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Back From the Brink — Helping America’s War Wounded
By Matthew Robb, MSW, LCSW-C
Social Work Today
Vol. 6 No. 1 P. 26

Wounded soldiers who may have been lost in past wars have been saved by advanced medical technology. Learning a new way of living is the challenge, and social workers are helping.

While friends back home in Arkansas were celebrating their youth and planning their future, Sgt. Chris Short, 23, was chasing al Qaeda guerrillas across Afghanistan’s war-ravaged moonscape. Usually the Army sniper and team leader find the bad guys first, but on Short’s final mission before returning to American soil, they surprised him.

On March 29, 2005, Short and his team in Charlie Company, Second Battalion, Fifth Infantry Regiment, were en route back to camp, after scouring Afghanistan’s badlands for two rogue Taliban warlords. Earlier that day, they had put the finishing touches on a new school in nearby Deh Rawod.

Short felt good. For a solid year, he had managed to dodge the bullet in Afghanistan’s hottest “hot zone.” In only three days, a helicopter would lift him to freedom.

All seemed well as Sgt. Short drove across a final bridge—until al-Qaeda detonated a “roadside bomb” directly underneath his five-ton, armor-plated Humvee. The improvised explosive device (IED) was huge—two Egyptian antitank mines fused to a 155-millimeter rocket. The explosion ripped through Short’s vehicle, sending a jet of molten fragments and human tissue flying skyward.

In another war, Short would have bled to death. Instead, doctors performed a miracle. But they had to take his right leg to give him back his life. The blast also crippled his left foot, shattered his right arm, injured his left hand, and inflicted acute brain trauma.

Approximately 72 hours later—on April 1—Short was wheeled into Walter Reed Army Medical Center in Washington, DC. Over the past nine months, the Purple Heart recipient has had to relearn how to walk, talk, and dress himself, alongside dozens of other Army and Marine wounded.

Life Over Limb
Just as machine guns evoke the carnage of World War I, the IED defines the gritty theaters of Iraq and Afghanistan today.

According to Lt. Col. Jeff Gambel, MD, MSW, chief of the Walter Reed Amputee Clinic, the use of the IED as a tactical weapon has inflicted unprecedented blast injuries on U.S. servicepersons. News reports note that IED’s account for roughly 60% of all military wounded—double the rate of World War II.

The U.S. military command has responded by beefing up defenses, but enemy combatants have since countered by quadrupling the average IED charge. The bottom line is that, while Kevlar body armor protects vital organs from light weapons’ fire, nothing can stop supersonic blasts from separating limbs from torsos. The catastrophic damage inflicted on soft tissue and bone is enough to give pause to even battle-calloused orthopedic surgeons. One trauma specialist recently commented, “Many of these injuries are devastating to the human torso—simply devastating.”

The IED trend is not encouraging. During the first six months of battle in Iraq, IEDs killed 11 U.S. soldiers compared with 214 killed in action during the same period in 2005. As of December 1, 2005, Walter Reed has treated 308 military amputees—15% of them multiple amputees—among a total patient population of approximately 1,400. “These are not fingers and toes,” Gambel says. “These are major limb amputations.” These statistics are indeed awful, but he notes that the toll of the U.S. Civil War included roughly 50,000 amputees and 620,000 deaths over a similar four-year period.

Despite its horrors, modern warfare has also been a catalyst for breathtaking advances in medical care. Since the 2001 start of the U.S. offensive in Afghanistan, the Department of Defense (DoD) has partnered with private industry to make amputee rehabilitation a top priority. Observers who recall the post-Vietnam era—characterized by crude prosthetics and substandard care—may be forgiven their skepticism. But an otherwise divided Congress in 2004 allocated nearly $35 million to the upgrading of prosthetic arms alone. The goal is to make electromechanical devices that look, feel, and function almost like the real thing. “We are on the cutting edge of amputee care. It’s a different story from even the Gulf I [war] years,” says Gambel.

The military’s focus on quality of life has major implications for the men and women of Ward 57, the hospital’s main orthopedics and rehabilitation ward. Whereas the typical civilian amputee is a 70-ish person with diabetes, Walter Reed’s “tactical athlete-warriors” are likely to live another half century and hope to resume a life of walking, running, and possibly team or competitive sports. By funding better care and research, the DoD reaps a side benefit: higher retention of skilled servicepersons.

However, quality costs. The computer-controlled leg allowing Short to walk from his studio apartment to a physical therapy session and then to the mess hall carries a $50,000 price tag, while sophisticated myoelectric arms and hands cost upward of $70,000.

“Our lower-extremity amputees,” Gambel says, “get several prostheses: A daily prosthesis for walking on even terrain and such, a running prosthesis, and a water prosthesis for use in a shower or swimming pool or at the beach.” Upper-extremity amputees can choose from an assortment of prosthetic attachments geared to their personal, recreational, and occupational needs.

