as the Vietnam War continued, military orthopedists grew progressively less satisfied about the results that they were achieving and, consequently, became increasingly involved in rehabilitation. Recognizing the significance of patient motivation, they attempted to stimulate and harness it to their ends and thus found themselves indulging in behavior modification, although they did not recognize it by that name. They found themselves involved in trying to get patients to do things that they didn’t necessarily want to do by making them want to. Once they became consciously aware of what they were doing, they found it increasingly easy to devise means to that end. In many patients, the process, once started, became self-sustaining, and individual patients often became contributors to the behavior modification of others.
The attempt to find enjoyable physical activities that would contribute to patient rehabilitation, combined with the memory of reports of Austrian skiers who had returned to skiing after World War II in spite of amputations, led to the consideration of their sport for Fitzsimons’ amputees. Willie Schaeffler, director of the ski school at Arapahoe Ski Basin in Colorado, affirmed that a skier who had lost a leg could ski, but stressed his belief that skiing would be feasible only for amputees who had already learned to walk, who were in excellent physical condition, and who had been expert skiers before their amputations. None of the Fitzsimons amputees met these criteria, and none were in the least interested in learning to ski. Nevertheless, we decided to try it.
Schaeffler agreed to lend his advice and ski instructors. Larry Jump, the owner of Arapahoe Basin, 10,800 feet up in the mountains 75 miles west of Denver, volunteered to supply the ski facilities. Special Services buses provided transportation. Head Skis donated skis and Cubco and Miller ski bindings. Generous donations from Colorado skiers supplemented Special Services ski boots and clothing. Aware that in Europe the one-legged skier used one normal ski and two very short skis mounted on some type of pole or crutch, the orthopedic brace shop at Fitzsimons set to work mounting 17-inch ski tips to Canadian crutches. They devised a mount that allowed the ski to tilt back and forth while retaining lateral stability.
Using a series of ski movies, instructions, and pep talks, Edwin Lucks, one of Schaeffler’s senior instructors, began to indoctrinate the Fitzsimons amputees. His great enthusiasm and obvious dedication to success created a modest amount of interest in the amputees and produced an agreement that it was at least worth trying. The chance discovery a few weeks later that Dr. William F. Stanek, chief of orthopedics at the Denver Children’s Hospital, had been trying to establish such a program for juvenile amputees for several years but had been unable to obtain much support for it, led to an agreement to join forces.
On the cold and snowy morning of 10 January 1968, twenty military and eighteen amputee youngsters, aged eight to seventeen, assembled on the slopes of Arapahoe Mountain. Assisting the amputees were numerous volunteer helpers, among
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them Red Cross personnel, physicaltherapists, medical corpsmen, and four bemused andsomewhat apprehensive ski instructors who, having practiced skiing onone ski, were determinedto remain on one ski throughout the day. The amputee ski program hadbeen born (fig.53).
The key to confidence in downhill skiing is control of direction and speed, which are obtained by the ability to change direction at will, which, in turn, is controlled either by torque applied to the long axis of the ski or by twist or cant of the ski, or by a combination of both. Cant, or edging, is the angle at which the edges of the skis are applied to the surface of the snow. The preliminary maneuver essential to the application of torque and edging is weighting and unweighting of the ski. Therefore, after learning to stand on the one long ski and to use the crutch outrigger ski for balance and support, the amputee learned to hop and change direction of the long ski by weighting and unweighting it, starting with a slight crouch followed by a quick knee and elbow extension and a twist of the trunk. Although many normal skiers take several seasons of ski instruction before they master such essentials, most amputees learned them in a lesson or two and some seemingly immediately, in the first morning on the slope (fig.54).
As soon as the amputee had learned to change the direction of his ski, he had enough confidence to attempt gliding down the beginners’ slope. Most conquered it by the end of the first day and were then eager for something more challenging. Having
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FIGURE 54. - Three-track skiers. Below-knee and above-knee amputees on skis.
discovered the fun and exhilaration of skiingduring the first few runs on the beginners’ slope,few amputees wished to quit. By the end of the day all of the amputeeskiers were gliding downthe beginners’ slopes and using the rope tow lift. Learning to get onand off the chair liftspresented no more problem for the amputee skier than for any otherskier; if anything,dismounting from the moving chair was made easier by the outrigger skiswhich allowed betterimmediate stability and balance than for the skier with two skis.Amputee skiers experienced fewfalls at either end of the chair lift. Mistakes and falls on the slopeswere numerous, but highspirits and good humor prevailed, and most patients were convinced thatskiing was not onlypossible but fun.
