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Friday, December 10, 2010

War needs medicine........ medicine needs war

UK Highway of Heroes
Not all wars are good but the medicine we learn from them have saved millions of lives, have allowed thousands to walk and the advancements on the battlefield and for the returning soldier effects us in a unique way.
War is not pretty or clean but within war if one looks.....there is bravery and sacrifice.  Each soldier sailor and aircrew know this. Each doctor, nurse, medic and rehab specialist know this as well, they see it in the effort soldiers bring to the table in not just trying to survive but trying to succeed.
Medical advancement especially in trauma care comes from the faces of death and those that barely survive war and its after effects.
Just in Canada alone...

1 Field Ambulance was stood up during the Northwest rebellion to help the Canadian militia and their fight against the Metis. Yet the Canadian ideals were already in motion, medical help would be offered to both sides equally. After the battle of Batoche, which ended the rebellion, Doctor Roddick set up a general hospital near the battlefield to treat all the wounded and sick of both sides. To staff it, Doctor Bergin despatched seven volunteer nurses from Ontario, under the leadership of Sister Hannah Grier Combe, a professional nurse and the Mother Superior of the Sisterhood of St. John the Divine.  Even from the beginning there has been a focus on civilian and military partnerships.
The Spanish Civil War a good doctor by the name of Norman Bethune perfected a treatment of doing battlefield transfusion. He died doing what he loved on the battlefields of China working with Mao's troops in fighting the Japanese and General Chiang Kai-shek.
Bethune by Blood Transfusion truck, Spanish Civil War
World War 1 allowed forward aid stations to repair and at times return soldiers that had been wounded.  (PTSD  which they call shell shock was believed to have come from being too close too multiple explosions, now known as a Traumatic Brain Injury, TBI)
World War 2 we saw the concept of front aid post, ambulance relay points and an integrated medical system
Korea saw the creation of Mobile Surgical Hospitals (MASH) and primitive helicopter air medivac.
Helio evac from the front lines to MASH centres
Vietnam, although not part of Canada's foreign policy saw many Canadians served and many lessons were learned. Especially from a PTSD standpoint. (Between 30 000 and 50 000 Canadians served in the US military with 110 killed in action)
Advance first aid in austere environments saved many as did the medivac by the workhorse of the Vietnam war the Huey helicopter.
Gulf War 1 again not a big part of foreign policy many Canadians did serve there.
There mobile ambulance that now not only carried the patient but in themselves became treatment centres.
Gulf War 2 the Canadians saw the benefits of tactical medicine and battlefield hospitals that allow patients to live much longer than ever before.
Gulf War 2 British Ambulance
In many ways the number of people that are dying from wounds has been reduced from a 40to 50% rate in WW1 to more like 1.5% to 1% in the war in Afghanistan.
Advanced front line treatments (called Combat Tactical Casualty Care), immediate medivac by helicopter to a surgical suite that has MRI, CAT scans, a team of specialists and doctors and even rehab facilities for those who are deemed could enough to back to the front line as that is and always will be the best prev enter of PTSD.  PTSD is now recognized but with almost the same symptoms of TBI we have the mental health community in a quandary.  Do you treat the symptoms with PTSD therapy or do you go down a different path.  If drugs and counselling work for one soldiers it may not work for both as the only way to truly know if some has a BI is to have a before and after picture.  Some spec forces are doing just that and can no focus on the treatments that work.  WW1 gave us the term shell shock but here we almost 100 years later and looking at the same ideals.
PTSD can be prevented and I have seen it done in many cases.  For myself I don't have the classic PTSD symptoms but there are some tell tale signs that not everything is right in my head. Over 20% of the front line soldiers have some sort of TBI, and you add in concussions from a military life were controlled explosions are a regular events and sports that involve full contact we are only just beginning to understand what each soldier is bringing to the table. It can take 10 years for the symptoms to even surface in some cases.
I have been telling my story from the beginning of my injury, media, TV, radio, books, etc. That has diffused a situation that for myself could/ should have me in much worse shape than I ever thought possible.  Someday life is hard but its hard for many disabled dudes and I'm just following in those proverbial footsteps.  I just focus on the simple idea that "am i having a abnormal reaction to a normal event and ensuring that if I am involved in an abnormal event I have a normal reaction".
DND has set up some great programs but there will be many that fall through the cracks.
I hate to admit it but many times without war we would never have the medical systems that we have today.  One just has to listen to the experts to really see what is happening, how far we have come and what the future hold not only for the wounded soldier but also for those that are part of their extended families.
Don’t ask me ask the experts:
Major Sean Comstock, CD, M.D., FRCSC
LCol Robert E. Stiegelmar, M.D. FRCSC 