“We use a lot of high technology,” Gambel says, “but we don’t specifically look for high-tech solutions. We’re aiming for right-tech solutions tailored to individual needs.” Some prostheses are driven by microchips or cables. Others are purely cosmetic but resemble works of art. “We bring in skilled artists who actually duplicate skin color, tone, hair pattern, and nail pattern,” he says.

The Veterans Administration (VA) presides over a sprawling empire of some 55 prosthetics labs, 150 “prosthetists,” and will spend nearly $53 million on artificial limbs in 2006. Since its inception, the VA has fitted an estimated 20,000 prostheses—a clear sign that the military’s mission is unlike any other. Visitors to the lobby of Walter Reed’s main hospital are reminded of this by medical personnel garbed in battle camouflage and an overhead sign that resolutely declares, “We provide warrior care.”

Mission: Rehab
While computer-controlled limbs garner much attention from the media, Gambel says recent strides in rehabilitation technologies are equally critical to patient recovery.

Improved surgical technologies for wound management better prepare the patient’s residual limb (or stump) for optimal healing and fitting of a prosthetic. Better pain management enhances comfort while allowing earlier and more aggressive “engagement” of physical therapy and occupational therapy.

Recovering from major blast injuries is often an arduous journey—for patient, family, and medical staff alike. An infantryman once blessed with an elite physiology may suddenly find himself struggling to take his first shaky steps at the parallel bars. Before wounded soldiers can run again, they typically need help with activities of daily living. Excruciating phantom limb pains radiating from severed nerves can overwhelm even the most stoic Marine. As the patient’s residual limb continues to shrink and reshape, adjustments are needed to the prosthetic socket.

While rehabilitation protocols tend to be “aggressive” and patient recoveries relatively rapid, Gambel says war-wounded soldiers must often learn to pace themselves. Seeing other servicepersons doing advanced activities and believing themselves lagging behind, newer patients may believe they are hardly making inroads, when instead their progress is “often miraculous,” he says.

Day outings slowly reintegrate soldiers with the world at large. Some days, they test their fine-motor skills at a firing range or shooting skeet. Other days, they may visit a shopping mall or museum. Gambel notes that an active group of peer-amputee visitors meets as soon as possible with new patients and families. There, he says, “they provide support and show by example that it is possible to move from the suffering of initial trauma to thriving with a full life again.” Trained and certified by the Amputee Coalition of America, these volunteers often receive from patients the highest satisfaction ratings among the entire healthcare team.

On Ward 57, shared battlefield experiences deepen esprit de corps and find a tightly knit brotherhood rallying each other through dark moments and physical setbacks. When counseling is indicated, they have ready access to a skilled team of psychiatrists, psychologists, social workers, and chaplains.

Depending on severity of injury, discharge may occur days, weeks, months, or more than one year after intake. In some cases, transition to another facility marks yet another chapter in an ongoing story—a story whose ending has not yet been written. In mid-November, Short underwent surgery to remove two screws from his knee. In early 2006, surgeons will remove abnormal calcification from his shattered elbow to help restore range of motion in his dominant arm.

Short acknowledges that his ground-pounding fortitude isn’t universal among the battle-shattered warriors of Ward 57. During the past Thanksgiving holiday, he reunited with family in Little Rock and went duck hunting with buddies. Recalling one golden morning with a chuckle, he says, “I went deer hunting and even used a climbing deer stand to climb up into a tree.”

On March 29, 2005, the notion of Chris Short ever going deer hunting again would have seemed preposterous. Today, he’s confident he will someday run again.

“He has an amazing attitude,” observes his mother, Deborah Short. “He’s always been very competitive, positive, and determined. My son doesn’t let anything stop him.”

Competitive, positive, and determined, yes. But all men are mortal and nine months after a blast trauma nearly killed him, Chris admits to his own emotional hurdles.

“At first,” he says, “it was really hard for me. I was keeping it all pent up inside. But I started going to these Thursday group meetings, where we could talk about whatever was on our minds and nothing would leave the room. It helps a lot to talk to guys who have done the same.”

Deborah nods. “At the very beginning, Chris had issues with post-traumatic stress. He tended to overreact easily and get really emotional, such as in traffic jams.” But Deborah herself has witnessed the transformative powers of the group—of universality, shared adversity, and hope—to bring out the best in each person. “His platoon buddies returned from Afghanistan and came to see him, which was a wonderful thing” she recalls. “Those guys really bonded over there, which isn’t surprising given the adversity they went through together.”

Reflecting on that terrible day in March, Chris says, “I don’t replay over and over the explosion in my mind. I remember bits and pieces before and afterward, but it’s kind of flashy. I remember going across the bridge—and then it was lights out for a minute. Next, I remember laying there and telling my buddy who was carrying me to the medevac helicopter, to get off my legs. Of course, he wasn’t on them. It was just that my leg was twisted sideways.” Haltingly, he adds, “But what I do replay are some of the incidents from when my friends got clipped. I think about them, but I don’t … dwell on them.”

