Wounded warriors' perspectives: helping others to heal.
Article Type: Guest editorial
Subject: Amputation (Usage)
Amputation (Methods)
Disabled veterans (Services)
Authors: Arredondo, Juan
Foote, Ned
Pruden, Jonathan D.
McFarland, Marc J.
McFarland, Lynne V.
Pub Date: 07/01/2010
Publication: Name: Journal of Rehabilitation Research & Development Publisher: Department of Veterans Affairs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Department of Veterans Affairs ISSN: 0748-7711
Issue: Date: July-August, 2010 Source Volume: 47 Source Issue: 4
Topic: Event Code: 360 Services information
Product: Product Code: 9105601 Veterans Pensions & Disability NAICS Code: 92314 Administration of Veterans' Affairs
Geographic: Geographic Scope: Iraq; United States; Vietnam Geographic Code: 1USA United States; 9VIET Vietnam; 7IRAQ Iraq
Accession Number: 241861741
Full Text: [ILLUSTRATION OMITTED]

They have walked the walk and paid the price. A very high price. They are veterans who sustained major limb loss during the Vietnam or Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts. Their names are Juan Arredondo, Ned Foote, and Jonathan Pruden. All three have adapted to their limb loss, but daily struggles still exist for them, as well as for others who have moved on with their postmilitary lives.

Jonathan Pruden and Juan Arredondo served during a different military era (OIF/OEF) than did Ned Foote (Vietnam); but despite the differences in age, the three men share a common goal, a common passion: to see that all wounded servicemembers receive the best possible care through a supportive rehabilitation process and a smooth transition from Active Duty into the Veterans Healthcare System and, especially, to receive comprehensive prosthetic care services and other benefits they deserve. Their mission now is to help other wounded warriors navigate through the recovery process and restore a satisfying lifestyle.

As active volunteers in national programs that assist fellow wounded warriors, they were invited to participate in the Expert Panel meeting, convened in Seattle, Washington, in 2008, to examine rehabilitation care issues and prosthetic device challenges for the study described in this issue of the JRRD. In addition, they participated in a joint interview to discuss their experience through the recovery process and share valuable lessons learned on how best to adapt to limb loss. We hope their stories will provide guidance and inspiration to others with disabilities.

THE BATTLEFIELD INJURY

Ned Foote was drafted into the U.S. Marine Corps and was sent to Vietnam in 1969 with the 3rd Marine Division as an infantryman. While Foote was on patrol in the demilitarized zone, a mine was detonated during an ambush, killing two and injuring Foote and six others. His severely injured foot was later amputated on a hospital ship. He was sent to Guam for further surgery. As a result of infections and other complications, his amputation was later revised to above the knee. He returned home to New York to continue his medical rehabilitation, including physical therapy and fitting and training for his prosthetic device at the Department of Veterans Affairs (VA), Veterans Health Administration.

Juan Arredondo, a U.S. Army sergeant in the 2nd Infantry Division, was driving on patrol in Iraq with two other servicemembers in 2006. A cellular phone-detonated device exploded through the door of their vehicle, seriously injuring all three men. The explosion instantly severed Arredondo's left hand below the elbow and inflicted extensive damage to his legs. Although the injuries to his legs were not life-threatening, his severed hand could not be reattached. He was sent to Brooke Army Medical Center in San Antonio, Texas, to begin his recovery process.

Jonathan Pruden, a lieutenant in the U.S. Army serving in Iraq in 2003, was wounded on July 1, 2003, becoming one of the first improvised explosive device casualties of OIF. He was hit with 173 pieces of shrapnel and 1 bullet. After initial surgeries in Iraq, he was medevaced to Landstuhl Regional Medical Center in Germany for additional surgeries and then transported to Walter Reed Army Medical Center (WRAMC). Arriving at WRAMC was the first step in his recovery. Over 3 years at seven different military hospitals, he had 20 surgeries, including the amputation of his right leg. Pruden, now a retired captain, recalls his many surgeries and long rehabilitation process with a positive light: "I would have died even 20 years ago due to the extensive injuries and blood loss."