Jackie S. Hebert, M.D., FRCPC, Clinical Director, Adult Amputee Program, Glenrose Rehabilitation Hospital, Associate Professor, Division of Physical Medicine and Rehabilitation, University of Alberta

These articles were written for the Canadian Orothopaedic Association conference in Whistler last year they can be found in Issue 86
Sean Comstock, CD, M.D., FRCSCMajor
Orthopaedic Spine Surgeon

1 Canadian Field Hospital
National Defence

When I was in my final year of residency, a soldier was repatriated home from Afghanistan. He was the first injured soldier to be returned to our institution from that conflict. As I was the senior resident on call that weekend, it fell to me to get him admitted and determine whether or not he needed emergency surgery or was stable. Details were sketchy - all I knew was that he had severe but not life-threatening injuries and would arrive at some point over the weekend. Being a Medical Officer of the Canadian Forces had some advantages. I knew the doctor who was coordinating the transfer, but she knew just as little as I did.
I informed the hospital staff and some resistance was apparent. This patient would need isolation, and a private room. The implications for the operating room were manifest, i.e. final decontamination, difficulty with staffing on a weekend night etc., etc. All of these the common plagues of a modern, publicly-funded hospital. As I heard more and more reasons why this was difficult, and why we can't do it, my thoughts turned to the injured soldier.
I knew he was a reservist, an infantryman in the same regiment I served in before medical school. He was a true volunteer, soldiers in the regular force are expected to serve overseas, those in the reserve may choose to, but are not required. They have other jobs, and pursue other careers. I found myself identifying with this man even before I met him. Like him, years before I had been a reservist and contemplated serving overseas in a different conflict. In fact I was doing work-up training for a tour of duty when I was accepted into medical school. I wondered if he had similar aspirations and goals. There was at least one important difference between him and I, he had been injured in the service of his country.
On the same day that he was injured, six others were killed. They were in the same vehicle. These were members of his section, a group of ten men which comprises the backbone of the Canadian infantry. A section is commanded by a sergeant and three sections make up a platoon, three platoons a company, three companies a battalion. The members of a section live and work together; they rely on one another, literally, for their lives. From the first day of basic training, soldiers are given fire-team partners and organized into sections. Your fire-team and section are everything in the infantry, you get all your orders from your section commander and carry them out with the members of the section, everything from a patrol to find or destroy enemies; a defence to "dig-in" and defend an objective; to a "section-attack" - a frontal assault on an objective such as a machine-gun. Because you train endlessly with these men, they become like brothers, going into combat has been said to solidify this relationship. No one has expressed it better than William Shakespeare:
We few, we happy few, we band of brothers;

For he to-day that sheds his blood with me
Shall be my brother; be he ne'er so vile,
This day shall gentle his condition;
And gentlemen in England now-a-bed
Shall think themselves accurs'd they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin's day.
- Henry V 

I certainly knew nothing about combat, but I was in the infantry long enough to know a little about this brotherhood and it struck me how devastating it would have been to lose six of my brothers.
The day that they were lost was very close to the anniversary of another dark day in the history of the Canadian Forces. In 1917, on a small ridge in a place called Vimy, 3600 Canadian men lost their lives. All of these men were also volunteers, sent to fight in a land overseas, in a conflict that they likely understood just as poorly. They came from all across Canada, boarded ships that brought them to England and then to Europe, and for 3600 on that day in April 1917, their final destination. They were young and just as filled with adventure and duty, but they, like all soldiers before and after, didn't go to war for duty. They didn't go for their country or their God or for pay. They went for each other. I remarked later to my wife, herself a veteran of Afghanistan, how that day in 1917 we lost 600 times as many, and she said six doesn't seem like that many. "That's not what I meant", I told her, each one of those men had a story just as these ones did, and I was trying to get to the devastating loss that Vimy was to a young and much less populous country, how six soldiers seemed an enormous loss, let alone 3600.
With these thoughts in my head, and a very overworked and highly underappreciated staff at my hospital, I had to put things in perspective. I told them that I didn't care about private rooms and resource allocation. We would never endanger other patients, but short of that we will do everything we can to treat this wounded soldier. I said that he is a hero of his country, and we will treat him as such. These comments produced a moment of reflection and pause and completely diffused the situation. He arrived and was treated, the first and certainly not the last. The civilian hospitals that treat these soldiers are unfortunately getting used to them, and they still are coming back.
Support our troops.

