Hands, Head, Heart: Orthopedic Surgeon Douglas G. Smith, MD

"Douglas Smith, MD, has been a wonderful advocate, a resource, and friend for the field of amputation. "

—Todd Kuiken, MD, PhD

For more than 20 years, Douglas G. Smith, MD, has been working to improve the quality of life for persons with amputation, not only through developing improved surgical techniques and reaching a high standard of excellence in amputation surgery, but also as a researcher and a passionate educator of fellow surgeons, other rehabilitation professionals, students, and consumers. "He is, in my opinion, the leading orthopedic surgeon in the United States for amputation," says Todd Kuiken, MD, PhD, director of the Center for Bionic Medicine, Rehabilitation Institute of Chicago (RIC), Illinois, and a longtime colleague and friend of Smith. Kuiken pioneered targeted muscle reinnervation (TMR) surgery, which has provided the platform for some astonishing breakthroughs in "thought-controlled" prostheses. Smith is a professor of orthopedic surgery at the University of Washington (UW), Seattle, and a UW Medicine orthopedic surgeon at the Harborview Medical Center, also in Seattle. (Author's note: UW Medicine manages Harborview, which is owned by King County, Washington.) Smith worked with Kuiken and surgeon Gregory Dumanian, MD, Northwestern Plastic Surgery, Chicago, Illinois, to prepare to use the TMR technique in Seattle, and became the first surgeon outside Chicago to perform it. "[Smith] is very attuned to the patient," says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics, Hanger Prosthetics & Orthotics, Austin, Texas. "He looks at the big picture and takes a holistic approach. He's a brilliant orthopedist and very meticulous in his management of amputation. He works with the prosthetist and the rest of the rehabilitation team and really wants to see successful outcomes. It has been an education for me to have had the opportunity to share patients with him over the years." The Making of a Surgeon Smith was born in Maumee, Ohio, near Toledo, in 1958, the second of three brothers. Growing up, he had a strong interest in building things. "I've always been interested in mechanical things and engineering aspects," Smith says. "When I decided to go into medicine—and I think that was because of the convergence of science and the chance to help people—orthopedics was always at the top of the list because of how much mechanics is involved." After being inducted into the Phi Beta Kappa honor society and graduating from the University of Notre Dame, Indiana, Smith received his medical education at The Pritzker School of Medicine at the University of Chicago, Illinois. He completed his internship and residency at Loyola University Medical Center, Maywood, Illinois. In 1989, Smith was offered what was supposed to be a one-year position at the Harborview Medical Center—"and I'm still here," he chuckles. He notes that Harborview is the only Level I adult and pediatric trauma and burn center in a five-state region including Washington, Alaska, Montana, Idaho, and part of Wyoming. The area encompasses between one-quarter and one-third of the landmass of the United States, Smith adds. "As such, we receive a high number of amputation patients." Smith performs about 150-200 amputations a year, in addition to other orthopedic surgeries. He also is an attending surgeon at the UW Medical Center, Seattle, and the Seattle Department of Veterans Affairs (VA) Medical Center, Washington. Smith is a consultant surgeon for Walter Reed Army Medical Center (WRAMC), Washington DC, and Brooke Army Medical Center (BAMC), San Antonio, Texas. Among Smith's mentors was renowned orthopedic surgeon and humanitarian Ernest M. Burgess, MD, PhD. Burgess founded the Prosthetics Research Study (PRS) ( www.prs-research.org ) in 1964 in collaboration with the VA Rehabilitation Research and Development Service. In 1989, he founded the Prosthetics Outreach Foundation (POF) ( www.pofsea.org ), which provides prostheses to amputees throughout the world. Working with children at the Shriners Hospitals for Children in Chicago, Illinois, during his residency, his recent work with injured military service members, and his work with amputees in developing countries, have given Smith keen insight into these patients' needs and challenges. Passionate Educator, Unbiased Researcher Smith is passionate about amputation and prosthetics education. He served as medical director for the Amputee Coalition from 2000 through 2008, writing a large number of articles for the organization's publication inMotion . The articles are available online in the library of the National Limb Loss Information Center (NLLIC), operated by the Amputee Coalition in cooperation with the Centers for Disease Control and Prevention (CDC) ( www.amputee-coalition.org/nllic_about.html ); on the PRS website; and on the Amputation Surgery Education Center (ASEC) website, www.ampsurg.org , a PRS project that Smith founded. [caption id="" align="alignright" width="250"] Doug Smith examines a wounded soldier's residual limb. Photograph courtesy of Doug Smith.