1

Introduction: Developing a System of Care for the Combat Amputee

Chapter 1

INTRODUCTION: DEVELOPING A 

SYSTEM OF CARE FOR THE COMBAT 

AMPUTEE

PAUL F. PASQUINA, MD*; CHARLES R. SCOVILLE, DPT†; BRIAN BELNAP, DO‡; and RORY A. COOPER, PhD§

INTRODUCTION 

THE MILITARY HEALTH SYSTEM

HISTORICAL LESSONS LEARNED IN COMBAT AMPUTEE CARE

DEVELOPING AN AMPUTEE PROGRAM WITHIN THE DEPARTMENT OF DEFENSE

KEY ELEMENTS OF A COMPREHENSIVE AMPUTEE CARE PROGRAM

Organizational Structure

Teamwork

Staffing Ratios

Graduate Medical Education

Continuing Education

Database

Prevention Programs 

Surgical Considerations

Medical Management

Pain Management

Advances in Prosthetics

Peer and Psychosocial Support Programs 

Military Medical Disability System

Outcome Measures

CONCLUSION

*Colonel, Medical Corps, US Army; Chair, Integrated Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center and National 

Naval Medical Center, Section 3J, 6900 Georgia Avenue, NW, Washington, DC 20307

† Colonel (Retired), Medical Service Corps, US Army; Chief, Integrated Amputee Service, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307

‡ Major, Medical Corps, US Army; Medical Director, Amputee Program, Comprehensive Combat and Complex Casualty Care, Naval Medical Center, 

34800 Bob Wilson Drive, San Diego, California 92134

§ Senior Career Scientist, US Department of Veterans Affairs, and Distinguished Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, 5044 Forbes Tower, Pittsburgh, Pennsylvania 15260
2

Care of the Combat Amputee

INTRODUCTION

For many Americans, the world changed forever on September 11, 2001, when Islamic extremists 

crashed hijacked commercial airliners into the World 

Trade Center in New York City, into the Pentagon, and 

over rural Pennsylvania. In response to these terrorist 

attacks the president of the United States launched 

a new war, the global war on terror (GWOT). Soon 

afterward, military operations were initiated in Afghanistan, on October 7, 2001 (Operation Enduring 

Freedom [OEF]), followed by the invasion of Iraq on 

March 19, 2003 (Operation Iraqi Freedom [OIF]). Conducting war against terrorism has proven extremely 

challenging for US military forces and costly for service members and their families. To date, thousands 

of young Americans’ lives have been lost and even 

more have sustained serious physical, emotional, and 

psychological injury, although advances in military 

medicine have contributed greatly to reducing morbidity and mortality. Improved body armor, advanced 

capabilities of field medics, forward area resuscitation and surgery, and sophisticated and rapid medical evacuation have all contributed to widespread 

survival of injuries that would have been fatal in 

previous wars. 

Caring for returning service members with complex 

polytrauma injuries necessitated flexibility within the 

Military Health System (MHS) and the Department of 

Veterans Affairs (VA). Multiple programs needed to be 

established or upgraded to ensure a well-coordinated 

system of care to address the needs of injured service 

members and their families across the entire continuum of care. In particular, given the large numbers 

of casualties with severe limb trauma and amputation, an amputee patient care program needed to be 

established within the Department of Defense (DoD). 

This chapter will document the need for this program 

within the framework of the core mission and values 

of the MHS. It will also highlight important lessons 

learned during OIF and OEF within the context of lessons from prior wars and examine the key components 

of a successful program.

Over the past decade, a cultural shift has occurred 

within the military giving individuals with major limb 

amputation the opportunity to stay in active duty service. Advances in medical, surgical, and rehabilitative 

care, as well as prosthetic design, are helping individuals achieve this goal. Whether or not the soldier desires 

or has the ability to remain in active duty service, DoD 

and VA programs are committed to helping all combat 

amputees reach their maximal function and return to 

the highest possible quality of life. 

Traditionally a textbook of this nature would not 

be written until the completion of military operations. 

This schedule normally allows historians, scientists, 

and clinicians to formulate their thoughts collectively 

in a time of peace. Unfortunately, despite over 7 years 

of active combat, the GWOT continues, military service members remain in harm’s way, and casualties 

continue presenting to the MHS. The DoD and VA 

leadership contributing to this textbook, therefore, 

saw the need to capture the lessons learned to date to 

facilitate ongoing care and planning. 

THE MILITARY HEALTH SYSTEM

The MHS is entrusted by the DoD to accomplish 

five core missions in support of US service members, 

who are asked by their nation to risk their lives, 

whether in response to natural disasters or threats to 

national security. While each mission of the MHS may 

be distinct, they are interrelated and their synergistic 

effect contributes greatly to the overall strength and 

effectiveness of US fighting forces. These missions are 

summarized as follows:

1. Combat casualty care.

1

 Unique to the MHS 

mission is the treatment of combat casualties. On the battlefield, care begins with 

basic first aid provided by well-trained 

nonmedical service members as well as 

trained combat lifesavers. The military has 

established five levels of care for wounded 

service members. For minor wounds, patients are treated and returned to duty. For 

injuries not conducive to immediate return 

to duty, evacuation to the next level of care 

is warranted. Depending on the nature and 

extent of the injury, service members may 

skip one or more levels of care to expedite 

immediate medical attention. Because of 

the capability to rapidly evacuate, medical 

care in theater is limited to life- and limbsaving procedures. Military surgeons focus 

their attention on stopping and preventing 

hemorrhage, debriding wounds to prevent 

infection, and preserving function. Often 

decisions about whether to reconstruct or 

amputate a limb are reserved for level V care 

within the continental United States treatment areas. The levels of care are categorized 

as follows:
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Introduction: Developing a System of Care for the Combat Amputee

	 	 •	 Level I: Immediate first aid and lifesaving measures are initiated in theater by 

Army combat medics, Navy corpsmen, 

and Air Force pararescuemen. Each service 

member carries a one-handed tourniquet, 

which may be applied by any member of 

the unit. Evacuation is then made to either 

an Army battalion aid station or Navy/

Marine Corps shock trauma platoon, where 

initial resuscitation and advanced trauma 

life support is initiated. If an injured service 

member requires surgical resuscitation, he 

or she will often bypass the aid station and 

go directly to level II or III care.