On the first day, the instructors and their students also began to discover skiing and teaching techniques that they continued to develop throughout the rest of that winter. The short-ski crutch outrigger worked fine in gliding downhill but proved to be of no help in climbing or walking on the level. A spring-loaded “snow, spike” was therefore developed which would be extruded through the bottom of the outrigger ski for walking and could be retracted for gliding downhill.
Every week thereafter for that first winter, a busload of military and juvenile amputees and volunteers met at Arapahoe Basin. For most, the rate of progress exceeded expectations, although a few passive patients quit after the first attempt and could not be induced to continue. By the end of the second session, having learned to negotiate the chair lifts, a few were skiing on intermediate slopes. By the end of the ski season, these few aggressive ones--all below-knee amputees--were skiing on expert slopes with skill and grace. Most took four or five days of lessons before they learned to handle chair lifts and intermediate trails.
Most of the amputee skiers had lost one lower extremity, and these, whether the loss was below-knee or above-knee, learned to ski with relative ease. Many of them, as well as other skiers and ski instructors, thought that learning to ski actually seemed to be quicker and easier for the one-legged skier than for the skier with two
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legs. The upper extremity amputee experienced much greater difficulty.He still had the problemof learning to control two skis but could usually use only one ski poleand thus had much moredifficulty with control and balance. Moreover, receiving his prosthesisseldom made skiing anyeasier. Those who continued skiing chose to use only one ski pole.
Initially, only amputees with healed stumps and in otherwise healthy condition were allowed to participate. As the program became popular and proved safe, however, many amputees with unhealed stumps joined and in numerous instances were skiing well before being fitted with a prosthesis. In a sense, they learned to ski before they learned to walk. There were many falls, few accidents, and only one injury. This last was a fractured tibia incurred by a below-knee amputee who became so enthusiastic about skiing that he tried ski jumping. The fracture was treated with a long leg walking cast that he was still wearing when fitted with his first prosthesis. He returned to skiing the following year.
Many amputee patients were recovering from multiple wounds, and all, of course, suffered from various degrees of depression because of their disabilities. The ski slopes developed into a great therapeutic atmosphere in which physical disability was looked upon only as a challenge and for which the mountain air, the exhilaration of skiing, and the magnificent mountain scenery were catalysts. The relationship between the soldiers and the children was mutually supportive. The children were excited over their association with warriors, all of whom they saw as heroes. The soldiers were flattered to be so admired and, at the same time, determined that the children would not outperform them. A fine sense of symbiotic camaraderie developed between these two groups.
As the program enlarged and its success became apparent, press coverage was quickly expanded. Although the publicity brought beneficial contributions of equipment, it also brought problems. Volunteers sprang up from everywhere, some sincere in their desire to help, some seeking publicity, and some simply troublesome do-gooders wishing principally to gratify themselves. Many agencies and individuals praised the program, although some condemned it as cruel and inhumane. The orthopedic consultant for The Surgeon General’s Office stated that it was inappropriate to the mission of an Army hospital and implied that time should be spent on other and “better” projects. With all the publicity over the amputee skiing, it probably did seem that it was an elaborate and time-consuming project, but in fact it was not. The use of funds and military personnel was extremely modest; private groups and individuals donated most of the equipment and provided most of the assistance on the slopes. Several military orthopedic services--notably in the Navy--also announced that it was dangerous and an inappropriate military endeavor. The charge was made that such programs tended to foster and prolong the inclination of amputees to rely exclusively on one another for companionship, thus serving as a deterrent rather than an aid to rehabilitation.