STEPS TO RECOVERY

During the Vietnam conflict, nearly 25 percent of wounded servicemembers succumbed to their injuries, largely because of the inability to reach mobile surgical hospitals [1]. With improvements in protective gear, Kevlar vests, and rapid medical evacuation to medical or surgery units, nearly 90 percent of servicemembers wounded during the OIF/OEF conflicts survive [2].While the core of the body is better protected, arms and legs are vulnerable to blast injuries. Rapid evacuation to military medical centers in the United States results in the medical care system seeing more severely wounded servicemembers with major limb loss surviving and requiring extensive rehabilitation.

After a servicemember is injured, he or she begins the road to recovery. Although this process is lifelong, the advantages of being in the military service include access to multiple support systems and the development of innovative medical care for combat injuries. Wounded servicemembers benefit from continual advances in triage, treatment, rehabilitation, and prosthetic-device technologies, which are used in military hospitals by skilled medical and rehabilitation teams to give servicemembers with major limb loss every opportunity for success.

Following what may be a series of amputation-related surgeries, it is important for the servicemember to gradually become more mobile as soon as possible in keeping with physicians' instructions. More than just the physical benefits of combating deconditioning, it can be a mental boost to regain more of a normal lifestyle. "I didn't believe it at first, but I finally was able to go rock climbing. If you think you can't do it [today], just give it time," Juan Arredondo suggests. Ned Foote points out that attitude is a big part of recovery: "You can do whatever you want to. Maybe not how you did it before, but you can adjust."

What were the biggest challenges faced by the wounded servicemembers recovering from a major limb loss? "The mental aspect. Am I going to be kicked out of the Army? How am I going to support my family? These are questions that are not answered right away, so you worry about them," Arredondo answered.

Another challenge that Pruden emphasizes is that veterans who lose limbs as the result of blast injuries also frequently suffer from brain injuries and posttraumatic stress disorder, factors that can be even more debilitating than having an arm or leg amputated. Pruden says, "When you lose an arm or lose a leg, very seldom is that your only injury.... Ninety-nine-point-nine percent of the time, you've got hearing loss, you've got other injuries, and you get your brain rattled around. The number one reason I've seen guys fail to thrive, fail to do well--amputees and all wounded guys coming back--is because of posttraumatic stress disorder and traumatic brain injury. Those two things, alone and together, are the number one reason guys fail. Not because of an amputation or anything else. It's their mind."

"I dealt with my posttraumatic stress by trying to help other veterans," Foote says. "And I've been doing this since '81, when I finally decided that being a Vietnam vet wasn't a bad thing. You can be, 'Poor me,' or you can make something of your life. And I chose to make something of my life."

DEVELOPMENT OF A SUPPORT SYSTEM

Support systems assist in the recovery process and can be invaluable to wounded servicemembers. Support systems are diverse and can be provided by the military, the VA, healthcare professionals, mental health staff, nonprofit organizations, families, friends, and peers.

Arredondo, Foote, and Pruden all emphasize the importance of peer support. "Peer" is a broad term that can include anyone in the military, someone from the servicemember's unit, anyone with limb loss or disability, veterans with limb loss who have learned to navigate through the recovery process, or friends and "buddies." For servicemembers and veterans with major limb loss, there are specially trained and certified peer visitors who are typically members of organizations such as the Amputee Coalition of America, Vietnam Veterans of America, or Wounded Warrior Project. These peer visitors have gone through training courses that enable them to effectively guide wounded servicemembers and veterans through the recovery process.

"At first, I wasn't motivated to really go anywhere or talk to anybody," Arredondo recalls. Then his fellow wounded servicemembers told him how much they appreciated talking to some of his friends who were visiting him. "I started talking to them, and it really motivated me. Peer mentoring is one of the biggest keys, I think, to get these guys started to being adjusted to life with a prosthetic device. That's what we're doing. That's the biggest key to someone using their prosthesis or being able to handle their prosthesis in public."

