Amputation & Inpatient Medical Rehab

[Music] Welcome to Medical Rehab Matters. In this episode we're talking about amputation, prosthetics, and inpatient medical rehabilitation. About 185,000 amputations occur in the US each year, and approximately 2 million Americans live with limb loss. I'm Patricia Sullivan, Director of Communications for the American Medical Rehabilitation Provider's Association, and co-host of this episode. And with me is co-host Dr. Robert Krueg, the immediate past chairman of the AMRPA Board, and Vice President of Medical Affairs for Mary Freebed Rehabilitation Hospital Advisory Group. Later in this episode we talk with a prosthetist, Scott Riddle, Vice President of Orthotics, prosthetics, and biotics at Mary Freebed. But in our first segment we talk with Rosanne Sadoia, a woman who lost her leg in the Boston Marathon bombing in 2013, and her doctor, David Krandel, Medical Director of the Amputee Program at Spalding in Boston. [Music] Welcome Dr. Krandel and Rosanne Sadoia. Thank you for being here with us today. Thank you for having us. Do you want to tell us a little bit Rosanne about how you were injured? Well, I am one of the 17 amputees from the Boston Marathon bombing that happened back in April 2013, and I was at the second bombing location and was rushed to the hospital. I knew that my injuries were severe, but didn't realize that I'd become an amputee until about 24 hours or so later when I was taken out of my induced coma and found out that the doctor had to amputate my leg. And then you worked with Dr. Krandel, actor you were released from the hospital and in impatient medical rehabilitation? Correct. I was at a mass general hospital in Boston for a week, and then I was transferred to what I call the old Spalding. I was there for four days, and they had just built this brand new facility that they were opening on Saturday. So I was transported to the old Spalding on a Tuesday, and then transported to the new Spalding on that Saturday, where my full rehab stay at Spalding was for a total of three weeks, and then one extra week afterwards once I got my prosthesis above me. I am putty on the right side. So obviously what transpired that day gripped the whole nation, and we all were with Boston and with you. Yes, thank you. But you could just share with with our audience, what was going through your mind, you know, when you realized that you you had the amputation, we've discussed how someone who's lost a limb, what they're thinking, and what are the questions that they should be asking their medical team, but really what was most important to you at the time? Well, I will put a disclaimer in there that my first thoughts were a little bizarre, and I'm blaming it all on the morphine, which was amazing at that point, and does make me more, as I feel more of a comedian than anything else. So when the surgeon had told me that, you know, he had amputated part of my right leg, and that he was going to have to go in and clean it out further. And at that point, I was below me, and that he wasn't sure if he'd be able to keep me a baloney, or if he would have to make me an above me. So like I really didn't in my head, or have the wherewithal to think about the difference between the two of having my knee joint and not having my knee joint. My biggest concern at that point was that if he could make my scar look like a rose to make it look pretty, like that was the initial thought, again, morphine, but, you know, coming out of that and really, you know, all jokes aside, realizing the severity of the situation, you know, I really didn't know what it meant. I don't have other amputies really, you know, in my circle. I have, I know of an amputee that I went to college with many, many years ago that believe it or not, instantly came to mind. And that was probably one of my first thoughts is that I need to reach out to Paul to talk to him. But the situation of how I went through becoming the amputee was much bigger than just becoming the amputee. And I think I was just in such a fog of what had just happened, and how instantaneously my life had changed. I didn't realize the impact. I guess one of my other questions was I was supposed to be leaving for a vacation on that Friday to go to Cancun. And my question was, can I still go on vacations? So the initial thoughts really didn't hit me until a little ways after all of that and having to deal with getting in and out of bed, getting into the wheelchair. About two years prior to losing my right leg, I had had a stress fracture to my femur. So I knew what it was like to be on crutches for some time and not really be able to use that leg. Ironically, it's the same leg that I'm now a below amputee on, but I kind of had the vision of crutches. And that was only for a period of time. So it didn't really hit me. I don't think right away that it was going to be a lifelong scenario. So many thoughts going through my head now as there were then. I'm not sure exactly what fashion that they've all come about, but it's something that I think I took and stride and still do for the most part today, but I still think I'm trying to figure out what exactly happened. David, you know, it's the director of the amputee program at Spalding. Really interesting in your perspective, specific to her case, but you know, more globally in terms of when a patient sustains whether it's a traumatic or anticipated plan amputation for other reasons, vascular reasons or whatnot, how do you determine what the best location or setting for them to go through their rehab is I think, you know, when I was training in the early 90s, it was sort of a foregone conclusion that folks