In that first year, several bilateral lower extremity amputees insisted on accompanying the skiers to Arapahoe Basin. We tried to accommodate them, but wheelchairs and snow proved incompatible. Some persisted, however, and demanded their share of winter sports. They tried rubber tire tubes tethered by a rope controlled by an instructor, an experiment that proved to be both exhausting and dangerous. They then started on ski sleds which could be controlled by shifting
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body weight. But getting these patients andtheir sleds on and off chair lifts proved difficult, andthe sleds, which developed considerable momentum and easily went out ofcontrol, weredangerous. After the first year, these too were abandoned.
At the beginning of the second winter, December 1968, however, one combined above-knee and below-knee amputee was so insistent that the possibilities of skiing were explored for him. Lucks, the instructor, fitted with bilateral double upright braces with locked knees and ankles, was able to demonstrate that controlled skiing was possible using only hip and trunk control. The amputee was then fitted with a type of stubby prosthesis for each lower extremity, and in these he learned to ski (Brown 1970). Enthusiastic about his skiing, in his first season he learned to ski on expert trails and even participated in slalom and downhill races. Mounting and dismounting the chair lift with rigid knees and ankles required courage and agility, but he managed and soon was able to accomplish this without interruption of the lift operation. Several other bilateral amputees, all above-knee amputees, learned to ski in the same fashion, and most did better on skis than they did with ambulation in their “normal” above-knee prostheses (fig.55).
Great courage and determination were required for a man with no legs to learn to ski. Those who succeeded truly were highly motivated. But they were also highly rewarded.
The amputee ski program at Fitzsimons continued for five seasons. Many physicians, ski professionals, and amputees from all over the United States visited the
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program and applied what they had learned totheir own ski areas. Orthopedists, too, learnedfrom them, and though a healthy rivalry developed, there was a generousexchange ofinformation and helpful suggestions. Amputee skiing was started inseveral parts of the UnitedStates at about the same time as in Colorado, some in conjunction withmilitary hospitals andsome under civilian auspices. The answer to the question of which skiprogram for amputees wasthe first to be established in this country is not known. Nor is itparticularly important.
Some ski instructors who started in the Fitzsimons program have devoted much of their subsequent skiing careers to teaching handicapped skiers and developing new techniques for them. The work of Edwin Lucks has been outstanding in this field. Lucks has successfully developed skiing methods for the blind and for people with many kinds of physical disability.
The program was discontinued during the winter of 1973 when the last of the Vietnam amputees was discharged from Fitzsimons. The Children’s Hospital program moved to another ski area and continued to teach amputees of all ages to ski. A total of 400 amputees learned to ski in the Fitzsimons program, and many continued to ski with pleasure, pride, and proficiency, often participating in ski racing and demonstrations and encouraging and even teaching other amputees to ski.
The primary objective of the program, however, was not to make skiers of amputees but to aid disabled patients to accomplish something that would help restore their pride and confidence. It was a tool to stimulate motivation to adapt and succeed. Many of the amputee skiers observed that, after having learned to ski, they looked upon themselves not as crippled but rather as merely “inconvenienced.”
Skiing was not the only sport used as part of the rehabilitation program. As the winter of 1967-68 turned to spring and the snow in the mountains began to retreat, the orthopedic staff in Fitzsimons, impressed by the accomplishments of their patients on the ski slopes, looked for other means to stimulate motivation. With the help of Red Cross personnel, a swimming, water safety, and scuba diving course was started in the large indoor Special Services pool on the hospital grounds. In this program, many patients convalescent from trunk and extremity injuries learned to swim or were enabled to return to swimming and underwater swimming. This achievement helped motivate the patient to participate in his own rehabilitation in the same manner as did skiing.
The most notable early success with this pool therapy was with the first bilateral amputee skier. After he modified the bottom half of a wet suit to conform to his stumps and affixed swim fins to it, he was taught to swim and to scuba dive. A triple amputee--upper extremity above the elbow, bilateral lower extremity above the knee--learned to swim and was then instrumental in enticing a second triple amputee with the same combination of extremity loss to learn. In each instance, this accomplishment helped considerably in improving morale, body image, and motivation to do other things. The swimming was good exercise and, once again, the sense of accomplishment helped keep the patient from thinking of himself as a “cripple” (fig.56).
The use of the pool for patients with pelvic and lower extremity injuries was extremely helpful in starting early ambulation. Buoyancy of the body with lightened load on healing fractures and damaged joints allowed exercise, weightbearing, and early gait training, often months before they would otherwise have been possible.
