Author Question: Amputations and Infections

June 10, 2014July 21, 2016 / Jordyn Redwood / Leave a comment

Kariss Asks:

A Navy SEAL team is on a mission in Ukraine. One of the guys gets shot in the leg by a sniper and then gets debris in his leg when the boat explodes. They dive into the Black Sea to get away before getting to the getaway boat. He is sent to a military hospital in Germany and then sent back stateside to make decisions with his wife. In the story, I need him to have his leg amputated but also be a potential candidate for a bionic leg/prosthetic down the road.

A few questions in that regard…where would he need to get shot in the leg for that to be an issue? I thought a major artery. But I’m not sure that is accurate. Would infection be a problem from the dirty water and wound? If so, how long would that take to set in? Since I need amputation to be the final outcome, how long would doctors deliberate and monitor issues before choosing to amputate? I think my timeline may be too long in the book and I want this to be accurate.

Also, I have one of the SEALs call the wounded warrior’s wife to let her know there is a problem and they are coming home. Because of mission sensitivity, he can’t tell her what happened, especially over the phone. My editor thinks a doctor would be the one to contact the wife instead of someone on the team. But I’m not sure that would be true in the case of classified special forces ops. Any input on this?

Jordyn Says:

Thanks for your question. It’s an excellent one and I’ve pulled in several people to help so thanks Tim (who serves as a military chaplain) and Angelique (a physician co-worker) for your insights.

Question #1: There are many indications for amputation– only one being lack of blood flow to the extremity. So damage to a major artery doesn’t necessarily have to be your mechanism of injury. Top three reasons would be trauma (the extremity has lost too much muscle, bone, etc), infection, and vascular insufficiency (damage to the blood supply that keeps the tissue alive.)

Question #2: Is infection a concern because he was swimming in gross swamp water? Yes, this will be a concern. Infection could show up in as little as 12 hours. More commonly is 48 hours. Of course, there are always outliers. What you could research is common skin infections, microorganisms, and such in the geographical area your incident happens. You might find something better that fits your time frame.

Question #3: How long would the doctors take to make a decision? Here, you could basically make the medical scenario fit your timeline. If you want them to amputate right away– go with major loss of tissue from the extremity. It’s basically not salvageable. Or– longer (days to weeks) then you could use a scenario where infection sets in, he doesn’t initially respond to the antibiotics, they try a different antibiotic– maybe surgical debridement, etc. That process could take a week or more.

Question #4: Notification. This is directly from the chaplain’s e-mail to my query.

I can only speak based on my experience in the Navy, and please recognize that the various military branches handle casualty notifications in different manners. That being said, a doctor would not be the one to call giving the nature of the incident. A command representative in addition to a chaplain would generally make an in person visit to the primary next of kin, in this case, the spouse. Also, if this is really a soldier, then he’s Army, whereas, the other branches would refer to themselves as Airmen, Sailors, or Marines.

As a side note, in discussing your question with the physician, she said below the knee amputations are easier to fit with a prosthetic versus an above the knee amputation so consider this as well for your story.

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Kariss Lynch began her writing career in third grade when she created a story about a magical world for a class assignment. Chasing her dream into college, she received a degree in English at Texas Tech University and fell in love with writing faith-based fiction about characters with big dreams, adventurous spirits, and bold hearts. Her first novel, Shaken, book one in the Heart of a Warrior series, released in February 2014, with the second book, Shadowed, scheduled to release in Winter 2015. Kariss is a diehard Texan, born and bred in Dallas, where she now works as a writer for a local communications ministry.

Phantom Limb Pain: 2/2

May 10, 2013July 21, 2016 / Jordyn Redwood / Leave a comment

Today, author and Christy Award nominee (two nominations!) Jocelyn Green concludes her two-part series on phantom limb pain. You can find Part I here.

As an added bonus, Jocelyn has graciously offered to give away a personalized copy of her latest novel, Widow of Gettysburg, to one commentor. To enter, leave a comment on any of her posts WITH your e-mail address. Must live in the USA. Winner drawn midnight, Saturday, May 11th, 2013 and announced here at Redwood’s on May 12th, 2013.

Jocelyn has also graciously said she’ll send you a signed bookplate if you have any of her novels and would like one. Again, MUST have your e-mail.

You can view Jocelyn’s previous posts at Redwood’s here and here.

Welcome back, Jocelyn!

What We Know Today

The study of PLP continues with today’s generation of amputee veterans. Most contemporary studies confirm what Mitchell found, but add to it some new information. Most recent studies report PLP at rates of 50% to 80%. A few of these are in constant pain, but for most, the episodes can last a few seconds or one to two hours.