Everyone benifits

Role 3 Multinational Medical Unit
surgical care in Kandahar 
LCol Robert E. Stiegelmar, M.D. FRCSC

Edmonton, AB 

As of as of early February 2006, Canada has become the lead nation at the Role 3 Multinational Medical Unit (R3 MMU) Kandahar Air Field (KAF). In civilian terminology, Role 1 is "buddy care" or a first aid provider in the field. In the past, Role 1 care was provided only by medical technicians or "medics"; however, new training encompassing the Tactical Combat Casualty Care (TCCC) has the goal of providing all soldiers with tactically relevant first aid training. Role 2 has been traditionally defined as the "Unit Medical Station" or the UMS, which has been the site where a patient first meets a physician in the chain of evacuation. Role 3 has surgical capabilities but limited holding capacity. Role 4 is back to a hospital in the home country and Role 5 sites are rehabilitation facilities.
The R3 MMU in KAF is a combat casualty trauma centre as well as a referral centre for all Role 1 and 2 facilities in Southern Afghanistan. This multinational unit has a staff of 180 made up of approximately 120 Canadians. Other countries providing medical personal to the Role 3 MMU include: Australia, Denmark, Holland, United Kingdom, and the United States.
Staffing consists of two surgical teams who alternate call. The surgical staff consists of a total of two general surgeons, one or two orthopaedic surgeons, one oral maxillary facial surgeon, and occasionally, a neurosurgeon. The OR staff is completed with two anesthesiologists, five OR nurses/ techs and two or more CSR techs. At times, the Europeans send in a "Trauma Surgeon". These are general surgeons who fix fractures, do thoracotomies and sometimes craniotomies for trauma. Other medical specialties include an internist and, on a variable basis, a radiologist. We try to ensure that one physician in the group has Intensive Care skills.
There are approximately six general practitioners and fortunately some have experience and emergency medicine training. Other support staff include: 20 nurses (4-12 with critical care experience), approximately eight med techs, lab and X-ray techs, and interpreters. In the hospital there are also administrative and support staff which includes an air Medevac cell.
There are two operating rooms. The ortho OR is the "cleaner" theatre and the one that the C-arm fluoroscopy unit can just barely fit. There are 20 to 40 beds and four to six ICU beds.
The laboratory has capability for hematology and chemistry panels. Microbiology is limited to Gram stain and cell counts with no ability to culture. Blood banking is via the Dutch system with limited blood bank, PRBC, plasma, and frozen platelets which may or may not have hemostatic function. The Americans prefer a "walking" blood bank over the Dutch bank.ank.
There is a digital radiography suite with the ability to send radiographs digitally to Canada. When a report is needed, we can call and have a report sent back to us from the radiologist in Halifax if there is no onsite radiologist in KAF. However, we rarely require a radiologist's report because most of us can read our own X-rays and CT Scans. Our two-slice CT scanner has been replaced by a 16-slice scanner which is usually functional. We also have ultrasound, FAST U/S and the C-arm has the ability to do digital subtraction angiography (DSA). The FAST U/S has saved lives by being able to diagnose urgent conditions such as cardiac tamponade.
The environment is harsh with KAF situated in the high desert in southern Afghanistan. Summer daytime temperatures are often greater than 50 degrees Celsius. The sand is fine and dusty (like flour) that permeates everything. Nighttime summer temperatures cool to the mid 30's. There is no appreciable precipitation in the summer. In the winter, however, it is cold and wet, sometimes snowy. In the winter the dry dust of summer turns into muck. I prefer the dry heat over the wet cold.
Flow of Casualties

Information on incoming casualties is received both by radio and secure intranet. Information from multiple casualties is tracked on a wipe off board (known as "The Board") so that all staff can see it and prepare accordingly.