Most patients were motivated to use the pool for their rehabilitation, but some were afraid of the water and required considerable encouragement to start. Pa-
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tients who had benefited from the pool andwho were enjoying it were the best aids to motivatingthe timid. Occasionally the program was made obligatory for the morepassive ones for whompersuasion was not enough, but this move was rarely successful. Onecannot order someone tobe motivated; the motivation must be stimulated, not commanded.
A third rehabilitation program was initiated by a Fitzsimons social worker, Mary Woolverton, who lived near Denver on a small ranch where she raised Morgan horses. An expert skier and equestrienne, she had much contact with amputees and other war wounded and their families in the course of her social work at the hospital. As the first amputee ski season came to a halt in April 1968, she enticed a few of the amputees to ride one of her even-tempered Morgans. They did so well that she was encouraged to start a regular riding program at Fitzsimons for any amputees or other patients deemed fit enough. Once a week Mary brought two of her horses to the hospital parade grounds and instructed orthopedic patients in the fundamentals of horsemanship, including saddling, mounting, riding, and grooming.
The first pupils were several below-knee amputees who had little difficulty in learning to mount, sit, and ride the horse at a walk. They were soon joined by above-knee amputees, and they, too, learned to ride, although balance and control were a bit more difficult for them. As still more amputees joined in and became adept at riding, they became enthusiastic boosters of the program and encouraged others to participate. When two bilateral above-knee amputees asked to learn, we started them in spite of our misgivings. We boosted them from their wheelchairs into the saddle and used a safety strap about their waists to hold them to the saddle. Easily learning to ride at a walk, they progressed to a trot and then to a canter in the first day. After a few sessions, they were riding at a gallop, whooping in triumph at their accomplishment. They were very proud of this--one told me, “Colonel,
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when I’m in this saddle, I’m taller than youare.” This first group was then joined by many otherpatients with many combinations of injuries, some with unhealed stumpsand open wounds andsome with an extremity in a plaster cast. Once they became confident oftheir ability, mostdisdained use of the safety strap (fig.57).
FIGURE 57. - Triple amputee in the saddle.Note the “holsters” for his thigh stumps.
One of the most remarkable riders was the triple amputee who had learned to swim. In addition to bilateral above-knee and left above-elbow amputations, this young man had a stiff right elbow and only one eye. He not only learned to ride, but insisted on learning to pull himself into the saddle from his wheelchair. Determined to become an expert horseman, he added trick riding and roping to his repertoire as he progressed. The saddle “holsters” devised at his suggestion for his above-knee stumps assisted him in maintaining a more stable and secure seat in the saddle.
Another highly motivated young man had had bilateral hip disarticulations; he, too, learned to ride. At first his saddle was built up with pads and pillows, but he eventually dispensed with these trappings and used an ordinary western saddle. Although he lacked any means of gripping the horse, and therefore was never really secure, he became an excellent rider. He and several other bilateral lower extremity amputees gave exhibitions of riding and roping at many horse shows and rodeos.
A bilateral above-knee amputee who was also blind was taught to ride. Although initially withdrawn and depressed, this patient learned to trot on a horse and to lead his mount by verbal guidance from an accompanying rider. He was
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never a great success as a rider, but hecommented that the ability to mount, sit, and trot a horsewas the only part of his rehabilitation program that gave him any realencouragement to face thefuture. Although far from a typical rehabilitative challenge, hedemonstrated the point aboutlatent motivation.
The amputee riders formed a riding group which participated in competitive trail rides and mountain pack trips. Competing against professional riders, they entered and won many trophies in riding contests. Several now make their living with horses, most notably the triple amputee, who runs his own 3,000-acre ranch and raises and shows quarter horses (fig.58).
FIGURE 58. - Twoamputeesat a gallop on theparade ground at Fitzsimons Army Hospital,July 1968. On the left, a triple amputee (bilateral above-knee plusloss of left arm). On the right,a bilateral above-knee amputee wearing a plaster cast for gunshotfractures of his left upperextremity.