would just come to a rehab hospital, but I think in today's world, there's a lot of competing courses that isn't necessarily the case, even if it should be the case in many instances. So I'm just interested in your thoughts about how you view it and how a patient who's thrust into that sort of situation, how they and their loved one should approach it. Well, again, thank you for let me participate and it's always nice to see Roseanne and talk to her. My bias obviously being in Boston where I've done all of my rehab training and clinical work is, yeah, if you have a fortunate to need or end up with an amputation, you should come and get the highest level of rehab possible. There are some folks who, you know, are having planned amputations and have had experience with crutches and sometimes they could be managed with a several day, a cute hospital stay and then, you know, be men as is an outpatient, but for those folks, a lot of them have had other experiences with mobility impairments. So if you suddenly have a change in your mobility status, having the inpatient environment to both practice and learn and really be educated so that you can be safe as you transition home and then into the community. So we are seeing some charts, even here in Massachusetts, saying having a significant lower limb amputation or upper limb amputation doesn't meet the criteria for acute rehabilitation, which is, you know, a little bit for us, a little bit of shock to think that we can't have access to those patients to be able to give what they need and sometimes they have to really advocate for that currently, you know, but we're going to work on the premise that somebody's going to come and be able to spend, you know, a week or sometimes longer after a new amputation and receive the benefit from the a interdisciplinary team approach, both dealing with their post-operative pain and dealing with their residual limb management as well as the whole mobility and activities of daily living or ideals. They're really set to stage for that new life that Rosanna was talking about life as a new amputee. And you still feel it's very important to have that up front. We think in the long run, it's better obviously for the patient, but it also has also more cost-effective so you can avoid re-hospitalization or other complications. Do you mind if I add something to that? You know, over the past eight years that I've experienced this situation, I try to be a proponent to meet with patients that are going to become an amputee. Even if they have had medical issues, but yet hadn't become an amputee, I think it's really important to get them to speak to somebody first, such as myself or somebody else who's been an amputee because, you know, there isn't any book out there that's going to tell you how to go through this. And it was such a new thing to me that I listened. We had so many veterans come meet with us and different organizations because it was so publicized that I've picked up little tidbits here there where, you know, even through the other survivors of that day. And it's not something that you're going to find out there unless you are searching for it or come across someone who may have experienced all these different scenarios. And, you know, I'll recall, I think the first person I ever spoke to afterwards of this happening was a friend of my aunts and she had had cancer in her foot and my aunts asked if I would speak with her. So I met, I actually spoke with her over the phone first. And at the end of the phone call, I felt awful because she was upset because I was telling her that she should really make sure where they're going to amputate because not only may they amputate her foot, but she may now become a balloony amputee rather than just a foot amputee. And the surgeon hadn't discussed that with her. And so I suggested to her that if she could find a prosthetic beforehand and have that prosthetic go with her to the surgeon and have the full discussion between the three of them, it would make such a huge difference, I think, in her recovery. But it was a huge, huge difference, she said, Rosanne, thank you so much for speaking with me because he showed me where he was going to amputate. She said, if I had woken up without having this conversation with him, you know, it would have been more than what I was expecting. And I would have been so upset and even more depressed of what was going to happen. So to have these conversations in advance, I think are huge. And I think that then also leads the patient mentally in a better position for when they're going into rehab or being released from rehab or having rehab at home. I think it just helps them understanding what's happening because unless you live with it, you have no idea. David, you know, I think when someone has an amputation, you know, certainly the question I often get first is, am I going to walk again? What's that going to be like? But very often, they want to get back to their jobs and their other pursuits. Many were active in sports or whatnot. And I know Spalding has a very active sports program. And I'm just curious if you could speak to both of those with regard to the amputation and their involvement in sports and just getting back to, you know, the activities and being who they were before. So I do think ideally what these patients were looking for and what we're trying to promote is sort of a system of care that would look at a new amputee and then bring them obviously all the way back to their highest level of function. And obviously that could be back to work or back to sports activities. So I did my residency, rotated to Spalding, and then came back. And obviously