[/caption] "[Smith] has spent a lot of his career educating others about amputation, and he educates in a way that is understandable to his audience," Carroll says. "I like to refer to his inMotion articles to help explain aspects of prosthetics to other professionals and to patients." Besides his teaching responsibilities at UW, Smith has presented at many professional conferences and served as a visiting professor and lecturer at universities throughout the United States and other countries. "Doug has a very practical, solid wisdom toward the treatment of amputees," Kuiken says. "He has a great depth of knowledge and a keen understanding of issues relating to amputation surgery and care and is a very good speaker. When he shares his knowledge at conferences, we all listen attentively." Kuiken continues, "Doug has led important research projects and has been a wonderful collaborator on many more." One of his largest contributions to the field, Kuiken points out, was becoming lead editor for the third edition of the Atlas of Amputations and Limb Deficiencies - Surgical, Rehabilitation and Prosthetic Principles, published by the American Academy of Orthopaedic Surgeons (AAOS) in 2004. Co-editors are John W. Michael, MEd, CPO, and John H. Bowker, MD. "This improved this very important textbook for the field," Kuiken adds. "Dr. Smith is an outstanding clinical researcher," Michael agrees. "His multiyear study of knees offering microprocessor stance stability, for example, first reported most of today's accepted findings about this then-novel class of prosthetic components. He calls them as they are, so he doesn't hesitate to report clearly and succinctly when perceived benefits to the patients aren't supported by the experimental evidence." When asked about what accomplishments have given him the most satisfaction, Smith cites his efforts in education. "I'm very proud of our website, www.ampsurg.org ," he says. "There are videos, audio, lectures, and articles, available anytime, anywhere in the world." The site provides just-in-time education for surgeons who may want additional instruction or a quick refresher before surgery, as well as information for other healthcare providers and consumers. "When orthopedic residents and surgeons tell me that this educational website has helped them, that is incredibly satisfying," Smith says. Besides Smith, who was the medical director for PRS, other team members included Brian Hafner, PhD, PRS project manager and senior bioengineer, and Katie Treadwell, BS, PRS engineering assistant. "Dr. Smith is a visionary thought-leader in the area of amputation and was one of the first to recognize and support the need to address mental health issues in the care of the amputee," says Amputee Coalition President and CEO Kendra Calhoun. "As our medical director, he raised the professional credibility of our publications, was successful in bringing diverse health disciplines to our Medical Advisory Committee, and helped us build important relationships with entities such as Walter Reed that have grown and continue today. His impact on the Amputee Coalition can be seen in the information in our National Limb Loss Information Center, our peer visitor program, and in the many articles he has authored for inMotion magazine." Michael adds, "His patient-focus is legendary, and no one could have a more fierce and effective advocate than Dr. D.G. Smith. He has a very relaxed and laid-back attitude that puts people at ease, but he will tackle third parties, administrative bureaucracies, government red tape, self-serving clinical recommendations, and pretty much anything else that might interfere with a client achieving the best possible result. He wins most battles because he's so well prepared, so genuinely persuasive, and so quietly tenacious." Perspectives Smith says he has seen a general shift in public and patient attitude toward amputation, largely due to some of the technological achievements in prosthetics that have been widely popularized in the media. "Early on, people really feared amputation and tended to put it off. They often waited, probably longer than they should have. And then, when they actually had the amputation, [the results] turned out better than they had hoped. Even with only average outcomes, they were very happy." Today, however, Smith says, "I think that because of very good media exposure and media highlighting of some unique, incredibly driven individuals—many of them in the military—many people actually have a better view of amputation than is reality. They see someone on the Internet running marathons, and they want an amputation so they can run marathons. For instance, I recently had a gentleman with arthritis who possibly needed joint replacement, and he said, 'I want an amputation and a prosthesis.' And I said, 'Why? You don't have cancer or some life-threatening infection. You don't understand what you're asking for.' In reality, he would have been incredibly disappointed." Even persons who have no choice about amputation are often somewhat disappointed to find out surgery, rehabilitation, and using a prosthesis are not as easy and glamorous as they thought the process would be, Smith says. Amputation and prosthetic devices can do much to help people get back into life and achieve goals, Smith says. "We see that every day." However, he cautions, "We are nowhere close to achieving the kind of bionics in The Six Million Dollar Man TV show we used to watch as kids." Difficult Challenges Wounded military servicemen