	 	 •	 LevelII: This is the first level of care where 

surgical resuscitation, basic laboratory, and 

radiographic capabilities exist. The Army 

forward surgical team is typically found at 

this level together with a medical company, 

which has two operating tables and holds 

up to 40 beds, with a holding capacity of 

approximately 72 hours. These medical 

units are 100% mobile and can provide 

up to 30 resuscitative surgical operations 

without resupply. The team is composed 

of one orthopaedic surgeon, three general surgeons, two nurse anesthetists, one 

critical care nurse, and additional nursing 

staff. Navy/Marine Corps level II care is 

provided by either a surgical company or a 

forward resuscitative surgical system. The 

surgical company can support ongoing operations without resupply to sustain four 

operating tables and a 60-bed capacity for 

up to 72 hours. The forward resuscitative 

surgical system is a smaller, more mobile 

unit, composed of only nine to ten personnel who can treat up to 18 casualties in 

48 hours, but the system has no holding 

capacity. The US Air Force has several different level-II–capable units. The mobile 

field surgical team, which can provide up 

to 10 surgical stabilization procedures in 

24 to 48 hours, is often combined with a 

small, portable, expeditionary aeromedical 

rapid response team composed of 10 members. The expeditionary medical support 

(EMEDS) basic is a 25-member team with 

one operating table and four holding beds. 

Lastly, the EMEDS+10 is a 56-person team 

with an additional 10 beds. Because of the 

high mobility of level II medical units, they 

are assigned to tactical units and are critical 

in a rapidly moving battlefield.

	 	 •	 Level III: This is the highest level of medical and surgical care available within the 

combat area of operation. Level III hospitals are modular, allowing adaptability to a 

given tactical situation. Army level III care 

is provided at the combat support hospital 

(CSH), which is composed of up to 248 

beds, made up of a 164-bed unit combined 

with an 84-bed hospital company that 

can split off and act independently. The 

combined CSH has six operating tables, 48 

intensive care unit beds, and 200 holding 

beds and covers up to 5.7 acres. In addition 

to laboratory and radiographic capabilities, the CSH also has a blood bank, a full 

complement of surgical subspecialties, 

and physical therapy capabilities. Level 

III care for the Navy and Marine Corps 

is provided by the fleet hospital. These 

hospitals comprise 1,000 personnel, six operating rooms, 80 intensive care unit beds, 

and 500 other beds. Fleet hospitals are also 

modular to accommodate various tactical 

situations. The Navy also has two hospital 

ships, which may act as level III or level IV 

facilities, with 100 intensive care unit beds, 

1,000 other beds, and 12 operating rooms 

each. The US Air Force theater hospital is 

similar in capability to the Army CSH.

	 	 •	 Level IV: This echelon of care is located 

outside the combat zone and may be 

provided by a CSH, a fleet hospital, or a 

fixed medical facility. During OEF/OIF, 

most level IV care has been provided at 

Landstuhl Regional Medical Center in 

Germany. At Landstuhl, injuries are further 

assessed, irrigated, and debrided. Definitive surgeries, especially amputations, are 

still generally reserved for level V facilities. 

Patients with severe injuries are usually 

held less than 72 hours before proceeding 

to the next echelon of care. Casualties with 

less severe injuries may be able to return to 

the combat zone from this level.

	 	 •	 Level V: This echelon of care is provided 

within the continental United States at 

fixed military medical treatment facilities 

(MTFs). Although every effort is made to 

evacuate injured service members to an 

MTF closest to their home duty stations, it 

is more important for individuals to be sent 

to the facility capable of providing the most 

appropriate care. For example, all burn 

patients, regardless of military service, are 
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Care of the Combat Amputee

evacuated to the burn center of excellence 

at Brooke Army Medical Center (BAMC) 

in San Antonio, Texas. For service members 

with amputations, centers of excellence 

have also been established at Walter Reed 

Army Medical Center (WRAMC) in Washington, DC, and Balboa Naval Medical 

Center in San Diego, California, to provide 

expert care more conducive to family and 

service member travel, and less disruptive 

of family life.

	 	 •	 Level VI: This echelon of care primarily 

refers to rehabilitation units within the VA 

system of care; however, the relationship 

between the VA and DoD continues to 

evolve, with increasing levels of collaboration as more and more injured service 

members receive care in both systems. It 

is important to note that prior to OIF and 

OEF the Veterans Health Administration 

had well-established rehabilitation centers 

for individuals with spinal cord injury, 

brain injury, blindness, and limb amputation. Over the past decade, however, most 

amputee care in the VA system involved 

disease-related amputations such as those 

seen with vascular disease or diabetes, in 

contrast to the traumatic amputations in 

younger service members currently returning from OEF and OIF. This situation, 

coupled with the desire of some service 

members to return to active duty following limb amputation, led DoD to create 

comprehensive amputee care programs 

within MTFs that cooperate with VA care, 

especially in the areas of long-term care, 

veterans’ benefits, recreation therapy, and 

the VA prosthetics and sensory aides service.

2. Healthcare services to active duty and 

military beneficiaries. Despite the attention 

given to care of combat casualties, military 

healthcare professionals also provide stateof-the-art primary, secondary, and tertiary 

care to military beneficiaries in a variety of 

healthcare settings across the globe. Beneficiaries receive the highest quality of preventive, medical, surgical, and rehabilitative care 

independent of age or military rank. Pediatric 

services for dependent children as well as 

world-class healthcare options for dependent 

spouses and retirees are equally important 

missions in preserving the fighting strength 

and in attaining recruitment goals within the 

DoD. For service members deployed to remote locations, the security of knowing their 

loved ones will receive the best of care allows 

them to remain mission-focused no matter 

where they may be deployed. To provide 

these services, most MTFs are staffed with 

medical professionals in virtually all specialties ranging from pediatrics to geriatrics. In 

addition, the military has partnered with civilian organizations in forming the TRICARE 

network throughout the continental United 

States to augment medical services not available within the MTF. 

3. Military readiness. In addition to ensuring that medical providers are available to 

deploy in support of military missions at a 

moment’s notice across the globe, the MHS 

is also responsible for ensuring that military 

combat and combat-support personnel are in 

good health to deploy. These services include 

health maintenance, dental care, immunizations, and medical clearance and assessment 

during premobilization and postmobilization. This mission is particularly challenging 

for the relatively high number of National 

Guard and reserve soldiers currently being 

deployed overseas in support of GWOT. 

Various mobilization/demobilization centers have been established across the United 

States, which receive staff and logistical support from the MHS.

4. Health education. A robust educational 

program is a fundamental component of 

the MHS. High-quality training and continuing education are needed to ensure 

that the highest quality of care is delivered 

to military beneficiaries. Over a hundred 

accredited teaching programs exist within 

MTFs in nearly all medical specialties and 

across various healthcare disciplines (eg, 

physicians, nursing, therapists, field medics). 