Pruden also credits his peers for providing support. "Fellow peers or buddies can be a source of insight and wisdom about dealing with the amputee veteran's fears, concerns, and prosthesis needs. These visits can be of great psychological and emotional benefit. Sometimes, little actually needs to be said. The wounded servicemember looks up from their bed and sees another person with limb loss who has adjusted and gotten on with life. There's the unspoken message that a fulfilling, rewarding life is attainable. The job ahead may be difficult, but a worthwhile life is possible. You [a visiting peer] are telling people the challenges you are facing are normal. You try to let them know that you've experienced the same feelings and frustrations. I'll never forget the support I received from another Vietnam veteran who was a double amputee. His insights and support really helped me as I struggled to cope with my injuries. Visits from veterans who are missing limbs and are thriving give you hope when you are laying in a hospital bed unable to see past the next surgery. I also think that helping the newly wounded is good for the Vietnam veterans."

Foote confirms this opinion. "Absolutely. Absolutely. I think we feel good, because we think we're helping you. We think we're teaching about posttraumatic stress and all the things we went through. We feel good that we survived."

But Pruden does point out that the visiting Vietnam veterans may not always be accepted as peers by servicemembers of a different era. "You guys [from Vietnam] aren't our peers." Pruden tells Foote. "It's not the same as having Juan or me come in to visit amputee veterans of a similar age. But, in other respects, it's better because I look at you and I think, 'Here's a healthy, well-adjusted person who has lived his life and has a family, and here he is 30, 40 years out from his injury and he's thriving.' And that can be me."

While visits from buddies of the same generation are beneficial and worthwhile, some questions they simply cannot answer for the person who is bedridden and recovering from life-changing injuries. One of the most pressing concerns for the newly recovering servicemembers is whether they can establish any sense of security about the future: What they are going to do for the rest of their lives, how they are going to support their families, and how their injuries are going to shape their remaining days.

Pruden says to Foote, "Seeing well-adjusted guys like yourself [a Vietnam veteran], makes me think when I'm your age, I'm going to be fine." This is the crucial point expressed by these three men--that the bedridden servicemember who is plagued by doubts can be so encouraged just by the appearance of a person with similar traumatic injuries who has overcome the loss and moved on to a productive, fulfilling life.

"Sometimes, it's hard," Pruden says of making buddy visits. "You see a guy struggling physically and psychologically, and it breaks your heart; it's hard. You come home and cry, sometimes. But you focus on the good things, the things you're able to help with. And, honestly, it's just an honor for me to be with those guys that gave so much, and their families, the people who are supporting them."

"One good thing they implemented at Brooke Army Medical Center is a town hall meeting," says Arredondo. "It exposes you to doctors, the VA reps. It's open--there's no officers, no NCOs [noncommissioned officers], just 'Us Joes.' ... It allows everyone to talk about what's important to them and how we can get problems fixed."

Family life is also a vital part of recovery. "When I started recovering, I wanted to get married to my high school sweetheart; I'm still married to her today after 38 years," Foote says. "I wanted to get married, I wanted to get back to work, and I wanted to start a family. That was my motivation, and I did that in a very short period of time. The mental and emotional challenges of feeling alone and isolated were very draining. I was always alone. I didn't have other amputees around. So, yeah, [for me the biggest challenge] was mental."

For Pruden, "One of the big things that helps is family support. I had my wife there at my bedside. And some of the study data shows that folks that have family support do better than those without."

ADJUSTING TO NEW LIFESTYLE CHALLENGES

Life can be a succession of adjustments and transitions. Certainly, the changes these three men experienced were daunting; and, at times, the challenges seemed overwhelming, even insurmountable. But they persevered and found that helping others can help their own transition from feeling like a victim to becoming caring, compassionate, and insightful.

"Adjusting to prosthetic life is kind of difficult," Arredondo says. "I would wear long-sleeve shirts all the time [to hide his prosthetic arm] until I started meeting people with the same injuries. That's what helped me adjust to life outside, as a civilian. Most of the challenges, I guess, are psychological, confidence, trying to work things out and do some of the same things I did."