it's a faculty physician. And one of the reasons that I was one, they were going to build a brand new hospital. The two was the Adapted Sports Program. You know, because I had seen in my experience in training, sports has a very powerful role to get people back to living their lives actively and then fully as possible. So even during someone's acute hospitalization, we will work with therapeutic recreation and our Adapted Sports Program. Working on the season and obviously the patient's interest to get them, you know, on recumbent bicycles or during the winter season when it wasn't COVID, we actually have ice time at the local hockey rink and we get people out doing those activities. And sometimes even doing an activity that they didn't do before helps show that individual and their family that obviously that at the amputation being obviously very significant can shape their individual. But it doesn't define them. And so if they start doing an activity that they always did or is a new activity, that can help give them a new goal and a new way to look at their current situation. So incorporating full spectrum of services, upfront education, plus the ability to transition them through sports and other activities to get them back to a high level function. You know, through spawling and, you know, the physical therapy and being an impatient, I learned of their Adapted Sports Program. And it's actually been vital in a lot of the activities, figuring out what I could still do, what I really didn't want to do anymore because it's changed so much. And going through the Adapted Sports through Spawling has helped tremendously. I know. And if it hasn't been through them, they have put me in contact with the right people. You know, I used to downhill ski and I tried it and I have to tell you, I hate it. Hate it as an amputee. Me and having to go to the bathroom and going into the lodge and not skiing with your brother leg on and all these things, you know, they connected me with a group up at Sunday River in Maine and to try it. And the instructor was great. It was just a bad experience for me knowing how I used to go and have a good time. However, through it, I then tried snowboarding and realized, well, because I can keep my tool fee, so to say locked in on one board and one leg isn't going to go this way and the other leg is going to go that way, I felt so much better with that. So, you know, that's given me the opportunity to try these things out. And I know that they do have the skiing sessions in the winter that you can sign up and go to. So, I really feel like these Adapted Programs are huge for people to try to get back to what they did before. And that was like one of my experiences. And then the other thing is my first time in a pool was at Spalding when I was inpatient. And, you know, I was scared about trying to swim without a leg on. I didn't, I don't know. I didn't know if you should swim with the leg on, without the leg on. You know, some legs aren't waterproof. And just even kind of the embarrassment of being an amputee and taking your leg off and leaving it on the side of the pool is a little weird, you know, or to take the liner off and you almost feel naked that people can see your thigh. Like, that's like, oh my god, don't look at it. So there's all these things that you can do in these situations through these Adapted Sports, like something through Spalding. And I feel like they're safety in numbers. So you're probably in a pool at a location skiing or something with multiple other amputees that are going through the same thing and look the same way. So you're not really kind of shocking so many two-legers or two-armors is how we want to look at it. We had the experience last week of one of our patients who was participating in the Paralympics in Tokyo and it was fortunate enough to do a lot of excellent training and work to come home with two gold medals. And they allowed. And they actually went to the hospital to connect with the staff and actually connected with her therapeutic recreational specialist was the first one to get her back into the pool after her amputation. So having rehabilitation play a role not only in getting back into the sport but then setting the stage for success for their future. How challenging is it from an insurance perspective nowadays to get the primary prosthesis, it's expensive, but most payers will pay whatever the insurance contract says. So when it comes to getting additional legs, whether it's a swimming leg or a sports leg, how does that work in today's world? Well, first of all, the part that Rosando's very well, obviously the shock on the patient that this is not covered by a typical insurance and the idea that technology might be available to allow them to participate in activity and then have actually the price tag actually interfere. We've been, again, fortunate we've had a number of folks who reach out to well established foundations locally. Some may actually start by heart patients that we've had that can allow people to access some prosthetic technology. We also put them in contact with national foundations, specifically looking to provide sports prostheses for people to get back in sports. And we've also been very fortunate to get some philanthropic support that allows our program through a application process to actually help support certain individuals getting prostheses. So one, you have to know that the technology is available and then we work in multiple ways to try to get it provided with both individual and foundation support. I'll give you the patient version. The squeaky wheel gets degrees. And some of the instances have had to kind of