Chris notes that some of Ward 57’s amputees are women—some of them double amputees. “One of them was a helicopter pilot—a Major convoying to a fire base in Kuwait, when she got hit by a rocket-propelled grenade.” They, too, must work through their own unique emotional issues.

Enter the Social Worker
Crippling, sometimes disfiguring, injuries are hard on soldiers and families alike, says Brenda Butler, LCSW-C, a Walter Reed social worker. When a parent begins to fully comprehend that a child may live the remainder of his or her life with extreme facial disfigurement or be unable to produce children, the reaction can be overwhelming grief.

“For most families,” Butler says, “this will be the biggest challenge and the biggest healing process they will ever see.” Among the critical issues the family must contend with is “adjusting to the fact that, with most of these injuries, life as they knew it with this person has forever changed.”

“Family members,” she says, “often approach the injured [serviceperson] as how he or she used to be. Part of recovery means letting go of that person as they used to be, whether they are missing a limb or have a significant brain injury. It’s as if the whole family has been injured and the whole family must now recover and move on.” Pausing, Butler adds, “We see the entire systems perspective here at Walter Reed.”

Butler and fellow social worker Grizell Blessing, LICSW, note that the war-related injuries at Walter Reed go well beyond amputated limbs. Among blast victims evaluated at Walter Reed during a two-year period ending in February 2005, 60% (or roughly 450 servicepersons) were diagnosed with traumatic brain injuries—usually mild. Sadly, treatment for this perplexing condition remains in its infancy, leaving some of its moderately to severely injured victims struggling with what may be a permanent disability.

The VA’s monumental task must provide lifelong care to young veterans likely to live a normal lifespan, without compromising the flagship treatment they initially received from institutions such as Walter Reed.

As a social worker from the Department of Veterans Affairs and a VA/DoD liaison with Walter Reed, Brenda Faas, MSW, is integral to the military’s “Seamless Transition Program.” Part of her job entails reassuring soldiers and swatting down old stereotypes. “We tell patients this isn’t your grandfather’s VA,” she says. “The VA has truly put a great effort into making things right and providing a huge array of quality services.

“My job,” she says, “is to help both servicepersons and families through an emotionally difficult, sometimes scary, transition. Many servicepersons had planned on making the military a long, satisfying career. Some had put in 10, maybe 15 years. Now they are wondering what the future might hold. As a social worker, I try to help decrease the frustration and uncertainty that’s part of transitioning into any new healthcare system. I use my clinical social work skills as a liaison, even though my duties may not fit into a clinical social work role.”

At any given moment, Faas may be helping transition an active duty amputee into a polytrauma center or spinal cord injury center. She also helps assist patients who are transitioning out of the military and into civilian life as a veteran. But not all servicepersons opt to leave. Gambel notes that approximately 15% of injured servicepersons seek to return—or have returned—to active duty. In such cases, the service branches provide training to acquire new skills.

Blessing, embracing a strengths perspective, expresses her admiration for military families. “They form such great support networks for one another,” she says. “These injuries rearrange lives, but we see families coming together over terrible adversity and finding strength in a moment of great uncertainty and upheaval.” By getting everyone involved in the recovery, she says, “it gives the wounded a needed sense of ownership and self-control.”

Deborah Short expresses unqualified gratitude to the medical staff at Walter Reed. “It’s amazing what these professionals have done for my son and the other soldiers,” she says. “Their ability to care for them and put them back together is just phenomenal. I’ve never seen anything like it.”

— Matthew Robb, MSW, LCSW-C, is a social worker and freelance writer residing in suburban Washington, DC.

Up Close With Jeff Gambel, MD
If Jeff Gambel, MD, seems unusually informed about the world of social work, there’s a good reason for it. After undergraduate school, he worked for seven years at a large urban hospital in Detroit as a University of Michigan-trained hospital social worker.

Recalling those early years, he says with a smile, “I had a great experience and remain very fond of my years as a practicing social worker.”

People sometimes ask him about his transition from social worker to physician to military officer, but he describes the career shift as “pretty straightforward.”

“Many of the best parts of being a social worker are really also part of effective clinical practice as a physician,” he says. “The social worker’s bedrock values, communication skills, and ability to match client needs with community resources have been tremendous aids to me as a U.S. Army physician. Yes, these elements are definitely part of medical education, but the sharpened focus on them as part of social work education and daily social work practice have made a critical difference.

“My entry into the Physical Medicine & Rehabilitation [PM & R] specialty was also natural for me. Both PMR and social work share common ground—to help individuals and families reach and maintain their highest levels of function within the lifestyle of their choosing.

“When I started out, I was amazed to find out about the rich training and worldwide practice opportunities available in military medicine,” he says. “The fact that I’m now nearing retirement as an Army physician is a testament to the tremendous experiences I have had.”

— MR