Elective Amputation Evaluations in Service Members

Virtual

Co-Author(s)

Shannon Ford, MD, DFAPA

CL Fellowship Program Director
Walter Reed National Military Medical Center
Bethesda, Maryland

Presenting Author(s)

Shruti P. Mutalik, MD (she/her/hers)

Transplant and Consultation Liaison Psychiatrist, Mount Sinai Hospital
Icahn School of Medicine, Mount Sinai
New York, New York

Co-Author(s)

AB

Anna E. Blech, BA

Medical Student
Icahn School of Medicine at Mount Sinai
New York, New York
AY

Ambika Yadav, MD

Assistant Professor and Attending Psychiatrist
Mount Sinai Hospital
New York, New York

Abstract:

Background:

Service members commonly suffer from traumatic limb injuries during combat and training exercises. Despite a variety of limb salvage procedures, these injuries are often associated with persistent pain and limitations in mobility. These functional impairments can be particularly psychologically challenging in patients who value athleticism and engaged in high levels of physical activity preceding the injury.

The METALS study showed that in lower extremity trauma, limb amputation has better functional outcomes than salvage. Following multiple limb salvage operations, service members often present requesting an elective amputation. Another subtype of patients requesting amputation are those with treatment refractory complex regional pain syndrome. Consultation liaison psychiatrists are often called upon to perform psychosocial evaluations preceding elective amputation procedures, though no formal guidelines for these evaluations yet exist.

Methods:

We draw upon pre-surgical clearance evaluations, including those for transplant and bariatric surgeries, to propose a framework for such evaluations. Like in other pre-surgical evaluations, we inquire about motivations, ambivalence, and expectations from surgery, assess the ability to provide informed consent, evaluate psychiatric stability, screen for substance use, assess coping and decisional styles, and determine social support. In addition, we screen for body integrity identity disorder and factitious disorder to assess for any possible primary gain, and screen for paraphilias that could motivate a request for amputation. While amputation can improve quality of life, it can also have long term health consequences that patients may not foresee and should be counseled on, including increased cardiovascular risk. In case of complex regional pain syndrome, a biopsychological evaluation of pain is also warranted. We will use the case of a 26-year-old male who sustained a combat injury involving a roadside explosion three years prior to our evaluation as an illustrative example. Despite multiple surgeries, he continued to have hypersensitivity to touch and chronic pain with limited mobility. He had good social support and reasonable expectations, but due to his extensive pain and surgical history he also had significant difficulty with post-operative pain management and high opioid requirements. We will compare this case with one of a 19-year-old Active Duty male, with a similar mechanism of injury but significantly different outcome: he had good function with the use of a brace and could even run but insisted that amputation was his only acceptable outcome for pain and mobility.

Conclusions:

Using illustrative case examples, we propose a framework for pre-surgical evaluation for elective amputation surgeries. Outcome data on our evaluations will help in the development of validated tools.

References:

Doukas WC, Hayda RA, Frisch HM, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013 Jan 16;95(2):138-45. doi: 10.2106/JBJS.K.00734. PMID: 23324961.

Quon, D. et al (2011). A Qualitative Study of Factors Influencing the Decision to Have an Elective Amputation. The Journal of Bone & Joint Surgery, 93 (22), 2087-2092. doi: 10.2106/JBJS.J.01998.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This presentation focuses on the psychosocial care of a population with a unique culture and identity: military service members and veterans. This group is a heterogenous group encompassing diversity in gender and sex, race and ethnicity, to include historically marginalized groups.
Our speaker panel / author group includes an Active Duty Army psychiatrist, an Army veteran who served as a military psychiatrist, a total of two IMG psychiatrists born outside the US and a medical student with an interest in Psychiatry.