resubmit, resubmit, resubmit, resubmit. And again, some of the things too that I wouldn't have known unless people came and spoke with me in advance. But obviously there's key words to use. And then there's also letting your therapist as well as your prosthist know what your level of ability was prior to your amputation. Because I think that if they think that you're someone who didn't exercise, that didn't walk, didn't run, do any of that. Correct me if I'm wrong, Dr. Crandell. But there's like a grading system as you go through like kind of the rehab part of it to kind of grade you as to what your ability is. And I think if you're not aware of that, then you may not produce as well on that test or the grading system. I think that what insurance companies want to do, want to give you something equivalent to how active you are. And if you don't express that right from the beginning, then you're kind of set at that level. And for you to get anything maybe higher than that level is going to be a challenge if not happen. And maybe I'm incorrect on that, but that's been kind of my understanding along the way or at least that's how it felt it's been along the way. So I think you kind of have to realize that you need to be an advocate for yourself and to really push for these things and don't give up because someone says no, like you've got to keep trying to do what you can and reach out to the resources that are out there or search for the resources that are out there. And I think that's why a lot of the online groups and different connections that can be made through the amputee world can be helpful. [BLANK_AUDIO] because there are tricks of the trade out there that you need to know how to access them and the resources that are out there, where to look. And I think those resources of what has been huge in my progression. - Yeah, and I think Rosanne's point that patient with the right coaching can be their best advocate as well as having a supportive system, through our clinic and our documentation and working in tandem with our number of our community and prositists, we can literally try to be prepared to deal with multiple appeals because we understand what's at stake. And it's not just the ability to participate, it really makes a fundamental difference in the individual's quality of life and in the overall health. If we find ways to get patients actively exercising and improving their overall lifestyle, then that ultimately will impact their general health and their blood pressure control of diabetes management and everything else that goes along with it. So it's really part of working with this patient population that we have that efficacy role built. - I couldn't agree more on, I think, we've touched on a bunch of different aspects of it, but what I'm hearing is that, going to a rehabilitation hospital is a place where you have a team of knowledgeable people around the amputation. You have a physician who specializes in this who understands how the other medical issues impact the healing and the recovery of the prositist, obviously the therapist. And you have this psychological support there as well because I really think the psychology of it is as important as the physical part of it. And to be able to have a peer come in as you alluded to earlier, to sort of be able to see into the future of what your life can be. And then to have that continuum where you can transition seamlessly from an inpatient to an outpatient and network and get access to different organizations or whatnot to ensure that you can get those other components in addition to the primary prosthesis. Just so critical to recovering holistically, not just the lake healing or the ability to walk, but to recover as a whole person. I think the other aspect is that the advances in technology have been incredible over the last couple of decades. I mentioned before that I remember in residency, the suspension systems we still used leather straps to hold the limon. And David, I was hoping you could just comment on how that has sort of advanced over time. And the limits don't have to be there. The barriers have been broken. I mean, we've had one arm pitchers in the major leagues, but we've had lower extremity FUTs played division one football. You're only limited by your own aspirations and the team that's available to you. Well, there's really two sides to that as well, because there's this societal expectation that technology will fix everything or that the technology keeps getting better. And as we've now, unfortunately, celebrated the two decades of experience, both in Iraq and Afghanistan, on the plus side with higher numbers of younger individuals sustaining not just single-leg amputations, but multiple and upper extremities combined. A lot of research and interest has gone on. And so we are seeing the downstream effects of both volume of research interest. And I also look at Rosanne, the experience and the other marathon experience that here in Boston eight years ago changed how people look at amputation in general, because they could see that it could happen to anybody who just happened to be on the sidewalk. So, the side of the view of limb loss has changed, at least here locally. And I think somewhat nationally, the technology has been improving. And even within the medical community, I feel somewhat blessed that we have surgical colleagues here in town, both at multiple institutions that look at now amputation as, what can we do to help with functional restoration? And we have novel surgical techniques being developed both at conjunction with MIT and at the Brigham and Wimbledon Hospital. We have the experience of a multidisciplinary