Professional skills and expertise to optimally 

treat the unique healthcare needs of service 

members are taught. Experience during OEF 

and OIF has demonstrated the critical impact 

that graduate medical educational (GME) 

programs have had in providing the finest 

care to service members, particularly those 

with combat injuries. Ongoing educational 

programs that include military-specific curricula have allowed military facilities to stay 

current with state-of-the-art medical, surgical, and rehabilitative care. 
5

Introduction: Developing a System of Care for the Combat Amputee

 Examples of this impact can be found 

throughout the DoD. Practitioners in surgical subspecialties such as orthopaedics and 

vascular, general, and plastic surgery, by 

continuing training in combat trauma care 

even in times of peace, were prepared to 

deliver life-saving care immediately upon 

the onset of operations in Afghanistan. The 

physical medicine and rehabilitation (PM&R) 

residency program at WRAMC and the National Naval Medical Center in Bethesda, 

Maryland, through its emphasis on teaching 

rehabilitation principles for severely injured 

service members with polytrauma, spinal 

cord injury, traumatic brain injury, and major 

limb amputation, produced graduates prepared to help create a system of care for the 

combat amputee. Air Force training programs 

and staffing of critical care air transport teams 

have revolutionized air medical evacuation 

during OIF/OEF.2 Intense teaching programs 

to enhance the skills of combat medics offered through the Tactical Combat Casualty 

Course at the Army Medical Department’s 

Center and School at Fort Sam Houston in 

San Antonio continue to help save lives on 

the battlefield. Furthermore, physical and 

occupational therapy programs at the Center 

and School have continued to produce leaders within these fields, enhancing the capacity 

of the MHS to deliver comprehensive care for 

wounded warriors and their families. 

5. Biomedical research. The DoD’s investment 

in biomedical research has made a major 

contribution to the current 90% survival rate 

for US service members wounded in Iraq 

and Afghanistan. Pioneering efforts such as 

Major Walter Reed’s research to unravel the 

cause of yellow fever have paved the way for 

generations of military medical researchers, 

scientists, and engineers to explore ways to 

save lives and reduce morbidity. Transitioning research discoveries into clinical practice 

is an extremely challenging process, requiring 

rigorous studies to demonstrate safety and 

efficacy, while complying with the regulatory 

statues of such entities as institutional review 

boards and the Food and Drug Administration. Examples of the military’s commitment 

to this achievement include the development 

and deployment of the smallpox and anthrax 

vaccines as well as recently developed clotting bandages to help control hemorrhage 

on the battlefield.3,4 Even simple discoveries such as improved field dressings and 

tourniquets have revolutionized battlefield 

medicine and continue to save lives.5 To keep 

pace with the technological advances on the 

battlefield, the MHS must continue to explore 

new technologies to meet the needs of not 

just today’s injured soldiers but those of the 

future. This requires continued partnerships 

between DoD, VA, and civilian academic 

institutions and industries.

HISTORICAL LESSONS LEARNED IN COMBAT AMPUTEE CARE

As described in his 1972 autobiography, A World to 

Care For: The Autobiography of Howard A. Rusk. MD,

6

Dr Howard Rusk volunteered for military service 

in 1942, was commissioned as a major, and served 

as director of the Army Air Corps convalescent and 

rehabilitation services during World War II. Dr Rusk 

quickly recognized that a large number of soldiers 

in military hospitals did not need full-time medical 

care, but remained unready for the rigors of returning to their units. Therefore, he began a program of 

“constructive training” that included physical conditioning exercises, practical courses taught within the 

hospital (for example, he hung model aircraft from 

the ceilings in the wards and had patients practice 

recognizing various airplanes, and later introduced 

courses such as trigonometry, calculus, and American 

history), and preparing soldiers for return to duty 

either in their original military occupational specialty 

or a new one. Dr Rusk convinced President Franklin 

D Roosevelt to create a comprehensive rehabilitation 

program within the Army, stating, “the country owed 

‘him’ [the wounded soldier] more than just an artificial 

leg, a discharge and the Purple Heart.” The program 

had the goals of

	 •	 returning soldiers to physical and mental

health,

	 •	 finding ways for soldiers to function despite

their disabilities,

	 •	 helping the Army and Army Air Corps preserve all the personnel possible by sending 

soldiers back to duty in the best possible 

condition in the shortest time,

	 •	 helping soldiers no longer capable of doing

their previous military job to choose new jobs 

in the military and retraining them.

The Army and Army Air Corps initially created 
6

Care of the Combat Amputee

two specialty amputee rehabilitation programs: one 

in Pawling, New York, and the other at Walter Reed 

Army Hospital. 

In addition to the new rehabilitation program, 

World War II saw an improved military effort to provide advanced prostheses. Before the war, military 

policy had been to stabilize soldiers with major limb 

amputations and provide them with temporary limbs; 

after discharge from military service, they were fitted 

by the VA with durable permanent limbs. To preserve 

the fighting force, Henry (“Hap”) Arnold, commanding general of the Army Air Corps, ordered the Army 

surgeon general to provide the highest quality artificial 

limbs available and to begin a prosthetics research program. With General Arnold’s urging, Congress passed 

the first prosthetics research bill, in 1943, to develop 

scientifically sound and workable artificial arms. This 

was the beginning of the Army’s formal rehabilitation 

clinical care and research program for soldiers with 

major limb amputations. 

By the end of World War II, with 18,000 amputations 

across all branches of the military, full-scale efforts to 

create better prosthetic limbs and improve amputee 

care were in place. By 1945 engineers and physicians 

working together had created the best prosthetic arm 

up to that time, which was demonstrated by a group 

of soldiers for President Harry S Truman at the White 

House. In 1946 President Truman appointed General 

Omar Bradley to head the Veterans Administration and 

bring about its transformation so that veterans would 

receive high-quality care and the latest technology. 

One of General Bradley’s accomplishments was to follow the National Research Council recommendation 

to locate VA hospitals near medical schools to share 

resources. Paul B Magnuson, MD, an Army physician 

in World War I, became medical director of the VA and 

was largely responsible for the current structure of VA 

medical care.7

The Vietnam War brought further advances to military amputee care. Paul W Brown, a retired colonel, had 

served as an enlisted soldier in World War II and then as 

a medical officer during the Korean War before becoming a senior orthopaedic surgeon at Fitzsimons General 

Hospital in Denver, Colorado, during the Vietnam War. 

His article, “Rehabilitation of the Combat-Wounded 

Amputee,” published by the Army Surgeon General’s 

Office in 1994, provided insights in the principles and 

practice of combat amputee care.8 Dr Brown recognized 

that the key to a successful program lay in tapping into 

and facilitating the “motivation” of the soldier/patient. 

His observations and lessons learned during Vietnam 

can be summarized as follows:

	 •	 Create centers of excellence. It became clear 

during the Vietnam War that amputations 

occurring as a result of combat wounds required specialized care, which an institution 

could establish only by seeing a high volume 

of patients. This care was recognized as more 

important than expediting a soldier’s return 

to his or her hometown. According to Dr 

Brown, “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.”8(p209) It was also observed that excellence in care could only be achieved with 

continuing education for practitioners, including active military GME training programs.

	 •	 Incorporate rehabilitation principles early. 

Orthopaedic surgeons observed during 

Vietnam that no matter how competent their 

surgical skills were, patient outcomes depended most on patient motivation, which 

was enhanced through early rehabilitation. 

The paradigm of waiting for all medical and 

surgical issues to be resolved before beginning 

rehabilitation was unsuccessful. Rather, rehabilitation principles needed to be incorporated 

into the treatment process as early as possible 

in the patient’s continuum of care.