Pre-hospital care includes battlefield care by unit medics and most patients have hemostatic dressings such as Quikclot © or HemoCon ©. Almost everyone has a tourniquet but not everyone has an IV or spine protection. Sometimes trying to start an IV in the field wastes precious time in getting a bleeding soldier to the OR and most patients with GSW (gunshot wounds) or other projectile injuries do not benefit from spine immobilization. When data from this conflict are further analyzed, we will have more information to support this view. Many casualties are received directly from the battlefield, usually airlifted to R3 MMU using US Blackhawk teams, Chinooks, or by ground if very close by.
There is a low threshold for activation of the "Trauma Team" due to the high acuity and severity of injuries. Pre-hospital communication is variable so we expect and plan for the worst and don't complain, but rather are grateful when the Trauma Team gets sent home because we are not needed. The limited holding capacity and frequent unexpected mass casualty scenarios require rapid triage, assessment, treatment and transfer of patients down line to make the system work.

Most of the data is still being analyzed and some of the information is privileged for security reasons, but on average, there are two casualties each day and most go to the OR for a debridement of one or more extremity wounds. For periods of more intense military campaigns or more importantly, increased insurgent activity, the casualty rate can double and frequently there are true mass casualty events where injuries can overrun the system. Most patients (60% to 80%) are local nationals from the Afghan National Army (ANA), Afghan National Police (ANP), or Afghan Border Patrol (ABP). Coalition soldiers receive "damage control surgery". Typically this treatment includes debridement of wounds, fasciotomies, application of external fixators, revision amputations without closure and vascular repair. Typically, patients are Air Medevac'd in 12 to 36 hours - as soon as the patient is stable for transport via CCAT (Critical Care Air Transport), which is a flying ICU. Most Canadians and American casualties are sent and re-assessed at LARMC (Landstuhl Army Medical Centre). Our wounded Canadians are (in theory) to spend five days at LARMC, but typically it is more than a week before they can be repatriated back to Canada. In the US, most of the injured are first sent to Walter Reed Medical Centre, but in Canada, casualties are dispersed depending on their military base of origin. This dispersion raises some issues because many of our military bases are not close to major trauma or rehab centres. LARMC is not a trauma centre and usually does not complete definitive surgery. Almost all repatriated patients dispersed to my facility from LARMC require several debridement and closure and half of the lower extremity fractures require revision surgery.