surgical clinic at the mass general where orthopedic oncology, trauma, plastic surgery, and physical medicine rehab are working together to both advise and manage patients in real time. And that's something that even with when we started our residency, it was not present. So, there seems to be some excellent alignment now in both the number of individuals and both clinically and research coming together. We are celebrating the second month of having our first amputee fellowship here at Spalding. And this is in conjunction with the mass general, the Brigham. And in November, December, our fellow is actually going to spend two months at Walter Reed. And the idea of combining the best of civilian clinical care, surgical management, physiiatric care, and then combining that with the experiences at Walter Reed is what we have developed is what was needed for-- to move amputee care in the right direction. And so both on the technology side, on the clinical side, and even on the educational side, I think that we're really seeing that alignment move things in the right direction. So I'm excited for patients that will be continue to work with going forward because of that combination. Through one of Spalding's programs, I was able to go to the amputee conference early on. One time it was only held every couple of years, and since they started doing it every year, and to go to that and see the amount of different mechanical or any of the new type of legs and feet and ankles and arms and you name it. And it was really eye-opening to me that I know my leg will never grow back. But is there a possibility somewhere down the line that my brain will control a prosthetic possibly? Rosanne, just yesterday, when I was at Mass General, at the interdisciplinary clinic, we had a young patient who's being referred. He's an above the amputee, and he was specifically sent for evaluation for direct-score attachment or osteointegration, which is not just being offered on a limited basis based on-- I'm not sure. I'm up for the osteointegration. I've seen it in real life. And that is just a little too intense for me. For some patients having that opportunity, also, I'd solve some issues. And the people that have done it love it. They love it. So that's also happening. And again, we're not sure that that individual will be able to go forward with that, but the idea that we're having those conversations and providing that education, talking about, obviously, the surgical risks and the management with that technology. To your point, there are developing direct skeletal or osteointegration that has the ability to have sensory input to really create a bionic interface between that technology and people's nervous system. So I used to think it was science fiction. Of course, I date myself back to Star Wars in the '70s. And the idea that someone would have an amputation by lightsaber and be fit with a bionic prosthesis that a bionic prosthesis would have sensation is now something that I do think will be coming online, obviously in the next decade. So I do think we're even closer to meeting that. Well, it was science fiction to actually be coming an option for some patient. And I keep thinking of the $6 million man, so I'm really dating myself. Yeah, of course, the price tag would be a lot of money. That's not for the man at the moment. In the bionic woman, don't forget her. [MUSIC PLAYING] I think everybody who's involved in post-cute care and focused in an inpatient rehab facility is really understanding that we have a unique responsibility to care for people in challenging times, certainly getting through and trying to do rehabilitation through the pandemic that is still ongoing with some of the most challenging work that I have done to me. We didn't have access to all our facilities. We didn't have the ability to bring patients in. So and families into do training. So we're coming off a very challenging period to do this very important work. And I do think that it's important to make sure that all the resources are still utilized to make sure we get some success. Rosanne talked about association with others. I do think within the rehab environment, you're really looking at good company, right? Is there-- I was just going to say that it takes my personal personal personal personal personal personal personal personal personal. I really want to work with others' patient populations. And so at times when things are challenging, this is a good time to know that you've got good support around you. Absolutely. And I think that in my experience over the last couple of years, is that it really takes a special person to do what you all do on the rehab side. Because you're dealing with people that are generally their lowest point of their life for whatever reason that they're going through these these circumstances and I think to help guide them out of that bad space to become better, really takes a special person, someone who's really dedicated, not to themselves, but really to the general good of others. And again, I don't think I would be where I am today without the support of the team that I had. Again, it's an unusual circumstance, but I do consider the team that I had. I consider them my friends now. And pre-pandemic, you'd see me probably it's falling more than I should be there. But it's always good to reconnect with everybody and say hi and let them see how well you're doing. And you're doing this well because of them. I think that it's no matter what the rehabilitation process is for, it's a huge, huge part of the person that's on that side of being the physical therapist, the doctor, the occupational therapist, the nurses. It's the entire