	 •	 Limit convalescent leave. Because of the long 

and protracted medical evacuation process 

during Vietnam, which often took several 

months, many injured service members immediately requested convalescent leave to 

return home to see their loved ones. This leave 

often created an unanticipated negative effect: 

injured service members who returned home 

prior to fully engaging in the rehabilitation 

process and not yet independent in many 

skills were observed to fall into a dependent 

role within their families, relying on others 

for bathing, feeding, mobility, and basic hygiene. Despite the families’ best intentions, 

this dependency had a negative psychological 

impact on the soldiers, who often were never 

able to reengage in the rehabilitative process 

of achieving maximal independence, function, 

and dignity. As the Vietnam War progressed, 

medical teams at Fitzsimons learned to limit 

convalescent leave and began linking leave to 

achieved rehabilitation goals. 

	 •	 Introduce recreational/motivational activities. What had been traditionally referred to as 

“recreational therapy” was recognized by Dr 

Brown and his staff as “motivational therapy.” 

Military providers partnered with local and 
7

Introduction: Developing a System of Care for the Combat Amputee

community groups to develop programs for 

amputee horseback riding, swimming, and 

skiing. These programs were observed to have 

some of the most dramatic positive effects on 

outcomes. The keys to success were not just 

getting patients out in the community, but 

also to challenge them beyond the typical 

paradigms seen in hospital-based rehabilitation programs. As these programs became 

more popular, press coverage brought further 

interest, resources, and opportunities for the 

injured service members. However, the programs were also scrutinized by many, including the orthopaedic consultant to the Army 

Surgeon General’s Office as well as many 

Navy orthopaedic surgeons, who claimed 

that these activities were both “dangerous” 

and “inappropriate” because they “fostered 

prolonged relationships with other amputees 

for companionship deterring from rehabilitation.” Fortunately, this criticism did not stop 

the programs, and many of the programs 

formed or expanded during Vietnam served 

as the catalyst for today’s numerous national 

and international sports and recreational organizations for people with disabilities. 

	 •	 Better define the VA’s role. During the Vietnam War, transfer to a VA hospital was often 

viewed as a decrement in medical care and 

a significant interruption of rehabilitation 

services. Hospital staff at Fitzsimons were reluctant to send their patients to the local VA for 

fear of this degradation of services, even if in 

meant going against the policy dictating that 

if a patient could not be “made well” within 

a certain period of time, he or she should be 

transferred to a VA hospital. If VA hospitals 

were going to play a significant role in caring 

for combat casualties, their services would 

need to improve, their role would need to be 

clearly articulated, and their staffing would 

need to be concordant with their mission. 

Furthermore, transfer to the VA should not 

have a negative financial or retirement impact 

on the injured service member.

	 •	 Provide holistic care. Concentrating on the 

surgical aspects of care only was not sufficient 

for optimal treatment outcomes. Practitioners needed also to treat other physical and 

psychological impairments of each patient, 

especially those with multiple comorbid injuries. Individualized care was best achieved 

through a team approach, with practitioners 

from each discipline working together under 

one service, enhanced by communication 

between members as well as with patients 

and their families. Additionally, it was noted 

that consistency of care was a key factor in 

delivering the highest quality of care. The career of General Fred Franks, Jr, whose combat 

wounds resulted in a leg amputation, illustrates the success of Vietnam-era amputee care 

programs.9 During his rehabilitation at Valley 

Forge Army Hospital, General Franks decided 

he wanted to continue military service. Aided 

by his surgeon, Dr James Herndon, Franks 

remained on active duty. After an exemplary 

military career, he has served in retirement as 

a tireless advocate for wounded soldiers and 

their efforts to remain on active duty.

DEVELOPING AN AMPUTEE PROGRAM WITHIN THE DEPARTMENT OF DEFENSE

According to data obtained from the Centers for 

Disease Control and Prevention, an estimated 1,285,000 

persons in the United States were living with the major 

limb amputation (excluding finger and toe amputation) in 1996. Despite better prevention and treatment 

programs, the number of individuals with major limb 

amputations continues to increase. Over 82% of US 

amputations occur as a result of complications from 

diabetes and vascular disease, mostly in individuals 

over the age of 65.10 Additionally, the vast majority 

of amputations performed in civilian communities 

involve the lower rather than upper limbs.11–14

Data from OEF and OIF reveal a much different 

patient population. As of August 2009, over 900 service members had sustained a major limb amputation 

in support of GWOT. Approximately 21% of these 

individuals have had an upper limb amputated, and 

over 23% have lost more than one limb. Nearly 90% 

of these service members were under the age of 35, 

an age group with unique psychosocial needs, generally seeking to return to a more active lifestyle than 

older individuals. Adding to the challenges posed 

by combat-related amputation, the majority of these 

injuries have not occurred in isolation. Over 50% of 

the amputees seen during OEF/OIF have a documented traumatic brain injury, many with impaired 

vision and/or hearing. Additionally, many amputees 

have multiple complex fractures, soft tissue wounds, 

paralysis from peripheral nerve injury or spinal cord 

injury, and mental health problems. 

In response, the DoD and VA together created a 

specialized system of care for combat amputees addressing these unique needs. To ensure communication between DoD and VA, Colonel Paul F Pasquina, 
8

Care of the Combat Amputee

MD, was appointed to the Advisory Committee of 

the Secretary of Veterans Affairs on Prosthetics and 

Special Disability Populations. The first step in creating a comprehensive amputee care program within 

the DoD, in consultation with leaders from academia, 

consumer organizations, and VA, was to establish 

a well-articulated mission and vision statement to 

communicate to military and civilian leaders, as well 

as medical providers and service members, the intent 

of the program:

Mission: Provide the highest quality of care to our soldiers, marines, sailors and airmen who are willing to put 

their life in harm’s way.

Vision: Through the collaboration of a multidisciplinary 

team, we will provide world-renowned amputee care, assisting our patients as they return to the highest levels of 

physical, psychological and emotional function.

While these statements articulated the goals of 

the program, a functioning system of care required 

acquiring and realigning resources within institutions, forming multidisciplinary teams, establishing 

productive partnerships with key constituencies (eg, 

VA, academia, veteran service organizations, industry, 

and relevant federal agencies and laboratories), and 

establishing strong leadership at all levels of clinical 

and administrative processes. It also meant adhering 

to and building upon the lessons learned from previous wars.

KEY ELEMENTS OF A COMPREHENSIVE AMPUTEE CARE PROGRAM

In preparation for OEF and OIF, WRAMC was designated as the primary site for amputee care in the US 

Army, with plans to expand the program to BAMC as 

needed, depending on casualty numbers. At WRAMC, 

providing holistic care for amputees has been a significant challenge for the medical and administrative 

staff, who have also been charged with caring for the 

over 8,000 other injured OEF/OIF service members 

arriving through August 2009. 