Programs in golfing, dancing, fishing, bowling, and water skiing were also organized by many Fitzsimons personnel who volunteered their free time. Many of the activities were conceived and organized by the patients themselves. Although for obvious reasons bicycling was never popular with the amputees, two below-knee amputees became adept on a tandem bicycle. Many further extended their activities beyond what might seem to be reasonable limits. Several took up skydiving. One bilateral below-knee amputee parachuted regularly wearing his prostheses and also enjoyed mountaineering and rock climbing.
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All these activities had their recreational aspects, but recreation was considered as only an extra enticement to stimulate the patient to push himself beyond what he might have considered his limits. Once started, most of these patients sustained their own momentum toward rehabilitation.
LESSONS LEARNEDAND RECOMMENDATIONS
The complex and pressing rehabilitative needs of the hundreds of amputees hospitalized at Fitzsimons General Hospital led physicians to devote much thought to motivation. This chapter describes the concepts and techniques developed at Fitzsimons in greater detail for the amputee patient than for other types of war wounded, but they are equally applicable to most other patients, regardless of the nature of their wounds. We discovered in dealing with amputees that, as far as levels of motivation were concerned, our patients fit the usual bell-shaped distribution curve, a fact that is much clearer in retrospect than it was at the time. At one extreme were the few so highly motivated to succeed that they did not really need medical personnel to stimulate them. Given the necessary technical support, they would have rehabilitated themselves without our efforts. At the other extreme was that minority of men who were by nature nonachievers on whom our efforts were mostly wasted, men who almost willed themselves to become permanently disabled, both physically and mentally.
Without motivation, the seriously wounded person will not thrive. Low levels of motivation will produce only mediocre levels of recovery, at least in the functional sense. The patient with motivation in abundance, the doer, the achiever--or the individual who can be stimulated to be an achiever--will not only cope with his injury and recover faster but may also overcome during his rehabilitation almost any physical loss his injuries have imposed on him. And since every patient has at least some potential for motivation that can be stimulated to develop and then used in his behalf, those responsible for rehabilitation found recognizing, encouraging, enhancing, and exploiting patients’ motivation potential a real challenge.
The patients who fell between these two extremes would heal, would cope with disability, and would become functional, but would do it better if the surgeon found ways to increase their motivation. Many techniques were used. Some patients responded better to the carrot than to the stick; some needed praise, some bullying. Reward, punishment, cajolery, praise, and constant encouragement were all useful. Our objective was to have the patient develop pride in achievement, to participate in his own recovery, to heal his injuries, and, if not to surmount his disability, then at least to succeed in achieving rehabilitation goals despite that disability.
The key to making the greatest use possible of the patient’s potential for motivation proved to be communication between surgeon and patient. Free communication--a clear explanation of what was wrong with the patient, what he could expect, when he could expect it, and how his own efforts could contribute to his own recovery--increased the patient’s confidence in his physician and served as a stimulus motivating him toward recovery. But to communicate successfully, the physician had to know the patient, his personality traits, his courage, his drive, and his degree of perseverance. In establishing a successful relationship with his patient, the surgeon also learned how to recruit and use allies. The ward nurse, the orderly, the physical thera-
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pist, the occupational therapist (in CONUS),other patients, and thepatient’s family all shared inthe effort to encourage the patient to participate in his own recoveryprocess.
The role of motivation in the recovery process must also be better understood and exploited. Achieving these goals will require theoretical and practical research into the genesis of motivation and a better understanding of behavior modification as applied to returning the wounded soldier to further duty or to a productive civilian role. Our crudely effective attempts at Fitzsimons originated with the managing physician, the military surgeon. Perhaps ways in which these goals could be more effectively attained would be revealed by a better analysis and structuring of our aims and efforts by psychiatrists and psychologists. Such an investigation should start in peacetime; it is too easily relegated to the realm of the theoretical or the “nice to have but not necessary” category when the shooting begins.