"Initially, you've got to focus on yourself because you're in a bad state," Pruden says. "But my mission now is to help other people. For a lot of guys, there is a pattern to the recovery process. At first, you're just surviving the surgeries and pain. Then there is the emotional time where you realize what you've lost and then have to figure out what it means to you. What will you be able to do afterwards? What will you never be able to do? I was very lucky to have my wife, Amy, by my side during this time. I can't overstate how much it means to have a loved one with you as you struggle physically and emotionally to cope with your injuries. After a while, you begin to focus on the things you will still be able to do and can see that you are better off than many other wounded servicemembers. Finally, you come to terms with your amputation, adjust some of your priorities, and start challenging yourself physically and mentally. Then you forge ahead."

Arredondo adds, "For the physical challenges, in the Wounded Warrior Project we sometimes provide rehabilitation trips . . . where the guys go rock climbing or whitewater rafting. When you complete something like that, something scary--where you could fall out of the boat, hit your head on a rock--when people pass that, they're like, 'Wow!' That helps out a lot. Once you get them up ... challenge them, and they complete that challenge, they feel like they can do anything."

Pruden confirms the importance of a positive mental outlook: "You can be missing four limbs, but if you've got a functioning mind and a great attitude, you're going to get on with your life. You're going to compensate."

TRANSITIONING INTO VA CARE

Once wounded servicemembers retire from active service, healthcare insurance is paramount. Entering the VA system can appear to be daunting, but great efforts have been made to facilitate an easy transition into the VA healthcare system. Help from the VA often begins with visits to a hospitalized servicemember who is in pain, uncertain, and frightened about what the future holds when he or she moves from Active Duty under the Department of Defense (DOD) to the VA. "The transition is a place fraught with peril as far as the possibility for hiccups and glitches," Pruden says. Foote points out that, "Guys come from the DOD, where you've been 1, 2 years rehabilitating with other amputees, where you have that support, where you talk to each other. Once you come into the VA system, that's no longer there. You're on your own."

One common frustration in transitioning from the DOD to the VA is the loss of medical records on both sides, a "problem almost everyone's faced," according to Pruden. All three warriors advise servicemembers to take a copy of their medical records and benefits statements with them when they are discharged from the military hospital, whether retiring into civilian life, using private insurance, or transitioning into the VA.

All three men have praise for many aspects of the VA system. Foote says the VA has improved considerably in the 4 decades since he left Active Duty: "I think the VA hospitals have changed, and for the good. The past few years I have used the VA heavily. Others tell me bad things about the VA. I did not go to the VA when I first retired, but I use the VA now and can't say enough good things about my care."

For Arredondo, getting information is paramount: "The transition to the VA system went pretty smooth because of some of the vets I talked to. We kind of help each other out when it comes to filing for our benefits and entitlements. There's a lot more help these days because people tell you more things. The only thing is sometimes the VA doesn't tell you [all] that you're entitled to, and they won't give them to you unless you ask. And you don't always know what to ask for, because you don't know who to go see. There's a lot more information that's put out, but there's some information that if you don't ask about it, you don't know about it."

At times like these, peer-support and veterans' advocacy groups, such as the Vietnam Veterans of America and Wounded Warrior Project, can be of tremendous help to the bewildered veteran who feels he or she is floundering within a large bureaucracy. "A lot of information, we get from our peers and buddies," Pruden says. "My number one source of information is my fellow servicemembers with amputations and also from some Vietnam veterans I know who work inside the VA." Arredondo credits the Wounded Warrior Project with providing the help he needed: "They helped me out. They explained to me how the VA system works. And I went through the system pretty good. Now I tell the guys, 'Here's how they do it, this is the system they go by.' And it really helps them a lot."