team that gets the patient to progress in life and huge thank you to what you all do. So, lots of love. We appreciate having you on the show today. Thank you for asking really. Anything I can always do to help, you know, you make me feel like I'm paying it forward. Thank you. Thank you both. This episode is brought to you by Murristera Putex, part of the Murristera group, a privately held family-owned company. Murristera Putex is committed to improving the lives of patients who suffer from movement disorders, spasticity, and neurological conditions. Focusing on advancing neuro-modulator technology, Murristera Putex offers Xiamen, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamen has a boxed warning and could result in potentially serious life-threatening side effects. Visit xiamen.com for important safety information and full prescribing information, including a boxed warning. In our next segment, we talk with Scott Riddle, vice president of orthotics, prosthetics, and viandex at Mary Free Bed Rehabilitation Hospital. Welcome, Scott. I think, again, this is still very relevant. If not more today, we have approximately 185,000 amputations that are currently currently in the United States alone. There's approximately 2.1 million U.S. citizens that are living with an amputation and many of those have prostheses. And if you look at the amputation coalition, which is a nonprofit organization, great organization, in fact, they project that by 2050, that number is going to double. So, it is a public health issue, and despite all the advances in vascular surgery and limb salvaging, the population is getting older in the United States, and this can continue to be a significant issue moving forward. It's a very interesting field because it's part engineering, it's part design, it's part medicine, the day-to-day of any, really any clinician within the field is extremely varied. You know, there's times spent swinging hammers back in the lab. If you're riveting a device back together, making a repair, and then 10 minutes later, it'd be uncommon to find a clinician back working with the patient, performing an outcome measure, a type functional test. So, it's quite varied, and what it's necessary, at the Bob's point, you know, there is a strong need for clinicians, and there will increasingly be so, currently there are eight grad school programs in the U.S., and I expect there will be more on the horizon because the increase in number of mutations in the generation and the aging population. So, there's a really significant need. You know, I like to see when we're thinking about the role of a prosthetic, the prosthetic to me, and this is speaking as a prosthetic, as a clinician myself, the prosthetic also ultimately is specialized clinician who manages the patient's prosthetic care. And there are certain parts of that role that I can confidently say all prosthetic engagement, and then there's certain parts that select few do and some will specialize in. So, the roles that all prosthetics will reliably perform are engaging with patients, performing a full and thorough evaluation on where the patient's currently at functionally, what their goals are, and then what is needed to achieve those goals. So, the next step that all prosthetics will engage in is they ultimately design the prosthesis, often in tandem with therapy and with desiatry and the rest of the medical care team, but a lot of that core design work comes from the prosthetic. They're the ones we're expected to know every singular component out on the market, and which of the thousands of components would be ideal for any particular patient? To that point, you know, you go back 50 years ago or doesn't have to even be that far back. I remember when I was getting started in my medical career, there weren't a lot of options. I mean, there were leather suspension systems, but as technology is advanced, and we just didn't episode actually on a assistive technology, the variety of componentry, it's a much more thoughtful process now that you have to go through to determine what's really to the benefit of this particular patient based on, you know, as you mentioned, their goals and on their physical condition and other comorbidities. There's a lot to there is a lot to factor in. I mean, yeah, you're speaking history at one point, your typical lower extremity prosthesis was held on via suspenders actually. So we've come a long way, and fortunately, you know, if we're talking suspension alone, so just the act of sort of keeping the prosthesis attached to the patient's residual limb off the cuff, there are at least six entirely separate types of suspension. And that's a huge consideration in the way we're designing a prosthesis for in particular patients. So there's this suspension, there's the socket design, there's the endoskeleton componentry, there's the foot, the knee, there's a whole lot that goes into it. So part of the prosthesis role is first determining where the patient's functional level is currently at, where they have potential to be at, and then really selecting componentry specific to two goals. So I had a patient about a year ago who had a goal of getting back to hiking. This was Alon Colorado, and she was highly active patient. She had had a fairly recent amputation, but a specific goal of hiking again. And we had for a while, she had been utilizing a carbon fiber prosthetic foot. And we just found that it wasn't giving enough articulation to account for the uneven terrain. So we demoed a microprocessor ankle on this patient, and we had a rock slope outside the office. And upon her first time sort of traversing down this rock slope, she got to