Some wounded soldiers are choosing amputation

From USA Today:

WASHINGTON — Army 1st Sgt. William “Mike” Leonard (pictured) found himself mourning the left leg that he had agonized for months about keeping. It was in December, just weeks before he would have doctors cut it off.

“There were a couple of nights,” the company sergeant recalls, “where I sat in the shower and just kind of had some tears about losing it.”

But the bomb blast in Afghanistan that had taken his right leg on March 22, 2010, had so damaged the left one that bones stubbornly resisted mending. Standing on the left limb was excruciating. Leonard could see other amputees at Walter Reed Army Medical Center up and running on new, high-tech prosthetics. “Why am I still in a wheelchair?” he asked himself during months of internal debate.

Doctors amputated Leonard’s remaining leg on Jan. 10. Within weeks, he was standing on gleaming new artificial limbs, balancing on bright green Nike Air Max running shoes, and sweating over a hip exercise machine.

“It’s nice to get up and get going finally,” says Leonard, 40.

Wounded soldiers and Marines are making choices about arms and legs that predecessors from earlier wars never had: whether to trade poorly functioning flesh-and-blood for microprocessor-driven substitutes. Advanced prosthetics created to replace limbs lost in battle now are being sought by troops with legs or arms that survived combat, but are not functioning well or are still causing great pain after months or even years of physical therapy.

What doctors call delayed amputations — defined as when limbs are removed three months after an injury — now make up 15% of all combat-related amputations, according to research in Military Medicine published in December. That’s up from a 5% military rate cited in a 2008 analysis in the Journal of Orthopedic Trauma, and far higher than the civilian rate of 3.9%.

Since the wars in Iraq and Afghanistan began, 134 troops — 101 soldiers, 23 Marines, six airmen and four sailors — have chosen to have their limbs removed and replaced with prosthetics months or years after being hurt, according to the Army, Navy and Air Force. The longest period between an injury and an amputation was five years, Army doctors say.

The vast majority involve removing legs rather then arms, the doctors say. The largest number of these surgeries occur here at Walter Reed, with smaller numbers of delayed amputations performed at Brooke Army Medical Center in San Antonio, Naval Medical Center San Diego and Bethesda Naval Medical Center in Maryland.

To avoid giving up too soon on limbs that could be salvaged with time and effort, doctors here have developed an informal protocol for handling such cases, says Army Maj. Benjamin Kyle Potter, an orthopedic surgeon who performs most of these elective amputations.

They encourage patients contemplating amputation to have a lengthy period of reflection and consultation with doctors, physical therapists and other amputees, sometimes lasting weeks or months while they work to improve the damaged limb. Any possible candidate for amputation is required to meet with a mental health specialist. And patients are urged to seek second opinions.

“It’s something that we struggle with consciously and transparently in order to make sure that patients who are considering delayed amputation are doing so for the right reasons,” Potter says. “These kids are 20, 24 years old and you want to make sure that they’re not doing it for the quick fix. ... An amputation is certainly something that is forever. And it’s something that we as a team and I as a surgeon consider very seriously.”

Leonard doesn’t remember the blast.

He vaguely recalls a medic grabbing him by his body armor and urging him to lay down after Leonard apparently was trying to stand on a shattered right leg and damaged left one.

His wife, Cheryl Leonard, back home near Fort Lewis, Wash., recalls it like it was yesterday: the phone call with a curious preamble of questions — “When was the last time you heard from your husband? — before the news was delivered. She furiously scribbled every word into a notebook.

Her husband had survived combat tours to Baghdad and Ramadi in Iraq. Now a company sergeant, he was not supposed to be going out on routine patrols, Cheryl thought. “I’m thinking, ‘This can’t be happening,’ ” she recalls.

It was their third separation caused by war since the two had married in 2003 after — by military standards — a storybook romance.

In 2002, she had been dragged to a recruiting center by her son from a first marriage, who was toying with enlisting in the Navy. The Navy recruiter was out and soldiers in the Army recruiting office nearby, where Mike worked at the time, waved her and her son inside. Mike says he was smitten. The son never enlisted, but Mike and Cheryl began meeting over coffee.

A year later, Mike was so eager to marry her before going to Iraq that they exchanged vows in a phone call — he in Germany and she in an Oregon courthouse, with a judge on a speaker phone. “It was our fairy tale wedding,” Cheryl says.

Early last year before heading to Afghanistan, Mike suddenly raised the issue of what medical care should or should not be taken if he were severely wounded. The result was that he signed papers directing doctors not to resuscitate him if he were left on life support.