ADAPTING TO THE ROAD AHEAD

Many Vietnam veterans with major limb loss have survived for more than 40 years and provide valuable encouragement for adapting to this challenging lifestyle. As Pruden has pointed out, seeing well-adjusted Vietnam veterans, 40 years out from their injury, is empowering to those just beginning to tackle the road ahead. For Vietnam veteran Foote, helping others heal "has been very fulfilling and life-affirming."

Another point for the future, Foote points out, is that as the population of Vietnam veterans ages, the number of veterans who can be involved in politics at both local and national levels is dropping. Without veterans to remind policymakers of the needs and priorities for wounded veterans, the political interest lags during nonconflict times. Foote suggests that "the newer OIF/OEF servicemembers have to realize they have to step up and have their voices heard in the political arena."

Long-term personal goals may change; a major injury can help to refocus life's priorities. "Before my amputation, my life was centered on my military service," Pruden reflects. "Now, I focus on spending time with my family and helping my fellow wounded warriors. For me, it's helped me heal, psychologically, to help the next guys coming along. I think when you're helping, you kind of internalize some of the things that you're trying to teach. It's almost like a self-affirmation. As you're helping them, you're helping yourself."

Arredondo suggests, "Find something that relaxes you and do it. It helps reduce the stress of adapting to your new lifestyle," and Foote adds, "You have a new mission. Help the vets."

FUTURE CHALLENGES FOR THE VA

"Unfortunately, all VAs across the country aren't the same," Foote says. Pruden agrees: "There are regional differences. There's so much variability. I know some guys travel across the country to get what they need, because they can't get it at home. The variability among VA facilities is pretty huge." For many years, most of the prostheses provided by the VA went to older veterans whose limb loss was due to diabetes and vascular disease.

Foote points out the disparity between the advancing technology and its availability: "In response to the current influx of veterans with amputations from OIF/ OEF, the VA has done an excellent job of fielding cutting-edge prostheses, but some of its prosthetists don't seem interested in learning about the new technology." Getting a responsive prosthetist should not be a hit-or-miss proposition depending on which VA facility the veteran accesses. They agree that the VA needs to provide quality care more uniformly nationwide.

The VA should expect to deal with increasing numbers of veterans with major limb loss, because survival from traumatic blast injuries is increasing, the three point out. More wounded servicemembers are coming home and will transition into the VA healthcare system.

The horrible truth of combat is that people get killed and maimed. Historically, many advances in prosthetic devices have come during and shortly after times of armed conflict, when the need for this technology is greater. Currently, with more servicemembers surviving wounds than in the past, healthcare professionals realize the growing need for more and improved prostheses and prosthetists. In addition, as veterans age and disease takes its toll, more may face amputation and prosthetic device issues later in life.

Expanding the VA's role in research on amputation rehabilitation and prosthetics would benefit veterans with limb loss from all eras, the three agree. "The VA, historically, has been the avenue for advancements in prosthetic device technology and all sorts of technology.... I'd like to see development of amputee centers of excellence where skilled prosthetists, physical therapists, and physicians can utilize the latest technologies to provide the best care possible," Pruden commented.

"All over the nation, there's an emerging new technology in prosthetic devices and orthotics," Pruden says. "You've got people who are interested, motivated, and smart. If the VA wants to provide the majority of prosthetic device care for this population, eventually they have to hire these quality individuals."

The three agree that a larger and better-qualified in-house staff of prosthetists in the VA system would cost more, but their expertise would benefit a greater number of veterans. Knowledgeable, competent prosthetists realize the temptations that new technologies offer but temper that excitement with the wisdom of what kinds of prostheses, sockets, and suspension systems are best for each individual.

Getting the word out to veterans about prosthetic device advancements would also be of great help, the men say. Foote notes that participating in the Expert Panel meeting in Seattle provided him with a prostheses Web site of which he was unaware (VA Prosthetics and Sensory Aids Service, http://www.prosthetics.va.gov).