the bottom, and she, she was in tears, and she had a, she was smiling from ear to ear, and she turned around, walk that up the rock slope and gave me a big hug, because it was, it was that foot solution that was going to allow her to reach her goal. And it was so clear and visible in this moment that the component can have significant effect on the outcome. So it's very important that the clinician understands fully what is out there in the way of tools to use for a patient, because having that deep understanding can really lead to tangible change for the patient. Yeah, so I really want to touch on a couple of different types of scenarios, particularly, you know, the loss of a limb is really a loss of a part of yourself, and there's a tremendous emotional and component engraving process that many patients have to go through, throughout the recovering process. And that's so important because having a knowledgeable prosthetist or rehabilitation physician, the rehab team, the physical therapist involved early on in the process can really help, I think, mitigate a lot of the anxiety and concerns that the patients have. And so there's two scenarios, right? There's the traumatic, unanticipated accident, so to speak, that occurs like a motor vehicle accident where a patient loses a limb suddenly. And they left it to just, you know, deal with that, you know, tremendous adjustment right from the onset. And then there's the other scenario where there's a peripheral vascular disease problem, or maybe it's a bone tumor. And there's time. There's time to try to, you know, once salvage the limb, but ultimately the decision is made that may not be possible. But there's time to prepare the patient. And I'm wondering if you could just, you know, sort of share your experiences in both of those and how you approach it. If we're looking to optimize success in a perfect world, we would be able to provide consultation to all patients. The decision to amputate would ultimately be elective because we find that when patients are making that decision, they, you know, way have that bind to what's going to happen to their limb. And then they, from the earliest stages, have an understanding of what will be required to achieve the outcome. they're looking for. That's in a perfect world. It does happen, whenever possible, if this is a pre-scheduled event, we do seek to have consultation with patients where we'll sit down with them. We'll walk very slowly through the process. We'll show them examples of prosthetic legs, show them videos of success stories, really lay the groundwork for a future of motivation and really an actual excitement around what we're able to do in the prosthetic world. When it's a trauma-related invitation, it's more reactive. It certainly delays the communication we're able to provide, which has some ramifications, but ultimately, regardless of the type of an invitation or the ability to anticipate it, the underlying goal we have is to communicate strongly as early as possible in the scope of the rehab for the patient. So we have currently a very free bed, as Patricia mentioned, and at my free bed, we have an empty seat carry liaisons. And this is a specialized clinical position. Our empty carry liaisons are made up of occupational therapists and certified occupational therapy assistants. And this is a team member who works very closely with the large rehab team as a whole, the physical therapist, desiatry, prosthesis. And they're the ones providing, sitting down with the patient, providing pre-op counseling, answering questions, post-op. They're the ones essentially hand holding the patient from time of surgery through to when the prosthesis starts working with them. And they're the ones who the patient has on speed dial. They call quickly, they can get questions answered. There's so many questions following an invitation. It's very helpful for these patients to have a quick and clear person that they can reach out to to have those questions answered. What are some of the questions that patients have? What are some of the common ones? A lot of the questions circle around timing on prosthetic use. When will I get my prosthesis? It's probably the most common one following the surgery. It's when will I walk again? When will I be able to insert activity again? Those questions are certainly harder to answer because they're just so dependent on the recovery following the invitation. But what we try to do is provide an answer that is in line with our own experience and what we've seen. But really what we try to do to answer that question, or to get the result the patient is ultimately looking for in timeline, we try to square their goal or align their goal with the practices needed on their end to achieve the goal. Because if I can give an example, I had a patient, again, who had had a unilateral amputation, and the ear following he had his second leg amputated, so he was then a bilateral transtibial amputate. And he broke it down. He broke his goals down in two individual rules. His first was to walk with bilateral prosthetic lens. And then his second goal, he was a avid golfer. So his second goal was to be able to get back to not only golfing, but golfing as well if not better than he had been prior to amputation. This was paramount to his success. And ultimately, long story short, he got to those goals because he had the goals. And then I as his prosthetic work with him and developing his-- the practices needed on his end to reach those goals. That typically will include regular limb inspection, actively engaging with therapy, engaging with position appointments, watching his diets, performing expected limb care