During the early phases of the war, amputees at 

WRAMC received their primary medical and surgical care from a variety of different medical specialties. Because of the complex nature of their injuries, 

each amputee was admitted to the service that best 

met their immediate medical or surgical needs. For 

example, those with cranial trauma were admitted to 

neurosurgery, those with primary extremity trauma 

were admitted to orthopaedics, abdominal trauma 

to general surgery, etc. While each of these patients 

received expert specialty care, their holistic and amputee-specific care was less than consistent. Additionally, with the constant arrival of new trauma patients, 

military surgeons found themselves in the difficult 

position of managing complex acute surgical issues in 

the operating room at all hours, while at the same time 

trying to remain attentive to patients on the ward with 

complex medical, pain, or psychosocial issues. 

To help meet this challenge, specialists in orthopaedics and PM&R partnered to help share inpatient and 

outpatient responsibilities. The PM&R department 

was well positioned to adjust its practice patterns and 

residency training program to help create both an inpatient and outpatient amputee service, in which the 

physiatrist acted as the primary care physician for the 

patient with complex injuries, allowing medical and 

surgical subspecialists to continue to provide expert 

consultation services. This synergistic relationship allowed focused subspecialty care and added consistency to amputee pain management, early rehabilitation, 

patient and family education, psychological counseling, traumatic brain injury screening, and surveillance 

and prevention of secondary complications such as 

infection, deep venous thrombosis, and heterotopic 

bone formation. Eventually, all the subspecialties 

critical to the care of amputees (orthopaedics, PM&R, 

occupational therapy, physical therapy, and prosthetics 

and orthotics) were united within a single department, 

a new Department of Orthopaedics and Rehabilitation, 

under a competitively selected department chief. The 

new department greatly facilitated communication 

within the institution and helped establish a clearer 

clinical pathway for amputee care.

In the new department, the physiatrist, following 

a rehabilitation model, coordinates the recommendations and interventions of multiple medical and 

surgical subspecialists, therapists, nurses, prosthetics, 

psychologists, and social workers. This system best 

ensures that holistic care is provided and also helps 

improve the quality and standardization of care across 

the institution. Weekly interdisciplinary amputee 

clinics are held in conjunction with interdisciplinary 

team meetings. The interdisciplinary meetings offer 

an opportunity for team members to share their observations and help develop unified treatment plans 

for complex patient issues or bring in other specialists 

as needed. These meetings have proved especially 

helpful in identifying patients with problems, which 

can then be addressed earlier during the recovery 

process: patients often form closer relationships with 

certain team members, who identify patient issues as 

they develop and address them with the rest of the 

team. The patient flow diagram developed at WRAMC 

is depicted in Figure 1-1. Although this model may 

not be adaptable to all military sites, the principles of 

patient flow should remain consistent across healthcare systems.
9

Introduction: Developing a System of Care for the Combat Amputee

Figure 1-1. Patient flow chart at WRAMC’s amputee service.

Gen: general

MEB: medical evaluation board

MICU: Medical Intensive Care Unit

Ortho: orthopaedics

OT: occupational therapy

Pain: Pain Management Service

PEB: physical evaluation board

PM&R: physical medicine and rehabilitation

Prosth: prosthetics

Psych: psychiatry/psychology

PT: physical therapy

RTN: return

SICU: Surgical Intensive Care Unit

Svc: service

VA: Department of Veterans Affairs

WRAMC: Walter Reed Army Medical Center

Organizational Structure

Standardizing medical care across different medical systems and geographic regions is dependent on 

multiple factors. Patient demographics, provider expertise and experience, and available resources greatly 

influence outcomes. To ensure that best practices are 

followed, it is essential to have a well-organized system in place. In addition, a model program should 

have adequate resources, support ongoing education 

and research, and incorporate continuous process 

improvement principles. Strong leadership is essential 

in implementing and sustaining such a program. The 

organizational structure of WRAMC’s Department of 

Orthopaedics and Rehabilitation, described above, 

greatly facilitated the formation and execution of the 

Amputee Arrives at WRAMC

Triage

(Orthopaedics/Surgery/Medicine)

Inpatient?

Gen Surgery

Yes

No

Amputee Svc (PM&R) Medicine SICU/MICU Ortho Svc Neurosurgery

PM&R consult within 24 hours

- Ensure PT/OT/Prosth/Psych/Pain/

Social Work/Case Management started

- Coordinate transfer to Amputee Svc

when appropriate (goal within 72 hours)

Amputee Inpatient Svc (PM&R)

- Comprehensive care

- Multidisciplinary meetings

- Medical Evaluation Board decisions

- Track with case management

PM&R Clinic

(walk-in appointment)

- Address medical/rehab problems

- Initiate consults

VA System/

TRICARE

For life-long

management

Amputee Clinic

(PM&R Clinic)

Wednesday morning

- Medical problems

- Prosthetic fitting

- Wound issues

- Pain Management

- Therapy

- Disposition

(MEB/PEB/RTN

Duty)

Duty VA System

Soldier desires WRAMC followup

(3, 6, 9, 12 month) or assessment for Return to Duty

TRICARE Network

On Post Quarters

Follow up with PM&R Svc

next morning
10

Care of the Combat Amputee

amputee care program at both WRAMC and BAMC, 

and also contributed to the formation of two state-ofthe-art rehabilitation facilities, WRAMC’s Military 

Advanced Training Center (Figure 1-2) and BAMC’s 

Center for the Intrepid (Figure 1-3). These two facilities were created with public and private funding after 

military, government, and civilian leaders recognized 

the need for additional support services at both locations. 

Teamwork

Optimizing care for the individual with major limb 

loss is complex, and medical, surgical, and rehabilitative care has become subspecialized. In addition, the 

varieties of prosthetic components available on the 

market make prosthetic prescribing and fitting a 

complicated process. Whether providing inpatient 

or outpatient care, experts agree that formulating an 

interdisciplinary team is an essential feature of a successful program. 

The “centers of excellence” concept developed in 

earlier conflicts6–8 espoused the need for interaction 

of multiple specialties as well as incorporating basic 

rehabilitation principles to provide holistic care to the 

amputee. Critical specialties involved in caring for the 

amputee include physiatry, surgery, medicine, physical therapy, occupational therapy, recreation therapy, 

nursing, mental health, social work, and prosthetics. 

This type of teamwork has been shown to improve 

a b

Figure 1-2. The Military Advanced Training Center at Walter 

Reed Army Medical Center, Washington, DC: (a) exterior 

view; (b) interior showing climbing wall.

Figure 1-3. The Center for the Intrepid at Brooke Army Medical Center, San Antonio, Texas: (a) exterior view; (b) interior, 

third floor, showing track and climbing wall. Photograph (b) by Don Clinkscales.

a b
11

Introduction: Developing a System of Care for the Combat Amputee

short- and long-term outcomes.15,16 Additionally, incorporating peer support, vocational rehabilitation, 

community reintegration, and assistive technology, 

as well as sports and recreational activities, greatly 

enhances a comprehensive program and improves the 

amputee’s quality of life and ability to reintegrate with 

the community.17 Finally, for a program to be successful, team members must recognize the importance of 

the patient and family members’ participation in the 

entire treatment process, including the establishment 

of short- and long-term goals.