Afghan forces and local nationals have poor local resources and receive definitive care at the R3 MMU. Long bone fractures get treated with IM nails if indicated. ANA soldiers are able to rehab at ANA hospital but rehab facilities are not structured for ANP or ABP. Civilians are not treated in KAF unless they are casualties of war as a result of coalition interaction, or "Hearts and Minds" cases which require "high level" approval. Most of the senior medical specialists in the military are concerned with doing humanitarian work because of the favoritism it may show for the person or group who "wins the lottery" and the ill feelings that occur when things go bad. Many of these cases are children and our military medical staff have a limited paediatric comfort zone.
Injury patterns have changed during the conflict as the combatants have adjusted their tactics. Originally there were high velocity GSW wounds and later fragment injuries form RPGs and other types of fragmentation projectiles. Currently most of the injuries are from road side Improvised Explosive Devices (IED's) which explode outside an armoured vehicle and result in fewer penetrating injuries but with mangled extremities, spinal compression injuries, and barotrauma.
After looking at the silhouette of a soldier, one can see that 70% of the shadow is extremity; therefore even without body armour, 70% of the injuries are extremity injuries. Ninety percent have musculoskeletal/extremity plus other injury. Seventy percent MSK/extremity alone and 30% have fractures. Ten percent of these extremity injuries are associated with a vascular injury, and ten percent have a nerve injury. For nerve injuries, we wait if the injury was from a GSW because it is usually contused. Early exploration and repair are performed if it is a fragment (low velocity) wound because the nerve is usually lacerated with a smaller zone of injury. In 60 days I personally saw median, radial, ulnar, peroneal, femoral and sciatic nerve injuries.
The Canadian Forces numbers estimate that more than 35 000 have served in the area of operations (Afghanistan and at times Pakistan) from 2001 to 2009. We have 600 WIA (Wounded in Action) and approximately 700 NBI (Non Battle Injuries). A total of 118 members of the Forces have died in Afghanistan or in support of the Afghan operation between February 2002 and April, 24 2009. We have about 25 amputees in the CF - half from battle injuries and half from civilian trauma.
US Global War on Terror (GWOT) data from 2006 (2009 estimate) numbered 3400 (5200) deaths, 40,000 injured (60,000), with 20,000 (30,000) minor and returning to duty. Regarding amputations; 560 (800), however 20% are multiple amputees and 18% have Traumatic Brain Injury (TBI). In 2006, sixty amputees had returned to duty with eight (9?) returning to Iraq. Two are "Iron Men". One is a Special Forces Medic and starts an IV with his prosthetic hand, and also punches his prosthetic hand through walls. Perhaps the full year that amputees spend at Walter Reed for advanced skills rehab allows this high level of function.
In Canada, we have the "Soldier On" program, which treats amputees like athletes and has a Peer Support Program and a link to Para-olympians. We are hoping to facilitate centres of excellence.
It is difficult to tell if we are better at treating war injuries than in the past. It is the intensity of battle and the size of the bombs that have a bigger effect than does the type of dressing or resuscitation. The Taliban often determine the level of conflict. However, 97 - 99% injured in battle survive if they make it to hospital. If the patient makes it to the hospital alive, there is 1 - 3% mortality in hospital. Those are good numbers compared to previous conflicts but most soldiers still die on the battle field.
Lesson We Are Learning: ABC'S of the ATLS © Save Lives
  • Airway management with intubation. Often a surgical airway is needed for GSW to the face.
  • Breathing: chest tubes save lives.
  • Circulation: Ten per cent of the wounded die from bleeding that could be controlled with a tourniquet - not with an IV. If a laparotomy is needed, get the patient to the OR fast. Hypo-tensive resuscitation, if used appropriately, can help prevent the lethal triad of hypothermia, acidosis and coagulopathy.
    • High energy wounds need surgical debridement. HemCon © is better than QuikClot ©. Whole blood is better than Factor VII and a cold patient's blood does not clot.
Afghans are a hardy people and do not seem to get infections easily or do not demonstrate a dramatic inflammatory response. They all have parasites and are malnourished. Their femurs are externally rotated and have an INR = 1.5 or more (I thought that INR was international and normalized?).
I have been asked how I personally feel about my experience in Afghanistan. This is best described by comparing my work there with my job here in Canada. When a trauma patient arrives in KAF, he is greeted by a four member experienced team who spend the next 45 minutes sorting him out. If he needs surgery, he goes there next and then gets admitted to ICU if needed. In Edmonton, patients wait for hours on stretchers in the ER, then we need to find a bed for admission and they wait days to get their surgery. My team in KAF all know the patient and are experienced medical staff. In Edmonton, staff are often in-experienced and do not perform as team members whose goal is care of the patient. In Canada, there appears to be a series of empires we have to navigate through to get our cases done. In KAF, it is the patient who needs the operation, not the surgeon. I feel far less stress in KAF dealing with a mass casualty scenario than being on call at the University of Alberta on a summer long weekend when the trauma/emergency list has 14 patients on the list. In KAF, we will get the cases done - in Edmonton half of my cases will get cancelled. In KAF, we get thanked every day, in Canada, we get complaints every day about wait times.
I cannot explain how it feels to have a soldier, in better shape than a NHL hockey player, brought into the trauma bay by his best friends, vital signs absent with his legs blown off. The next day, he is eating breakfast; all his medical parameters are stable, and he thanks you for amputating his legs and saving his life. 
Does the wounded soldier feel important? 
Do health care consumers in Canada feel important? 
Which one feels like they have received appropriate care?
Are we making a difference? In Taliban times less than 30% were able to read. There was no legal schooling for girls. There was no real health care for women because women could not be educated and male physician could not exam women. Afghanistan has the highest fetal and maternal fatality rate. If a baby is breach, typically both the mother and baby will die. Before, less than one million (600,000?) were in school, now there are more than six million. Some say that if we leave, the first thing they will do is kill the teachers, then the students.
  1. CRS Report for Congress; Order Code RS22452, United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom. Fischer, Hannah. Updated September 9, 2008.
  2. Franklin, MCpl. P. CAS SUPPORT BRIEFING NOTE V2: Actual Casualty Rates for Task Force 1-08. 26 August, 2008, Internal CF BN.
  3. Armed Forces Amputee Patient Care Database, Walter Reed Army Medical Centre, Washington DC. April 2006.
  4. Emergency War Surgery: Third Unites States Revision. Washington DC: United States Government Printing Office, 2004.
  5. Butler Capt F., Hagmann LTC J., Butler ENS G., Tactical Combat Casualty Care in Special Operations, Military Medicine, 161, Suppl:3, 1996.
  6. American War and Military Casualties: List and Statistics. Updated 14 May 2008http://www.fas.org/sgp/crs/natsec/RL32492.pdf.
  7. Bringing Our Wounded Home Safely. Report of the Standing Senate Committee on National Security and Defense. http://www.fas.org/sgp/crs/natsec/RL32492.pdf.
  8. General Statistics - Veterans Affairs Canada J:\afghan talk\General Statistics - Veterans Affairs Canada.
  9. Iraq War Facts, Results and Statistics as of June 09. J:\afghan talk\ Iraq War Facts, Results and Statistics.
        The Wounded Soldier: Rehabilitation and Recovery
        Jackie S. Hebert, M.D., FRCPC

