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Since Gulf War, Advanced Prosthetic Technology Saves Lives, Careers

Image of Soldier walking with prosthetic leg. Army Spc. Ezra Maes underwent physical rehabilitation at the Center for the Intrepid, Brooke Army Medical Center’s cutting-edge rehabilitation center on Joint Base San Antonio-Fort Sam Houston, in October 2019. (U.S. Army photo by Corey Toye)

This is the third in a series of articles on advances in military health care and technology since the Persian Gulf War, 30 years ago this year. See part 1See part 2.

Since the first Gulf War ended in early 1991, military medicine and battlefield care has made enormous strides. Many of those strides are being taken by warfighters who have lost a leg, or the use of multiple extremities, in Iraq or Afghanistan, and have learned to walk once again with the use of modern-day prosthetic limbs.

“Blast-related polytrauma was the signature injury that we were taking care of, and continue to,” said Dr. Paul Pasquina, a retired Army colonel who is now professor and chair of the Department of Physical Medicine and Rehabilitation at the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland.

“When you look at the folks with limb loss that we’ve taken care of since 9/11, a high percentage have lost more than one limb,” he said. “About 40 to 60% also sustained a brain injury. Because of some of the lessons learned and the innovations that have taken place on the battlefield, whether they be in acute resuscitative care, or tourniquets, or rapid med-evac, we were taking care of service members who in previous conflicts would have died.”

Advances in artificial limb technology would be moot without these developments made in combat care between the Gulf War and the post-9/11 conflicts, experts say. Getting critically injured service members off the battlefield and home alive in a timely and efficient manner spurred technical and career-related innovations.

“There’s not a ‘golden hour’ in military medicine — there’s a platinum 10 minutes,” said Dale Smith, an author and professor of military medicine and history at USU. Speed and efficiency of care save lives, he explained, and after the Gulf War, “Forward care and accelerating movement of the wounded were advanced, and the tactical combat casualty care system grew. New synthetics would be developed.”

“We would see casualties sometimes within 36 hours of severe injury on the battlefield in our ICUs,” said Pasquina. His service as a deployed doctor bridged the first Gulf War and post-9/11 operations. He retired as chief of orthopedics and rehab at Walter Reed National Military Medical Center in Bethesda, Maryland, where he now works in a similar role as a civilian.

After that came the process of healing, often with the aid of synthetics, including many of the increasingly sophisticated prosthetic devices created since the start of the wars in Iraq and Afghanistan. Ground troops who before operations Iraqi Freedom and Enduring Freedom would not have necessarily survived were instead alive, at home and facing life without a limb.

The first step is saving lives, Pasquina said. “But the next step is restoring lives, and providing some meaning to those lives. It’s been incredibly humbling to see how resilient most of our service members and families are in their ability to often thrive after catastrophic injuries.”

‘Hey, Doc.’

To that end, prosthetics, new therapies and advanced pharmaceuticals have allowed commanders to bring people back for limited duty, maintaining their knowledge and experience. This has transformed the all-volunteer force over the last 10 years into a viable career even for some who have been grievously injured.

That includes staff and rear-area jobs, Smith said. If you were an E-4 or E-5 in the field, “and now you’re back in supply, you know how important it is to the guy at the pointy end that this works.”

Officers doing staff work who have lost a leg to an IED as a brigade commander, Smith added, can serve on a division staff and be much more sensitive to “the ambiguities of deployment” than someone not so familiar with combat. These wounded warriors now working new jobs provide a healthy sense of urgency, and often inspire those around them in their new duty stations. As a bonus, close monitoring of their continued rehabilitation has helped to further the technology.

“Historically, advances that have come in assistive technology, particularly in prosthetics and orthotics, and even in wheelchairs, have come mainly from folks with impairments or disabilities that are just not satisfied,” Pasquina said. “It’s like, ‘Hey, Doc — I know this is what ya’ got, but it ain’t good enough.’”

Pasquina added that he’s not picky about where a new technology originates, but said it’s incumbent upon military doctors to bring world-class treatments to American service members.

Osseointegration – a procedure that permanently, surgically anchors an artificial implant into a bone, which then grows over the implant – was developed in Sweden, for example. Like so many procedures described by Pasquina, it involves physicians from many disciplines: orthopedic and plastic surgeons, rehab and nursing specialists, prosthetists, psychiatrists, and more.

“We are all charged to go out and look, not just in the literature, but with our colleagues in the military, in civilian facilities, or in other countries,” he said. “We all now have a mission to bring the latest and greatest.”

Stand by

The use of prosthetics as part of bio-medicine will only increase, said Alan Hawk, manager of historical collections for the Defense Health Agency’s National Museum of Health and Medicine. The development of regenerative medicine, funded through the Defense Advanced Research Projects Agency (DARPA), holds promise for some patients sustaining nerve and vessel damage to retain a limb instead of having it amputated. The possibility of using stem cells to grow new skin is another example on the horizon, he said.

Nevertheless, Pasquina prefers to temper his enthusiasm for new prosthetic devices and procedures developed since he was a young officer in the Persian Gulf, 30 years ago.

“I get a little nervous when we celebrate too much the advances that have been made,” he said. “Despite how well many are doing, there are still many that continue to suffer. But [with new devices] we want to bring folks back and have these available for them, whether they were injured yesterday or 10 years ago. With advances in prosthetic technology in particular, many of the patients I take care of – from Vietnam, Gulf War I, ... training accidents – everybody can benefit from this technology.”

Pasquina also cited DARPA research, including an exoskeletal program employing robotics for people with paralysis or limb loss. Other groups are working on microprocessors built into prostheses that can sense the speed or actions of an individual, and adjust joint reaction in real time. All the while, motors and batteries are getting smaller, allowing for actuators in limb prosthetics for greater ease of movement.

He also spoke of a “brain-machine interface” where thoughts can lead to electrical signals picked up by a computer and translated into a motor, to manipulate a robotic hand. Even the restoration of a certain amount of sensation via prosthetics is on the table, he said, and there are prototypes for prosthetic fingertips that pick up on tactile stimulation and send impulses into the body that are perceived as touching.

“That’s really exciting,” Pasquina said.

“When we think about our hands, touch is as important in many aspects of our lives as is manipulating objects.”

Continuing next month: How 3D printing is re-writing what's possible in post-traumatic care.

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