Staffing Ratios

As articulated by former Secretary of Defense Donald Rumsfeld, “you have to go to war with the Army 

you have, not the Army you want.”18 Although this 

may be true to a certain extent, the MHS strives to 

provide the best medical, surgical, and rehabilitation 

care achievable for wounded American service members. Essential to meeting this mission is establishing 

appropriate medical staffing ratios. Unfortunately, no 

standard matrix or formula exists to serve the complex 

needs of this unique patient population. Staffing ratios 

are dependent on factors such as patient acuity, experience and expertise of the provider, access to resources, 

and partnerships with other institutions and outside 

organizations. Table 1-1 presents ratios developed by 

expert consensus.

Graduate Medical Education and Research

Experience treating injured service members during OEF/OIF has demonstrated the critical impact 

GME has had on amputee care. Ongoing educational 

programs that include military-specific curricula 

help military facilities stay current with state-of-theart medicine, surgical techniques, and rehabilitative 

approaches to care. WRAMC’s PM&R residency program (the only one in the DoD) has greatly enhanced 

the incorporation of fundamental rehabilitation 

principles into the care of combat amputees. Even in 

times of peace, DoD surgical programs emphasized 

combat casualty care to ensure that today’s surgeons 

are prepared to meet even the most complex trauma 

surgical issues. DoD-sponsored GME programs are 

vital to the strength of the MHS and ensure its capacity to meet current and future needs in military 

medicine. 

An active research program is also an essential component of a successful amputee care center of excellence. To ensure that military-relevant clinical research 

is being conducted, active engagement of clinicians 

who care for the patients is paramount. Unfortunately, 

TABLE 1-1

SUGGESTED STAFFING RATIOS FOR 

AMPUTEE CARE

Specialty FTEs for 10 

Ward 

Inpatients

FTEs for 20 

Outpatients 

(Excluding TBI 

Impairment)

Orthopaedics 1 1

Physiatry 1 1

Physician Assistant 2 1

Physical Therapy 2 2

Physical Therapy Assistant 2 2

Occupational Therapy 2 2

Certified OT Assistant 2 2

Recreation Therapy 1 1

Nursing (RN) 1 0

Nursing (LPN) 2 0

Social Work 1 1.5

Case Management .5 1

Administrative Assistant .5 .5

FTE: full-time equivalent

LPN: licensed practical nurse

OT: occupational therapy

within most military clinical settings, a formal research 

infrastructure is not as robust as in most university 

programs. Despite the productivity of individual DoD 

clinicians and researchers, every opportunity should 

be taken to bring these groups together to collaborate 

on solving problems. Partnerships with the VA, universities, and industry have helped to build capacity 

in performing relevant research that can translate into 

clinical care. 

Involving medical residents in research is also 

key. The partnership with the VA Rehabilitation 

Research and Development Service, which incorporates WRAMC residents into VA research activities, 

has resulted in military amputee care program successes. One such program, which included WRAMC 

PM&R residents in the Human Engineering Research 

Laboratories research team at the National Veterans 

Wheelchair Games and the National Disabled Veterans 

Winter Sports Clinic, cultivated residents responsive 

to research and encouraged some to become clinician 

scientists. 

RN: registered nurse

TBI: traumatic brain injury
12

Care of the Combat Amputee

Continuing Education

In addition to GME, an ongoing educational program must be part of successful amputee care because of the varying levels of experience within DoD 

military treatment facilities and the high turnover of 

staff. Educational experiences must be comprehensive 

while at the same time targeting individual disciplines. Key leaders should be identified within each 

service (PM&R, nursing, orthopaedics, prosthetics, 

occupational and physical therapy, psychology, etc), 

who will first identify the educational needs of their 

services and then determine how these educational 

needs can best be met. A cost-effective way to meet 

these needs is bringing in outside experts or partnering with existing national organizations, such as VA, 

the Defense Advanced Research Projects Agency, 

and universities, as well as private companies and 

foundations. Issues of a cross-disciplinary nature, 

including pain management, wound management, 

and psychological adjustment, should be presented 

in a forum with all disciplines present to promote 

interdisciplinary discussion. The military amputee 

care program, in partnership with the VA, Human Engineering Research Laboratories, Paralyzed Veterans 

of America, and University of Pittsburgh, initiated a 

“state-of-the-science” symposium series in 2004 to 

bring the nation’s best scientists and clinicians to 

WRAMC to facilitate communication, build collaborations, and accelerate the translation of research into 

clinical practice. Furthermore, collaborations were 

established with key universities, government agencies, and veteran service organizations to expand 

education opportunities, grand-rounds presentations, 

and clinical training. 

Database

Any effective system of medical care requires accessible information on the patient population served; for 

military amputee care, a database is needed to track all 

patients as they enter the system. Important data elements include demographics, comorbidities, pathologic anatomy, and etiologic data, as well as interventions 

and outcomes. This database requires technological 

support and accurate data entry by employees (other 

than clinicians) skilled in these areas. Furthermore, 

the database must be secure, password-protected, and 

capable of removing all personal identifying information from the data. Data analysis such as prediction of 

outcomes, utilization of resources and equipment, and 

identification of areas in need of alternative interventions or approaches provides essential feedback to the 

clinical team.19

Prevention Programs 

Preventative programs can help reduce the risk of 

both traumatic and nontraumatic amputation. Safety 

education and training have contributed to a significant decrease in trauma-related amputations.20 The VA 

Preservation-Amputation Care and Treatment (PACT) 

program has contributed to an almost 40% reduction in 

nontraumatic amputations performed each year at VA 

medical centers. The program incorporates interdisciplinary coordination by the surgeon, rehabilitation 

physician, therapist, nurse, podiatrist, social worker, 

and prosthetic and/or orthotic personnel, as well as the 

primary care medical or diabetes team to track every 

patient with an amputation, or those at risk of limb 

loss, who enter the VA healthcare system.21 Prevention 

of traumatic amputations from combat is also a priority 

of military forces. Medical teams have helped partner 

with military research teams in designing extremity 

protection armor as well as improving immediate 

medical aid to help save limbs. 

Surgical Considerations 

Standardizing surgical approaches to amputation 

is challenging, especially for combat victims whose 

wounds are not only extensive but also contaminated 

with dirt, bacteria, and fragments. With most amputees 

requiring comanagement of multiple surgical subspecialties, good communication between these services 

is essential. Limb-salvaging decisions remain complex 

and should be made in conjunction with the patient, 

as well as the entire medical and rehabilitation team. 