and servicewomen often suffer from polytrauma, including blast injuries with severe soft-tissue damage and multiple limb loss. Many civilian traumatic amputees generally have healthy, undamaged residual-limb tissue. In blast injuries, surgeons work to construct a residual limb from severely damaged tissue. "We try hard to save their knee joints and other upper joints, but it's a big challenge," Smith says. Many injured military men and women deal with multiple limb loss, and surprisingly, this is becoming more common in the civilian population as well, Smith observes. Medical advances have enabled many more people suffering from necrotizing fasciitis or other life-threatening infections and severe shock to survive. "Vasopressive drugs keep people alive in very dire circumstances in the ICU by keeping the blood flowing to their brains and hearts, but this happens by decreasing the circulation to the legs and arms," Smith says. "Ischemia and limb loss are a direct consequence of successfully keeping these individuals alive." Persons with multiple limb loss face a difficult road. "Managing life with the loss of one limb is difficult enough," Smith says, "and losing multiple limbs is just an incredible challenge. I see people with these losses get back into life. I'm incredibly impressed by the motivation and drive and determination they have. They have had things happen to them that should never happen to anyone, and they have risen above them, healed, and done amazing things." Looking to the Future When asked about what he anticipates for the future of prosthetics technology, Smith says he sees an increase in sophistication of the man/machine interface. "We have always had a man/machine interface; it has just been very crude. For example, a below-elbow prosthesis using a standard socket, cable, and harness carries our thoughts in a very awkward way to the device." However, continuing surgical and technological advances are enabling faster, more natural, and efficient ways to manage the man/machine interface. Smith points to improved nerve management as an important change in amputation surgery to enable better prosthetic device use. Traditionally, for hundreds of years, nerves were divided in surgery, and surgeons were careful with how they performed divisions and where they placed the nerve ends—except in amputations, where "basically," Smith says, "nerves were just left hanging, like wires." He regards the TMR technique in amputation as a big step forward. "This is an amazing way to convey our thoughts to muscle and relay it to electronics in the prosthesis." He adds, "We're still learning about what this type of nerve management does and when it can safely be done and when it probably should not be done." The other big wave of the future lies in direct skeletal attachment, or osseointegration, Smith believes. Although the surgery is not yet approved for use in the United States, it is being used in Sweden, the United Kingdom, and Germany. He has met with limb osseointegration pioneer Rickard Brånemark, MD, PhD, at the Brånemark Osseointegration Center in Göteborg, Sweden, and is impressed with the potential of osseointegration to improve the prosthetic man/machine interface. "These implants are going to change the way artificial limbs are connected to the skeleton in our lifetime," he says, foreseeing a much wider use of the technique in the next ten to 20 years. Bacterial infection is a challenge, although this has been largely eliminated in the implant/bone interface, Smith notes. "However, we do not yet have a very good skin interface to prevent bacteria from getting inside to the implant." A biologic barrier to the bacteria is being researched, and Smith believes this hurdle will be overcome. "Direct skeletal attachment, targeted muscle reinnervation, and improved nerve management will continue to make how humans and machines work together better and better," he sums. Personal Plans Smith enjoys being with his three children: Christina, who has an honors degree in nutrition from Arizona State University, Tempe, and works at Harborview; Aliena, is a junior at UW pursuing a major in accounting and finance; and Kevin, a high school senior who plans to attend UW this fall in the bio-resource engineering program. Though Smith is not considering retirement anytime soon, when asked what he envisions for this time in his life, he says he would like to use his medical and surgical skills to help amputees in war-torn and developing countries. Accompanied by his daughter Christina, he recently made a trip to Sierra Leone to help amputee casualties from its brutal civil war. Smith also has provided amputee care in Southeast Asia. These experiences have fueled his desire to work in areas "where there is a lot of need for trauma and amputation care and where people are not as fortunate as we are." Reflecting on his friend and colleague, Kuiken says, "I can think of no other physician who has done more for the field or who has greater passion." Carroll concludes: "We need a lot more people like him." Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at linkEmail('miki.fairley','gmail.com');

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Hands, Head, Heart: Orthopedic Surgeon Douglas G. Smith, MD

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