protocol, which includes sort of using trinkers at night, and massaging your limb, and breaking in any type of prosthetic device. He followed these goals in a way that ultimately led him to get the outcome he was looking for. And I think that is of real significance to him getting to that point of success. One real fun story, too, when he had a goal of walking for the first time with bilateral limbs, he came in, and I had his-- what we call a definitive prosthesis ready. And he was over the moon excited for the appointment. And he actually came in, and he had had a playlist he had created of the five songs he wanted to play during his first steps. And I was curious what kind of songs we're going to be on this playlist. And he wanted to play them out loud in the clinical room. And he hit the first one, and it was "Walk This Way" by Aerosmith. And it was Donnie Cash, "Walk the Line," and then it was "Walking on Sunshine," and he had all these walking-themed songs. And I loved it. And it just pointed to, like, he was so successful in his rehab because he developed his own sort of points to motivate him, and that ultimately proved to be key. Does the patient's family play a role in their recovery, learning how to use their prosthetic limb or adapting to having a prosthetic limb? What's their role? You know, speaking from experience alone, I can say there's really a direct correlation between family involvement and prosthetic success, the successful patients I was speaking on this bilateral trans-stabilanputic golfer prior, and the common denominator with all these patients is they have families who support them, who motivate them, and ultimately are alongside them through the entire care timeline for that patient. So for this particular golfer, his wife was a golfer as well, and his wife was at all of the appointments with myself and with the physiatry, and she was going to his physical therapy appointments. There will be bad days for the life of anybody with a limb difference. And having somebody there to provide them with that motivation and that feedback and that counsel can get them through those bad days and ultimately, that will result in certainly improved success. What are some of the things that patients need to learn, like especially lower extremity patients? Yeah, if we're getting back to, what is the most common patient question in my experience is that timeline? You know, when I'm going to be able to walk again. And if we're using that, there isn't anybody who wants that to be delayed. The goal is always to shorten that timeline. And if the goal is to shorten that timeline, the point of highest priority in my experience really is limb health and limb care. So that begins with what is done immediately post-op, in way of protection, in way of compression, in way of safety. So if we talk about what are the benefits of patients being in an inpatient rehabilitation setting, one of those is safety. If they're inpatient, they're less likely to have a significant fall in suffer the consequences because of one. It's very common for new amputees following an invitation to wake up in the middle of the night and forget that they have an inpatient limb and they get out of bed and they try to start walking and they fall. And I can really compromise limb health, certainly if you fall into your residual limb. So protecting the residual limb is best as possible. And then once healing starts to begin, it's the care that's being provided to prep the limb for processes use. So it's the massage. Again, it's the compressions, the massage. It's the regular inspection. It's following certain particles. You don't want to shave the hair on your limb in any way. You don't want to use the right soap if you're cleaning your limb. You want to clean your limb regularly. There's just a lot that goes into that. But really prepping the limb for prosthetic use is paramount to success. Yeah, I couldn't agree with you more, Scott. I would take it even a step further in saying that being in an inpatient rehabilitation setting where you have rehab nursing, you have the rehab physician, the prostitist, at least in my experiences in the building on a regular basis and really as part of the team, everything that you do with that patient is focused on getting that limb to where it needs to be. So as an example, these patients are going to be their major mobility is going to be via wheelchair initially. But positioning in that wheelchair is so critical so that you don't develop a contracture. Let's say at the knee, which would obviously be impactful in terms of when you're ready to get up and across the system. If you no longer have your full range of motion, your knee, it's going to severely impact your function. So really having that team there and educating the patient and the family about how to manage and position and move around and just facilitate that healing process as rapidly as possible is so critically important. Absolutely. That cannot be expressed enough. Having that specialist care team around the patient 24/7 in a post-op setting is extremely valuable. Thank you so much for your time this morning. We really appreciate your insights. Thanks for listening to Medical Rehab Matters, a podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor Merc Therapeutics for its support, as well as their gold and platinum association sponsors. Our platinum sponsors are Bioness, Casa Kalina Hospital and Centers for Healthcare, and Select Medical. Our Gold Sponsors are Cerner, JFK Johnson Rehabilitation Institute, Boss Rehab, and the Center for Improvement and Healthcare Quality. You can learn more about medical rehabilitation at AMRPA.org.