Tools such as the mangled extremity severity score are 

helpful in facilitating a decision (but may not be definitive). In addition to anatomic and physiologic factors, 

anticipated functional outcome should be considered, 

especially for this generally young and active patient 

population, many of them eager to return to high-level 

sporting and recreational activities. Similar considerations must be made when the rehabilitation team 

decides on amputation length and level. It is critical 

that the rehabilitation team, especially the prosthetist, 

be involved in these decisions preoperatively to ensure 

optimal length for prosthetic fitting and function. 

Medical Management

Most service members with combat-related amputations have multiple comorbidities and a greater risk for 

secondary complications. Traumatic amputees are at 

increased risk for developing deep venous thrombosis 

in both their intact and residual limbs. For prophylaxis, all patients are started on low-molecular-weight 
13

Introduction: Developing a System of Care for the Combat Amputee

heparin (enoxaparin), unless contraindicated. A high 

percentage of combat amputees also develop heterotopic ossification, although whether this incidence 

correlates with the nature of injury (typically, from a 

blast); patient demographics (age, race, genetic predisposition); wound management (vacuum dressings); or 

perhaps the presence of comorbid head injury is unclear. The secondary effects of heterotopic ossification 

can be significant pain, skin breakdown, and trouble 

with prosthetic fitting. All WRAMC patients receive 

a cyclooxygenase-2–selective nonsteroidal antiinflammatory agent, unless contraindicated, for both prophylaxis and treatment of heterotopic ossification. 

Faculty have observed that in this patient population, signs of secondary complications such as deep 

venous thrombosis or heterotopic ossification are 

typically very subtle and may first appear only as a 

mild, low-grade fever; therefore, medical vigilance is 

imperative. Because of the high incidence of comorbid head injury, it is important that the medical staff 

have experience in managing patients with cognitive 

deficits. For posttraumatic seizure prophylaxis and 

treatment, levetiracetam has been very effective. Finally, because of the high incidence of multitrauma 

and blood loss, combat amputees have benefited 

from the use of epoetin alfa to stimulate red blood cell 

production. This treatment not only helps healing but 

also increases energy during rehabilitation. It should 

also be recognized that each patient has his or her own 

distinctive psychosocial needs, greatly affecting issues 

such as pain management, adjustment to disability 

and body image, ease with movement through the 

military disability system, and reintegration into the 

community or back to active-duty service. 

Pain Management

An essential component to any successful inpatient 

or outpatient amputee program is expertise in pain 

management. Residual limb and phantom limb pain, 

reported in 55% to 85% of amputees, have a significant 

negative impact on long-term functional outcomes and 

quality of life.22,23 The incidence of chronic pain may 

be reduced by aggressive preoperative and perioperative pain management. New Joint Commission on 

Accreditation of Healthcare Organizations standards, 

as well as the Accreditation Council for Graduate 

Medical Education, recognize pain medicine as a distinct medical subspecialty.24 These organizations have 

helped establish institutional guidelines for appropriate pain management, as well as sensitizing medical 

institutions and clinicians to the patient’s right to pain 

management. Furthermore, advances in medical and 

procedural interventions offer new ways to mitigate 

pain associated with trauma care. 

The entire medical and rehabilitation staff should 

be aware of the amputee’s pain perception, incorporating questions about pain as part of routine evaluation. 

Team members who have subspecialty training in 

pain management contribute greatly to a successful 

outcome. Within the amputee care program, nurses, 

physicians, and therapists all play critical roles in 

monitoring patient pain complaints and optimizing treatment. WRAMC experience has shown that 

adequate pain control in most combat amputees requires multimodal medication. Nearly every patient 

is issued a patient-controlled anesthesia pump during 

the perioperative period and then quickly converted 

to long-acting opioids after definitive surgery. Shortacting opioids are also used for breakthrough pain or 

premedication prior to therapy. 

Most patients are prescribed an anticonvulsant 

(gabapentin, oxcarbazepine, lamotrigine); a tricyclic 

antidepressant (nortriptyline, amitriptyline, desipramine); and a nonsteroidal antiinflammatory agent, 

typically one that is cyclooxygenase-2–selective, given 

the number and nature of comorbidities as well as 

frequent concurrent use of anticoagulation medication. Quetiapine fumarate is a very effective sleep aid, 

especially in cases when the soldier reports trouble 

with nightmares. In addition to pharmacological 

management, physical agent modalities (ice, heat), 

desensitization, and transcutaneous electrical nerve 

stimulation units have been helpful. Perhaps most effective, however, has been the support of the regional 

anesthesia team. The placement of peripheral infusion 

catheters to the brachial, lumbosacral plexus, or sciatic nerves has had a dramatic positive effect on pain 

control, reduction in medication use, and participation 

in therapy. 

Cutting-edge programs should consider the use of 

topical agents, regional anesthesia, and multimodal 

pharmacological management, as well as complementary, integrative, or alternative measures such 

as biofeedback, hypnosis, relaxation techniques, and 

acupuncture. Physical and occupational therapists 

should be knowledgeable about both the indications 

and contraindications when applying modalities such 

as heat/cold, electrical stimulation, and desensitization techniques. The literature does not support clear 

evidence of a single agent as the treatment of choice 

for phantom or residual limb pain, but medications 

such as opioids, anticonvulsants, tricyclic antidepressants, botulinum toxin, and topical agents (lidocaine, 

capsaicin) may work synergistically along with 

mechanical stimuli modalities (eg, transcutaneous 

electrical nerve stimulation, tapping, massage) and 

mirror therapy to provide optimal pain relief. It is also 
14

Care of the Combat Amputee

generally accepted that the use of an appropriately 

fitted prosthetic socket reduces pain.

Advances in Prosthetics 

Military amputee care providers believe that the 

technological advances in prosthetic design not only 

significantly improve patient satisfaction and functional outcomes, but also facilitate progression in 

rehabilitation. 

Upper-Limb Prosthetics

Because of the complex nature of combat wounds, 

prosthetic fitting is often delayed to allow time for 

graft healing. Comorbid fractures, nerve plexus injuries, or soft tissue defects often prohibit the use of 

body-powered prostheses and suspension harnesses 

or cables. During the immediate postoperative period, myoelectric control sites should be identified. 

At WRAMC, occupational therapists work closely 

with the patients using preamplified electrodes over 

remaining intact muscles. These electrodes capture 

electromyograph signals that trigger audio and video 

feedback to the patient and therapist. These signals 

are also used to operate video games, which create a 

friendly and therapeutic competitive environment for 

the patients and quickly lead to mastering of certain 

skills. Once these skills are acquired, patients progress 

rapidly to operating myoelectric prostheses as soon as 

their limb is cleared for fitting. Body-powered prostheses are introduced later, as comorbid injuries permit. Today’s advanced prosthetic components allow 

simultaneous operation and control of both the elbow 

and terminal device. The addition of a wrist control 

unit permits more useful upper-limb functioning in 

some patients. Newer terminal devices allow faster 

and more responsive opening and closing. They also 

have the ability to maintain constant grip force, utilizing built-in sensors within the fingertips. 