Since the beginning of the conflicts in Iraq and Afghanistan more than 1000 amputees have been treated at Walter Reed Army Medical Center in Washington, DC. Almost all experience PLP, either within the first 24 hours of amputation, or within two weeks. The following insight comes from an article in a 2010 issue of The Neurologist:

“As part of routine treatment efforts, the patients are asked to describe their experience with phantom sensation and phantom pain. There have been a plethora of responses regarding the onset, duration, description, and location of phantom sensations and phantom pains from those queried. Furthermore, some explain they have volitional control over their phantom, and can move their phantom at will, while others report their phantoms being fixed in a specific position. Some even report the inability to make movements with the phantom, despite the presence of a strong sensation or pain emanating from their residual limb. For example, one service member reported that his phantom hand was in a distinct position: he felt he was pulling the trigger on his rifle with his index finger, and was unable to move his hand to a different position. He also felt cramping pains in his hand muscles. Another service member, a bilateral, above knee amputee, described the feeling of heavy legs, asserting that the feeling was similar to weights attached to his calf muscles. He also described that it felt as though his combat boots were on too tightly.”

There are multiple theories as to the cause of PLP, all of which can be read in this online article [http://sunburst.usd.edu/~cliff/Courses/Advanced%20Seminars%20in%20Neuroendocrinology/Pain/Weeks10.pdf].

The most successful treatments have been with opioids and mirror therapy, the latter considered the most promising treatment plan.

In this treatment, the patient views the reflection of their intact limb moving in a mirror placed between the arms or legs while simultaneously moving the phantom hand or foot in a manner similar to what they are observing. The virtual limb in the mirror appears to be the missing limb.

Patients have reported a relief of cramping and “frozen limb” phantom pains as a result of even one session with the mirror. In one study in which patients used mirror therapy for 15 minutes each weekday for four weeks, significant decreases in pain were reported. More about mirror therapy can also be found in the online article hyperlinked above.

For further reading:

Mitchell, Silas Weir. The Case of George Dedlow. (fictional account of quad amputee) New York: The Century Co., 1900. Read it online at Google Books here, and begin on page 115. http://bit.ly/ZixtJd

Gunshot Wounds and other Injuries of Nerves. Philadelphia: J.B. Lippincott, & Co., 1864. Read it online at Google Books here: http://bit.ly/17hhuvf

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A former military wife, Jocelyn Green authored, along with contributing writers, the award-winning Faith Deployed: Daily Encouragement for Military Wives and Faith Deployed . . . Again. Jocelyn also co-authored Stories of Faith and Couragefrom the Home Front, which inspired her first novel: Wedded to War. She loves Mexican food, Broadway musicals, Toblerone chocolate bars, the color red, and reading on her patio. Jocelyn lives with her husband Rob and two small children in Cedar Falls, Iowa.

Phantom Limb Pain: 1/2

May 8, 2013July 21, 2016 / Jordyn Redwood / Leave a comment

Author and Christy Award nominee (two nominations!) Jocelyn Green joins us again this week for a two-part series on phantom limb pain.

Jocelyn has also graciously said she’ll send you a signed bookplate if you have any of her novels and would like one. Again, MUST have your e-mail.

You can view Jocelyn’s previous posts at Redwood’s here and here.

Welcome back, Jocelyn!

Though the phenomenon of phantom limb pain had been recorded long before the Civil War, it was Silas Weir Mitchell, a Philadelphia physician specializing in nerve injuries during the Civil War, who coined the term. Phantom limb pain, or PLP, occurs when a patient feels pain in an arm or leg that has been amputated. Mitchell studied PLP (or sensory hallucinations, as he also called them) in depth at the Turner’s Lane hospital in Philadelphia, dubbed the Stump Hospital because it focused on caring for amputees.

If a character in your story is an amputee, like one of my characters in Widow of Gettysburg, the following will be helpful to you.

What Mitchell Found

· Almost every amputee at Turner’s Lane Hospital experienced PLP.

· Most of them came out of anesthesia feeling the presence of the amputated limb.

· Those who did not immediately feel PLP usually felt it within three weeks.

· Usually, the patients felt the missing hand/foot but not the section of limb directly beyond the stump.

Mitchell wrote: “The patients describe themselves as knowing that they have a hand which is connected to a stump, and feel able to move it, but of the rest of the limb they are unconscious, and the subjective sensations which are so common are always referred to the hand or foot, and rarely to the continuity of the member.”

· In about one-third of the leg cases, and in one-half of the arm amputations, the patient felt that the foot or hand is nearer to the trunk than the extremity of the limb.

· The type of pain could be burning, itching, stabbing, or cramping.