        Clinical Director, Adult Amputee Program, Glenrose Rehabilitation Hospital
        Associate Professor, Division of Physical Medicine and Rehabilitation, University of Alberta
        Edmonton, AB 

        Military patients are unique in the rehabilitation setting. 
        Canadians have been fortunate to have relatively few seriously wounded soldiers as a result of the current conflicts compared to the vast numbers of war wounded in the United States(1). However, the soldiers that do return to Canadian soil with severe life-altering impairments such as major limb amputation require a comprehensive integrated approach to their care.
        An interdisciplinary rehabilitation team focuses on patient-centered care and goals that improve an individual's function, participation, and quality of life. The military patient adds an extra layer of complexity to the already integrated team approach. The injuries sustained are usually multiple, with severe tissue trauma, and have occurred in an "unfavorable" environment. Infections typically require isolation which complicates rehabilitation treatment. The rehabilitation diagnoses are multiple and complex.
        There is a higher incidence of pre-existing mental health issues in soldiers; greater in those returning from combat zones2. The rate of traumatic brain injury (TBI) accompanying all injuries is about eight times the rate of amputation, with mild TBI the most predominant(1), strongly associated with Post Traumatic Stress Disorder (PTSD) and physical health problems after soldiers return home(3). At the time of injury, the seriously wounded soldier is immediately extracted from a war zone, separated from their unit with no decompression and placed under medical and surgical care. The occurrence of stress disorders and other psychological trauma is expected. For this reason, psychology and mental health support needs to be instituted immediately for the wounded soldier; not for diagnosis of PTSD (at this early stage), but for medical management of acute decompression stress and to begin a relationship with a mental health professional who will follow them throughout their recovery and watch for warning signs of mental health deterioration.
        The surgical team treating the wounded soldier must understand that precise surgical technique affects outcome. The soldier will push the limits of what is possible throughout their recovery. Less than a perfect adductor and hamstring myodesis in a transfemoral amputee will result in an uncorrectable truncal lurch when walking that is unacceptable to the wounded soldier. They expect not just to regain perfect gait but also to run. Therefore approaching amputation as true "functional reconstruction" with careful balancing of muscle tension and skin closure is essential, and will greatly impact their physical outcome.
        Surgical and rehabilitation decisions must involve the wounded soldier. Although soldiers are used to authoritative decisions, they need to be fully informed regarding potential consequences of treatment decisions such as limb reconstruction versus amputation. For example, a major latissimus dorsi flap may be a good choice to preserve femoral length in a unilateral transfemoral amputee, but in a bilateral transfemoral amputee that is expected to use a wheelchair and their upper extremities for transfers and daily mobility, it could be a disaster to lose functional latissimus strength. Individual tolerance to a year of multiple procedures for reconstruction versus immediate amputation and moving on to the recovery phase is highly variable. These are very individual decisions that cannot be made without involving the patient, and ideally a rehabilitation practitioner.
        Wounded soldiers work out at Walter Reed Army Medical Centre
        Rehabilitation must be instituted early in acute care. Between surgical procedures, the patient should be started on physical strengthening exercises. Core strengthening, isometrics, and range of motion can prevent complications and prepare the soldier for the hard rehabilitation work ahead. Giving clear guidelines on restrictions and allowed exercise gives the therapists in acute care the permission to start the rehabilitation process, and the soldier the power to start taking control of their recovery. Phases of recovery must be outlined and understood by all military and civilian personnel treating the wounded soldier. (Table 1)
        Table 1: Phases of Amputation Rehabilitation for the Wounded Soldier