Lower-Limb Prosthetics

Advances in technology have been applied to both 

prosthetic component design and socket fabrication. 

Traditional plaster casting, while still utilized, is augmented with computer-aided design and manufacture 

equipment, which has contributed to a more rapid 

and standardized approach to socket delivery for 

traumatic lower-limb amputees. The computerized 

system allows the fabrication of a custom-made socket 

in a fraction of the time needed for traditional casting. 

The shorter fabrication time is especially helpful in 

caring for the combat amputee, whose residual limbs 

have complex scar and suture lines and experience 

substantial rapid volume changes. 

Advanced components, such as microprocessor 

knees and dynamic response feet, have not only enhanced function but also promote a more rapid progression through rehabilitation. The prosthetist’s ability to program microprocessor knees to provide more 

or less stance or swing control assists advancement 

from early weight bearing to initial ambulation and, 

eventually, to stair and obstacle negotiation, without 

having to change prosthetic components or alignment. 

MHS and VA providers have also found that during 

initial ambulation, patients perform well with multiaxial feet and vertical compression pylons. As patients’ 

confidence and activities increase, they perform better 

with lighter-weight feet that have vertical compression 

features built into the heel of the foot itself. 

A fully equipped gait laboratory provides useful 

functional measures during the early phases of fitting 

to aid with prosthetic alignment and choice of components. Staff can also provide feedback to the patients 

and therapists on specific items to work on during 

therapy sessions. 

Peer and Psychosocial Support Programs

An extremely important aspect of a comprehensive 

program includes professional behavioral health and 

amputee peer support. DoD amputee programs have 

formed partnerships with VA and the Amputee Coalition of America to find and train outstanding individuals with limb loss who volunteer their time to support 

combat amputees returning from war. It is ideal if these 

volunteers have military experience. In addition to the 

emotional support they provide patients, they also 

provide valuable feedback to the rehabilitation team 

as to how a patient is progressing in rehabilitation both 

physically and emotionally. Family members are also 

encouraged to be fully engaged in the rehabilitation 

program. The DoD has been proactive in supporting 

nonmedical attendants, often family members, who 

stay with injured service members during their recovery. DoD provides travel and housing allowances to 

nonmedical attendants, enabling them able to assist 

in the recovery of the injured service member and 

provide much needed emotional support through the 

process. The VA should consider adopting a similar 

model based on the success of this program and the 

positive impact it has had on veterans and their families. Communication among patients, their families, 

and their multiple providers is greatly facilitated by 

social workers and nurse case managers, who help to 

coordinate continued care, discharge planning, and 

equipment purchases. 

Events such as the National Disabled Veterans Winter Sports Clinic, National Disabled Veterans Summer 
15

Introduction: Developing a System of Care for the Combat Amputee

Sports Clinic, National Veterans Wheelchair Games, 

and the Paralympics, sponsored by VA in coordination 

with public and private organizations including the 

Paralyzed Veterans of America, Disabled American 

Veterans, Disabled Sports USA, Wounded Warrior 

Project, US Paralympics, Achilles Track Club, Team 

River Runner, the Yellow Ribbon Fund, and numerous 

others, introduce patients to the variety of sports and 

recreational opportunities available for individuals 

with disabilities. Improving both access and awareness of these programs is essential to the success of 

the amputee program.

Military Medical Disability System

Navigation through the military medical disability 

system is complicated. A single amputee service promotes communication and standardization. Physicians 

should be well educated and experienced in writing 

medical evaluation boards. In addition, a physical evaluation board liaison officer should be assigned to each 

patient during his or her inpatient stay. VA counselors 

are also necessary to ensure that patients are aware 

their potential benefits. Educational programs must 

be tailored to the service member’s needs, especially 

those with head injury, hearing loss, or vision loss. 

Optimal disposition of patients is often complicated 

by the frequent geographical challenges created when 

the patient’s duty station, home of record, and nearest 

military or VA medical facility are far apart. In these 

situations, medical follow-up must be coordinated 

through the TRICARE military healthcare system. 

Unfortunately, standards and availability of healthcare 

services vary in both the private and public sectors 

across the United States. Through partnerships between the DoD and VA, military amputee programs 

are committed to provide ongoing care to veterans 

with limb loss for the rest of their lives, as needed to 

supplement VA programs.

Outcome Measures

An essential element to developing a program focused on best practices is a mechanism for collecting 

and analyzing outcomes. New Joint Commission on 

Accreditation of Healthcare Organizations and Accreditation Council for Graduate Medical Education 

guidelines emphasize the importance of outcomesbased practices. A multitude of outcome measures are 

available for the amputee population. While numerous 

reliable and validated measurement tools have been 

reported in the literature, considerable debate continues as to which tool is best for the various populations 

of patients. Additionally, the success or failure of a 

particular intervention in amputee care is often the 

result of many factors. Therefore, several tools may 

need to be employed to adequately assess a particular 

patient population.

The most common outcome domains to be examined in various amputee populations include mobility, function, and quality of life. Tools employed to 

measure these domains are generally self-reporting 

(survey) or observation based. Several examples of 

measurement tools are listed below.

Self-reporting measures: 

	 •	 the Medical Outcomes Study Short Form 36-

Item Health Survey25

	 •	 Legro and colleagues’ prosthesis evaluation

questionnaire26

	 •	 the locomotor capabilities index27

	 •	 the sickness impact profile28

	 •	 the questionnaire for persons with a transfemoral amputation (Q-TFA)29

	 •	 the TrinityAmputation and Prosthetic Experience Scale (TAPES)30

Performance-based measurement tools and devices: 

	 •	 the “get up and go” test31,32

	 •	 the 6-minute walk test33

	 •	 Gailey and colleagues’ amputee mobility

predictor34

	 •	 the disabilities of the arm, shoulder, and hand

(DASH) questionaire35

	 •	 the box and block test36

	 •	 the Jebsen-Taylor hand function test37

	 •	 the step activity monitor38

	 •	 three-dimensional gait and motion analysis39,40

	 •	 energy consumption measurements41,42

New technologies and improved methods are being 

developed to record activity in unstructured environments within the home and community to measure 

community participation, provide further insight into 

the usage and effectiveness of technology, and assess 

the impact of various rehabilitation interventions.

CONCLUSION

Today, science, advanced technology, and improved 

material design are being brought together to revolutionize the care for individuals with amputation. Optimizing this care requires significant teamwork and partnership both across and within different disciplines. 

Current medical research must involve all areas of sci-
16

Care of the Combat Amputee

ence, including those not traditionally associated with 

healthcare. Clinicians must clearly identify and communicate the functional needs of patients to engineers, 

biologists, computer scientists, and systems scientists to 

achieve common goals. Furthermore, a mutual sharing 

of ideas among public and private universities, federal 

agencies and laboratories, and industry is essential to 

further advancements in the field. 

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