Comprehensive Model System for Amputee Care in Boston

1. March 7, 2013

2. Can We Create a Model System for Amputee Care in Boston?

3. Can We Create a Model System for Amputee Care in Boston? • Achieving optimal outcomes requires optimal care from a well-functioning and coordinated interdisciplinary team, where each member is recognized as having equal importance. • Dedicated Amputee Inpatient Service • Outpatient Amputee Clinic, short and long-term follow-up care and consultation

6. Boston Marathon Bombings April 15, 2013

7. The Comprehensive Rehabilitation of the Boston Marathon Bombing Survivors David M Crandell, MD Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA; Spaulding Rehabilitation Hospital Charlestown, MA

8. Marathon shot

9. Responders • Immediate and targeted resuscitation at the scene • Fast and efficient transport to Trauma Centers • Emergency Departments with skilled teams and capacity • Operating Rooms with skilled teams and capacity • Ongoing medical, surgical and psychological management

10. Responders • Large numbers of survivors with ongoing complex medical and surgical needs requiring comprehensive rehabilitation services Photo Credit: Charles Krupa AssociatedPress

11. EMS + Acute Care + Post Acute Care Photo Credit WBUR Boston

12. Boston Marathon Bombings Timeline • Within 45 minutes all seriously injured had been transported to Trauma Centers • • 127 patients within first 24 hours • • 75 Admitted (60%) • • 31 exsanguinating hemmorrhage (24%) • 15 Amputations • • 33 patients to Rehab • Days to Rehab (DTR 5-50) • Last Discharge from Rehabilitation Day 100

15. Fortunate Circumstances Boston has 5 Adult Level 1 Trauma Centers • Boston Marathon is on Patriots Day Holiday • Operating Rooms are open, but little elective activity planned • Blasts occurred at “Change of Shift” (double number of nurses available) • EMS positioned at Finish Line Brand new “State of the Art” Rehabilitation Hospital poised to open within days

16. Spaulding

18. Case Description 19 year old female with complex open fracture of her tibia

20. CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL Case 11-2014 — A Man with Traumatic Injuries after a Bomb Explosion at the Boston Marathon A 34-year-old man was brought to the emergency department because of injuries sustained when a bomb exploded at the Boston Marathon. His right leg had been amputated below the knee and his left leg was burned. Imaging showed metallic foreign bodies in the legs, pelvis, and chest. N Engl J Med 2014;370:1441-1451 April 10, 2014 DOI: 10.1056/NEJMcpc1314240

21. Imaging Studies on Admission Eikermann M et al. N Engl J Med 2014;370:1441-1451

24. Rehabilitation Admissions • • 33* patients • • 15/16 Lower Limb Amputees • • Ages 7-71 • • Bilateral Amputees (2) (AKA, AKA/BKA) • • AKA (8) • BKA (9) • BMC (5), MGH (5), BWH (2), BIDMC (2), Children’s (1) • Days to Rehab (DTR) (5-50) • LOS (11-55) * Police officer injured in manhunt and firefight with terrorists

25. Rehabilitation Challenges Amputation of a limb is a life altering event • Life saving procedure • Limb loss results in loss, physical, psychological, social, financial well-being • Unique challenges: unplanned amputations, short residual limbs, multiple limbs, young people, terrorist act • Spotlight for expedited recovery The road to recovery and rehabilitation for injured service members with limb loss: a focus on Iraq and Afghanistan. Isaacson BM et al. US Army Med Dep J. 201, Jul-Sep:31-6

26. Rehabilitation Admissions • DTR– 14 days and under, LOS 14 .6 (Shortest 8 days) – 15 days and over, LOS 24.3 (Longest 55 days) • Complications– Superficial infections (2) – Hemodialysis (1) • Further Surgery– 3 patients required free flap procedures – All over 15 DTR • Readmissions for Subsequent Inpatient Rehabilitation – 5 Patients – AKA, 1 Bilateral amputee • Heterotopic Ossification– 4 Patients: 3 Adults, 1 Child

35. Rehabilitation Late Complications • 1 patient had total of 16 additional surgeries for limb salvage and then had subsequent below knee amputation after 1 year • 1 patient had a number of additional surgeries to try to improve on initial limb salvage with free flap who subsequently had below knee amputation after 1.5 years, becoming a bilateral BKA

37. http://www.jospt.org/page/special-reports/it_takes_a_team#.VQXiXBZKO8ohttp://www.jospt.org/page/special-reports/it_takes_a_team#.VQXiXBZKO8o

38. It Takes a Team • Be broad and collaborative in mass-casualty planning; an occasional emergency preparedness exercise isn’t enough • • Practice frequently, and include low-frequency, high-impact scenarios such as an active shooter • • Senior-level commitment to preparedness in hospitals and government agencies is essential • • Identify the gaps in response to nonlocal disasters, and practice to eliminate them in your community • • Any communication you make during a disaster should be clear, quick and truthful • Provide ample emotional support for both patients and clinical caregivers during and after a mass-casualty event • Everyone has a role and responsibility in an emergency; know where to go and from whom you will get information and instructions http://www.jospt.org/page/special-reports/it_takes_a_team#.VQXiXBZKO8o

40. Emergency Management System (EMS) Done Right Why Rehabilitation Should be Considered When Planning for a Mass Casualty Event Why Rehabilitation Should be Considered When Planning for a Mass Casualty Event

41. Be Prepared for the Success of EMS • Large numbers of survivors with ongoing complex medical and surgical needs requiring comprehensive rehabilitation services Why Rehabilitation Should be Considered When Planning for a Mass Casualty Event

42. http://bppa.net/wp-content/uploads/2014/01/14-TEAM-07.jpg

43. Photo Credit: Charles Krupa AssociatedPress