"That's a great point," Pruden says. "One of the things that really came out of [the Expert Panel meeting in Seattle] is that Vietnam and OIF/OEF veterans want more information about their prostheses and what's available. When you get a thick package of information about benefits, it's not really helping, because most guys aren't going to read it. Create a Web site." Pruden also suggests adding a clinical reminder in the VA's computerized medical records so that, for anyone with limb loss, "a little indicator pops up on the screen and says [to the primary care clinician], 'Ask patient--Are you interested in receiving information about technologies available for prosthetic device use?' Then, [the veteran] doesn't have to go online, doesn't have to be savvy on the Internet. His address is in the system, so the central office can automatically send him information on prostheses that are available, benefits that are available, what activity level they're for."

Arredondo suggests a 30-day trial on a prosthesis, after which the prosthetist could suggest more choices if, for example, there is a lot of pain. "The practitioner makes the call. I see my buddies do it all the time, they see a new prosthesis and they say, 'I want one of those!' A good practitioner can tell you if it is not good for you. The VA needs to get the good guys in-house." He also sees the need for research and development at the VA: "The research and development would be in-house. They did away with it at some of the VA centers because there was nobody coming in; there was hardly any work to be done. So, that department was a waste of money, let's take it out. But every so often there's a new war. It's going to happen, and you're going to have guys [with limb loss] come in. I think the VA can do it."

FINAL THOUGHTS

Currently, Ned Foote is President of the New York State Council of Vietnam Veterans of America, Juan Arredondo is a benefits liaison for the Wounded Warrior Project, and Jonathan Pruden is an Area Outreach Coordinator for the Wounded Warrior Project and a Volunteer OIF/OEF Patient Advocate at the Gainesville VA Medical Center. In 2007, Pruden completed a master's degree in political science at the University of Florida. All three are committed to helping others heal. They share their final thoughts here.

Foote

"If you want to sit in that wheelchair, that's your choice. If you want to feel sorry for yourself, go for it. But if you want to make something of your life--after I retired from the service, I worked 13 years in a paper mill, and I worked 24 years for the post office. That was my choice. Now, I play golf as much as I can. You can do whatever you want to do."

Arredondo

"I agree. I didn't believe it at first. But after they showed me another guy who had the same amputation that I have, I started to. If you think you can do it, just give it time. It takes time. It's really terrible, that time you're waiting to get your prosthesis and get out of bed. But once you get out of there, you'll do well. A lot of the vets provided freedom, they all had something to do with the change in history ... from the lowest private to the highest general ... and they should all be taken care of like generals ... they gave up their limbs for freedom."

Pruden

"It has changed what my life priorities are. I was so focused on my job, but I don't know if that would have been good in the long run. This has caused me to reevaluate my priorities. My job is still important, but I place more emphasis on spending time with my family, watching my children grow up, and helping my fellow warriors."

Arredondo

"Mission first--that's how we're trained in the military. If our mission is to help the veteran, that's our new mission."

DOI: 10.1682/JRRD.2009.02.0021

ACKNOWLEDGMENTS

These men are 3 of the nearly 600 participants in the national Survey for Prosthetic Use (Appendix 1, available online only). Their stories and viewpoints are their own and are not meant to represent all wounded servicemembers and veterans. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the DOD.

REFERENCES

[1.] Dougherty PJ. Wartime amputations. Mil Med. 1993; 158(12):755-63. [PMID: 8108012]

[2.] Peake JB. Beyond the purple heart--Continuity of care for the wounded in Iraq. N Engl J Med. 2005; 352(3):219-22. [PMID: 15659720] DOI:10.1056/NEJMp048312

Juan Arredondo; (1) Ned Foote; (2) Jonathan D. Pruden, MPS; (1,3) Marc J. McFarland; (4) Lynne V. McFarland, PhD (5) *

(1) Wounded Warrior Project, Universal City, TX; (2) New York State Council, Vietnam Veterans of America, Queensbury, NY; (3) Gainesville VA Medical Center, Gainesville, FL; (4) Freelance healthcare writer, Seattle, WA; (5) VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA

* Email: Lynne.McFarland@va.gov
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