The Vietnam War was the first war in history in which the lessons learned about wound management in earlier conflicts were promptly applied from the beginning. This, of course, resulted in the salvage of many lives and extremities which would otherwise have been lost to gas gangrene and other infections, vascular insufficiency, and shock. But the Vietnam War also perpetuated mistakes of policy and omission characteristic of the management of patients in earlier wars, mistakes that undermined patient morale and sabotaged rehabilitation efforts. A number of recommendations should therefore be made concerning the management of the medical aspects of the next war--if the next war should be of a nature to permit the salvage and rehabilitation of the seriously injured casualty. Rehabilitation goals and responsibilities for both the military medical establishment and the Veterans Administration should be defined. A clearer delineation of the mission of military and government medicine is needed, as is a forthright statement—never popular in either political or bureaucratic circles—of responsibility for specific levels of rehabilitation in the psychologic, vocational, functional, and anatomic sense. In short, the mission of each type of hospital should be defined in terms of who does what to whom and with what ultimate goal. The closer to the tactical situation the hospital is, the simpler this definition will be. Conversely, the more removed from the scene of wounding, the more difficult and the more important it is that the hospital’s role in rehabilitation be stated, defined, staffed, and planned.
Although the primary responsibilities of the medical personnel in forward installations will always be preservation of life, support of vital functions, and saving of tissue, all military medical echelons should be indoctrinated in established rehabilitative goals. Because the difficulty and the importance of defining and delegating rehabilitative goals and responsibilities increases with the distance from the scene of injury, the goals that must be achieved to return wounded soldiers to productive function should be publicized throughout both the military and civilian populace, including the political. As a part of this program, there should be a correlative and coordinative effort between military rehabilitation centers and the business and industrial complex.
A mobile consultant in each of the major medical specialties should be designated. This assignment should be viewed as clinical rather than administrative. His duties should include frequent inspections of the chain of evacuation. He should have the authority to effect changes in evacuation policies, although he would, of course, have to coordinate his efforts with the medical regulating officer of The
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Surgeon General’s Office according to bed availability and otherpractical considerations. Thesituation that arose during the Vietnam War, when the orthopedicconsultant to The SurgeonGeneral was the chief of orthopedics at Walter Reed General Hospitaland could not bothdischarge his varied responsibilities at Walter Reed and be attentiveand reactive to orthopedicproblems throughout the Army, should not be permitted to recur.
The chain of evacuation of patients should be reexamined and greater importance given to ultimate patient outcome in the location and staffing of medical installations. Although factors such as distance and the availability of medical facilities and personnel cannot be known in advance of a future conflict, given this country’s total capability, such factors should not be permitted to play as great a role as they did in the Vietnam War, when patient outcome was badly slighted. Multiple transfers should be avoided. Specialized treatment centers should be established, staffed, and supported to accomplish their clearly defined missions, and the patient moved as quickly as his physical condition permits to a definitive hospital for the major portion of his treatment and recovery.
The role of Veterans Administration hospitals must be better defined. When designated as specialized treatment centers, they must be staffed and supported accordingly. Transfer of casualties to the Veterans Administration system should not inflict financial or retirement penalties on the wounded man.
We must examine the role of surgical residency programs during wartime, balancing their advantages and disadvantages to both the individual patient and the Medical Corps as a whole. Modifications of residency training may be necessary, and a better liaison with the surgical specialty accreditation boards would be in order.
Hospital commanders should be charged with the indoctrination of all medical officers in their hospitals in rehabilitative responsibilities and in the need for communication between physician and patient to improve patient education and orientation about his injury and its prognosis for functional recovery. The entire hospital must be geared to this effort, not merely the orthopedic service, as was generally the case during the Korean and Vietnam Wars.
Leave policies for the convalescent patient should be tailored to his rehabilitative program and progress; hospital commanders should be given relative immunity from congressional pressure to implement this policy. Periods of home leave of more than two weeks should be discouraged except for exceptional reasons of compassion.
The recreational rehabilitative techniques developed during the Vietnam War should be examined, improved, enlarged, and implemented. Rehabilitation teams of surgeons, psychiatrists, vocational guidance counselors, and, in some instances, members of the patient’s family could be formed to stimulate and catalyze the patient’s return to useful function. Sound medical care combined with good doctor-patient communication and an overall interest by our government in the ultimate outcome would serve to motivate the majority of war wounded to make the most of what the vagaries of war have left to them.
REFERENCE
Brown, P. W. 1970. Rehabilitation ofbilateral lower-extremity amputees.J. Bone Joint Surg. 52:687-700.