        Phase of Rehabilitation
        Essential Tasks
        I. Post Surgical
        • Physiotherapy and mobilization, core strengthening
        • Provide guidelines on restrictions and safe exercise
        • Psychological and peer support
        II. Prosthetic Training
        • 4 - 6 weeks for initial phase of prosthetic training
        • Advanced skills such as running, high impact activities and full functional prosthetic use take an additional 4 - 6 months and up to a year to reach full potential
        • Sporting events and peer support from more active amputees
        • No back to work while in active rehabilitation
        III. Reintegration to normal activities
        • Return to responsibilities of home, family, and community
        • Close monitoring of mental health essential as the soldier is disengaged from the sheltered rehabilitation environment and returns to their life as a changed individual (highest risk time for mental health deterioration)
        • Transitional support needed to prevent feelings of abandonment and isolation
        • Informal interaction with a supportive work environment
        IV. Return to productive activities and roles
        • Must find a meaningful purpose in life; vocational or otherwise
        • Address concerns over "not deployable - not employable" standards (acceptance back into the military family through re-employment or assistance with retraining)
        • Community, family and social roles take on increasing importance
        In Canada, seriously wounded soldiers are integrated into treatment programs that serve Canadian civilians. In this way, the military patients are fortunate to have the experience of a rehabilitation team that sees a concentrated number of patients with a similar diagnosis. A rehabilitation team encourages a person to set individual and life goals, reassess their priorities, and consider how to get maximal fulfillment from their life. Although this approach can give hope, show options, and help a wounded soldier achieve their potential, it can also make it difficult for a soldier to fit back in to the military structure, where rank plays a major role in a soldier's influence on their organization. There is also often encountered a sense of entitlement, not only from the soldier but also from public expectation stemming from our gratitude for their sacrifice, and eventually a sense of betrayal if those expectations are not met. Prosthetic and rehabilitation technology advancements as a direct result of the current conflicts have made lives for persons with multiple impairments dramatically better, but come with a price tag in some cases too high for government budgets. However, both Canadian soldiers and civilians benefit from the massive amounts of funding being invested into research by the US military. It pushes us to provide higher and better levels of care to our patients as we become aware that better technology is available, and we see the improved results of intensive, prolonged rehabilitation treatment.
        Maximizing outcome for a wounded soldier involves a coordinated team approach, setting realistic and appropriate goals, instituting early rehabilitation strategies, and continuing therapy until full functional recovery is attained. 

        The approach must be comprehensive, addressing patient and family psychosocial issues, and coordinated with the military. Physically and functionally, most patients reach their maximum potential at the end of their formal rehabilitation. But recovery is lifelong, with the primary determinant of long-term outcome likely being an individual's mental health and support system. 

        Adjusting to a permanent impairment means finding a meaningful purpose in life and a meaning for their loss, and this is true more so for the wounded soldier than the average civilian.

        1. CRS Report for Congress; Order Code RS22452, United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom. Fischer, Hannah. Updated September 9, 2008
        2. Hoge C.W. et alCombat duty in Iraq and Afghanistan, mental health problems, and barriers to care.NEJM 2004;351:13-22.
        1. Hoge C.W., McGurk D., Thomas J.L., Cox A.L., Engle C.C., Castro C.A. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med 2008;358:453-63.

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