· Missing legs usually felt as though they are hanging straight down, while missing arms felt as though they were bent at the elbow or locked in the last position they were in prior to the operation.

· Treatment of water dressings on the stump helped with burning sensations in some cases, but most efforts to relieve PLP were ineffectual.

· Amputee veterans wrote to Mitchell decades after their operations and shared that in their dreams, they had all their limbs perfectly whole.

Return Friday as Jocelyn finishes up her Civil War medical series.

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The Civil War and Prosthetic Limbs: 2/2

April 26, 2013July 21, 2016 / Jordyn Redwood / Leave a comment

Jocelyn has returned for Part II in this series on Civil War medicine and amputees. Check out Part I here.

As an added bonus, Jocelyn has graciously offered to give away a personalized copy of her latest novel, Widow of Gettysburg, to one commentor. To enter, leave a comment on any of her posts over the next three weeks WITH your e-mail address. Must live in the USA. Winner drawn midnight, Saturday, May 11th, 2013 and announced here at Redwood’s on May 12th, 2013.

Jocelyn has also graciously said she’ll send you a signed bookplate if you have any of her novels and would like one. Again, MUST have your e-mail.

Good Luck!

Jocelyn appeared before at Redwood’s and you can read those posts here and here.

Welcome back, Jocelyn!

Many entrepreneurs who developed artificial limbs were Civil War veteran amputees themselves. In fact, one of the most successful pioneers in prosthetics was Confederate veteran James Edward Hanger, whose amputation in West Virginia was the first recorded amputation of the Civil War. He was 18 years old at the time. Union surgeons discovered him wounded and performed the amputation, giving him a standard issue replacement leg: a solid piece of wood that made walking clunky and difficult.

Hanger’s adjustments included better hinging and flexing abilities using rust-proof levers and rubber pads. He also used whittled barrel staves to make the limb lighter-weight. He won the Confederate contract to produce limbs, and by 1890, had moved his headquarters to Washington, D.C., and opened satellite offices in four other cities. The company he founded – Hanger, Inc. – remains a key player in prosthetics and orthotics today.

One of James Hanger’s early patents from 1891. Courtesy of Hanger.com.

The Civil War-era commitment to support veterans continues today through programs of the VA and the Defense Advanced Research Projects Agency (DARPA) to ensure ongoing progress in prosthetics design. The war set the prosthetics industry on a course that would ultimately lead to today’s quasi-bionic limbs that look like the real thing and can often perform some tasks even better.

To see just how far we’ve come in the realm of prosthetic limbs, I invite you to take a look at the video below. This is a brief look at the story of Taylor Morris, the fifth quad amputee veteran in the U.S. Army. You will see Taylor, who is from my hometown of Cedar Falls, Iowa, go from the hospital bed shortly after his surgeries, to dancing with his girlfriend again at the end of the video. (Have a Kleenex handy!)

http://youtube.googleapis.com/v/opWV472p5NQ&source=uds

For further reading:

Hasegawa, Guy R. MendingBroken Soldiers: The Union and Confederate Programs to Supply Artificial Limbs. Southern Illinois University Press, 2012.

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Civil War Amputations and Anesthesia

August 31, 2012July 21, 2016 / Jordyn Redwood / Leave a comment

I’m so pleased to be hosting author Jocelyn Green this week. She e-mailed me a feasibility question and I managed to rope her into writing a few posts about the medical aspects of the Civil War!

I know…I’m a tricky girl.

Jocelyn has graciously agreed to give away a signed copy of her novel Wedded to War. Just leave a comment in the comments section that includes your e-mail address on any of her posts this week and you’ll be eligible to win– though must live in the USA. Drawing will be Saturday, September 1, 2012 at midnight. Winner announced here on Sunday, Sept 2, 2012!

Here is Part I and Part II.

It’s impossible to write a Civil War novel about medical care in the Union army without having at least some text devoted to amputations. Here’s some of the information that helped me as I wrote Wedded to War, and even now as I’m working on the next novel, Widow of Gettysburg.

Contrary to popular belief, the days of “biting the bullet” (or a leather strap) during an amputation were over by the time of the Civil War. Anesthesia was available in the form of chloroform and ether, even in field hospitals. However, if the soldier had been wounded more than 24 hours prior to amputation, the surgeon would not give anesthesia for fear the patient would not recover from it. And unfortunately, the Confederacy had a severe shortage of medicines, including these, to work with. So even though the medicine existed, there were plenty of cases where the patients had to go without it.

Photo courtesy of Kevin Ling

But in the cases where anesthesia was available, there were specific guidelines for how to administer it.