He was haunted by one possible outcome, Mike says: “I didn’t want to be a double amputee.”

Cheryl knew this too well when she caught up with her husband in the intensive care ward at Walter Reed after the blast.

She was told that Mike had nearly died. Doctors twice had revived him at an Army hospital in Germany during his transit from Afghanistan. His right leg below the knee was gone. He was unconscious. And doctors were urging her to let them remove Mike’s surviving, damaged lower left leg.

The blast had shattered or even obliterated bones in the left heel and foot. What was left would likely not mend and the pain would be intense if Mike eventually tried walking on it, doctors warned.

But aware of her husband’s worst fear of losing both legs, Cheryl declined. “I told them that he has a high tolerance for pain and I think he needs to be the one to decide,” she recalls.

In a heavily medicated state, Mike was dimly aware of his broken body, Cheryl recalls. At one point, tears streaming down his face, he asked her to have doctors remove his feeding tube and let him die. “Mike, you’re fine,” Cheryl recalls pleading with him. “You’ve taken care of me for many years and so it’s my turn now. So you just heal and get better so we can get back to our lives.”

He also had suffered a traumatic brain injury from the blast. But his head was clearing by late April and early May of last year. “I came out of the haze and fog and started really realizing what was going on,” he says. “I still had my left leg. But I couldn’t use it.”

Depression set in for a few weeks. Mike met with an Army psychologist. And there were infections and more operations on his left foot.

Soldiers in previous wars had the option of amputation for a damaged leg that was not getting any better. But they didn’t have the array of advanced artificial limbs available today: bionic feet fueled by lithium batteries, mechanical legs with microprocessors that anticipate movement and curved carbon-fiber prosthetics that allow high-performance running.

The choice of an artificial alternatives is better than ever.

Fueling the decisions to amputate are the living and rehabilitation environments at the military’s leading hospital. There, amputees work side by side in physical therapy with troops trying to salvage damaged arms or legs.

Every day in the halls of housing complexes or in the rehabilitation centers, service members who are working to save their limbs make comparisons with those who have lost legs and are more rapidly becoming mobile on prosthetics.

“Some, if not most, of our delayed amputations were influenced in their decisions by their frequent interaction with other amputees,” according to published research on the trend by Army doctors.

Doctors say that those patients trying to save their limbs grow frustrated with time.

“(Amputees) are up and walking — potentially running — faster, when a similar person undergoing limb salvage is ... having additional surgeries with months of continued rehab and operations ahead of them,” Potter says.

“I think we’ll see late amputations continuing, the numbers will increase,” says Col. James Ficke, the orthopedic consultant to the Army Surgeon General, who has performed these operations at Brooke. “Because as the injuries occur, and you go through your life (with ongoing pain or lack of function) you’ll finally say, ‘I am tired of this. I want something different.’ ”

Doctors warn that artificial limbs are not free of problems. Research shows that even with advanced prosthetics, the human body will not function as it did before, Potter says. There can be long-term costs — lower back pain and arthritis — that get worse with age.

Even so, patients can be insistent on amputations. A few with elective amputations have manage to return to active duty, doctors say. Ficke says the decision to agree to an amputation can be “gut wrenching” for doctors.

“This is final,” Ficke says of the operation. “I never want a patient coming to me (in the future) and saying, ‘You took my leg off and that was a mistake,and I regret it.’ ”

What tormented Mike Leonard, besides his failure to regain mobility, was how the damage was confined primarily to his left heel and foot, where bones were gone or failing to knit together with time. When he was alone in the shower looking down at the limb, it nearly looked undamaged.

And if he chose amputation, Mike would not simply lose his left foot, doctors told him. To even the stress on his body, they would amputate at the same location where he lost his right leg — about five inches below the knee.

He struggled with a decision for nine months last year. Mike and Cheryl consulted with civilian doctors who were equally pessimistic about his left leg’s recovery.

At best, they told him, he would have a limp and never run again.

“Stairs would be difficult. Uneven terrain would be difficult,” Mike says. “I mean it was just one bad prognosis after another.”

And Cheryl was noticing how Mike enviously watched amputees at Walter Reed active on their prosthetics.

“He was in the wheelchair more often than not,” she recalls, “He said, ‘Honey, I’m a double-amputee already.’ ”

On Friday, Jan. 7, Mike told doctors to take the leg off. Surgery was the next Monday.

“I was really glad (the amputation) was less than a week away,” he says now. “If they had said they would do the operation in March, I probably would have backed out.”