Chloroform

According to the Manual of Military Surgery Prepared for the Use of the Confederate States Army (published 1863):

· Chloroform should be given in the fresh air with the patient’s head on a pillow and the body remaining horizontal throughout inhalation.

· Clothing should be loosened about the neck, chest and abdomen so that breathing is not restricted.

· Only a light but nutritious meal should be given earlier, or the state of unconsciousness during the second stage of the anesthetic might bring on vomiting.

· Before giving the chloroform, first give brandy. (Union surgeons did not always follow this point. They used alcohol stimuli only on physically depressed patients because they felt it could slow down the induction of anesthesia in a healthy patient.)

The Confederate manual went on to instruct: “all special instruments of inhalation have been discarded, and a towel or napkin, folded into a cone, by having its corners turned down, is not almost universally employed for the purpose. The chloroform, about a drachm (one-eighth ounce) is poured into this cone, and is held over the patient’s mouth and nostrils which should previously have been anointed.” Holding the cone a half-inch from the patient’s face prevented facial blistering and allowed adequate air flow.

The first stage of anesthesia was one of excitement, producing “muttering, wild eyed, the cries, the exalted imagination” followed by “violent struggles, attempts to rise, and rigid contraction.” If the spasm extended to the larynx, there would be danger of breathing being obstructed. Surgeons were instructed to remove the cone temporarily if this were the case.

The second stage was that of unconsciousness, insensibility and relaxation of the voluntary muscles. Eyelids would no longer contract when touched. The pulse would slow and weaken, respiration became shallow and feeble.

Ether

Ether was slow-acting, had a foul smell patients objected to, and caused coughing. But it was frequently used in general hospitals where time was not as pressing, because, unlike chloroform, it did not cause vomiting, prostration or increased excitement.

It was also far less dangerous if the wrong dose was given. Throughout the Civil War, only four deaths were recorded from overdoses of ether, while chloroform’s rate was 5.4 deaths for every thousand that used it.

The Operation

The book, Civil War Medicine, by C. Keith Wilbur, M.D. has easy-to-understand explanations and diagrams of various types of amputations. Those interested in primary source material for the operations can thank SonoftheSouth.net for posting excerpts from The Practice of Surgery by Samuel Cooper, here: http://www.sonofthesouth.net/leefoundation/amputation.htmThe book, written in 1820, would have served as the how-to guide for surgeons in the beginning of the war. These online excerpts provide detailed instructions for amputation of legs, arms, fingers and toes, including photos of original Civil War instruments.

Carl Schurz, commander of the Union’s 11^th Corps at Gettysburg, offers this account of amputations after the battle:

Most of the operating tables were placed in the open where the light was best some of them partially protected against the rain by tarpaulins or blankets stretched upon poles. There stood the surgeons their sleeves rolled up to the elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth while they were helping a patient on or off the table, or had their hands otherwise occupied around them pools of blood and amputated arms or legs in heaps sometimes more than man high. Antiseptic methods were still unknown at that time. As a wounded man was lifted on the table often shrieking with pain as the attendants handled him the surgeon quickly examined the wound and resolved upon cutting off the injured limb. Some ether was administered and the body put in position in a moment. The surgeon snatched his knife from between his teeth where it had been while his hands were busy, wiped it rapidly once or twice across his blood stained apron and the cutting began. The operation accomplished the surgeon would look around with a deep sigh. and then—“Next!”

Read The Reminiscences of Carl Schurz at Google Books here: http://bit.ly/OCf1CD

Recommended Sources:

For more in-depth study, in addition to the resources I listed on my last post, I recommend:

Cooper, Samuel. The Practice of Surgery. London: A and R Spottiswoode, 1820. Available at Google Books here: http://bit.ly/OvS97P.

Hamilton, Frank Hastings. A Practical Treatise on Military Surgery. New York: Balliere Brothers, 1861. Available at Google Books here: http://bit.ly/O72JCN

Teacher Tube video (5 min.) from the Museum of the Confederacy about amputations and artificial limbs. Not graphic at all. http://bit.ly/SZhlEF

I also did a post on ether and chloroform. You can find that here.

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A former military wife, Jocelyn Green authored, along with contributing writers, the award-winning Faith Deployed: Daily Encouragement for Military Wives and Faith Deployed . . . Again. Jocelyn also co-authored Stories of Faith and Courage from the Home Front, which inspired her first novel: Wedded to War. She loves Mexican food, Broadway musicals, Toblerone chocolate bars, the color red, and reading on her patio. Jocelyn lives with her husband Rob and two small children in Cedar Falls, Iowa.

Connect with Jocelyn:
www.jocelyngreen.com