The Prosthetist’s Role in Early Patient Assessment

In the life of the patient, it's a terrifying seminal moment: amputation is imminent. They have a thousand questions and as many fears concerning their future. As their prosthetist, what should your role be? How deep should your involvement be and at how early a stage? William J.J. Ertl, MD Most agree that the earlier a prosthetist is invited into the assessment and planning process-along with or possibly even preceding other members of the rehabilitation team-the better for all concerned, and the greater the likelihood of a successful outcome. A Team Approach William J.J. Ertl, MD, assistant professor at the Oklahoma University School of Medicine, notes that for the patient's ultimate benefit, it's important to have a prosthetist capable of fitting patients with a quality prosthesis and to involve them early in the process. "If you have an opportunity to get a prosthetist involved early, it helps patients both emotionally and physically. Just telling patients, You're getting an amputation,' and not providing them with the emotional support, the physical therapy support, and the prosthetic insight is a disservice to the patients," Ertl says. "Since we're the only Level I trauma center in the state, we see up to three mangled, traumatically amputated limbs a month. I think the involvement of the prosthetist should start as early as possible, as should the physical therapist and the surgeon and any peer support that patients and their families can get." In some cases, Ertl will talk to prosthetists pre-operatively and ask them if they have determined how much room the prosthetic componentry will need. "The last thing I want to do is make a limb too long to be useful. "In the early phase of my career, I talked to the prosthetists quite frequently, and now that I have an understanding of prosthetics and componentry, that becomes less of a need for me." Dave Baty, CPO, with C-Leg patient. Because he views amputee care as a team approach, Ertl tries to keep the line of communication open with the prosthetist although he observes that sadly, the majority of surgeons really don't care about prosthetic outcomes, since they still regard amputation as a failure. "You need a surgeon who is committed to it, you need a prosthetist who's committed to it, and a physical therapist who understands the challenges of prosthetic rehab." He points out that since an Ertl amputation requires an end-bearing, maximal-surface-bearing socket with appropriate componentry, many prosthetists who were traditionally educated find it difficult to break the habit and try to create an end-bearing socket. "Recently I recommended an end-bearing transtibial socket for a patient I had operated on, and the prosthetist just didn't do that. It's a little frustrating that I spent a significant amount of time doing a surgical reconstruction to where we were able to form a bridge, we got good soft-tissue coverage and nice dynamic length, but they're doing a traditional socket, which defeats the purpose in my opinion." Another Surgeon's Perspective Daniel Fisher, MD Daniel Fisher, MD, associate professor of surgery at the University of Tennessee at Chattanooga, has been doing amputations since 1984, when he taught at a medical school and served as Special Team for Amputation and Mobility Problems (STAMP) program co-chair at the Dallas, Texas, Department of Veterans Affairs (VA) Medical Center, which is one of seven geographic referral centers designated to handle amputee problems. "As a result, I was sent to a variety of places to study what was happening in the amputation world," he explains. "When I moved to Chattanooga in 1989, I carried that interest with me." As staff vascular surgeon at the Erlanger Medical Center, Fisher serves as a resource for people anticipating less common amputations, including Symes, hip disarticulations, etc. "Rather than involving a prosthetist prior to these elective amputations, a lot of patients end up in my office, and I look at them from that standpoint because I feel like I understand the prosthetist's perspective. "On the other hand, if someone were to ask me if it is helpful, in general, for a prosthetist to be consulted if a doctor were thinking about doing an amputation on the average patient, I think the answer to that question is probably yes, it would be helpful, because there may well be input that may be helpful to somebody who's not very knowledgeable about amputations." Fisher observes that while its Level I trauma center also handles traumatic amputations in young people, most of the people undergoing amputations today are elderly people who have long-standing diabetes and the complications of running out of blood supply. "If you have diabetics who are totally insensate, but they have pulses in their foot, are you doing them a favor to keep the amputation level at a Syme's so that it's going to remain insensate, and they can beat that stump to death? Or would you be better to move up to a BKA level where they have some sensation? Maybe that would be a better level of amputation even though, in general, the longer the limb length, the better the functional result from the amputation." Fisher makes many such decisions-more than 100 amputations per year, and a staggering estimated 1,000 amputations logged during his career to date. "I don't need prosthetists to tell me what works. At this point, I think I know what works. But I think that the average guy who has not had good amputation training and does an amputation once every four to six months could be helped greatly by a prosthetist's advice. "There has definitely been a change in who gets amputations over the last 2030 years," Fisher adds, "and we're not talking about young guys who are getting war injuries. We're talking about old guys who are in the process of closing their lives out. "My point is that all of this prosthetic stuff is only as relevant as the limb you can save. If there's no circulation involved with the limb, then all this advanced technology and all these fancy gizmos and new feet&don't do an AKA very much good if he's going to sit in a wheelchair the rest of his life." Prosthetists' Perspective In view of the surgeons' expressed preferences for prosthetic support and involvement, and the current climate, prosthetists offered the following observations and advice: David Baty, CPO, Dynamic O&P, Houston, Texas, has developed a relationship with area surgeons that is close to ideal. "We have set up a protocol through one of the hospitals, where every scheduled amputation patient is referred to us for a pre-amputation consultation, even if it is a possible limb salvage. This puts the power in patients' hands a little more, and they can make the decision whether they want a limb salvage or an amputation." Baty meets frequently with surgeons in the orthopedic department to present prosthetic options and benefits, including new products that keep the hospital on the leading edge of post-operative care. Baty sets up advisory in-services as he becomes aware of new technology, and thus he positions himself as a reliable consultant and source of useful information. He has also written an outline to help orthopedic surgeons talk to patients about different level amputations. "If it's an option to go with a knee disarticulation over an AK, here's what patients needs to know if you have that discussion with them, and allow them to make this decision." Deane Doty, CPO Deane Doty, CPO, vice president of Active Life O&P, Glendale, California, notes that from his perspective, with 21 years of prosthetic experience, relations with surgeons haven't changed much. "If it is our own patients who have chosen elective surgery, we will have been involved early on, providing them with diabetic shoes, toe-fillers, off-loading devices, etc. If they are progressing on to losing their foot, for example, then we have prepared them for the kind of things that are going to take place. We have already encouraged them to have the doctor discuss with us prior to their amputation any concerns or fitting issues that we may have down the road regarding using a prosthesis. "We get patients involved, and we have them ask their doctors to call or allow us to participate in their pre-op discussions. For the most part, the doctors are pretty reliant on their own education and skills and don't necessarily feel a great need to involve us most of the time." Doty also says he believes that it is those surgeons who are relatively new to the process of amputation who are also more open to having discussions and even meetings with him-sometimes inviting him into the surgical suite to help decide what level of amputation will work better when such options exist. "If we've had discussions with the patient previously, and thus we know that he or she is not as concerned about cosmesis relative to getting more function, then we can make sure that physicians are aware of the options the patient is comfortable with." Building Relationships The single aspect of surgeon/prosthetist relations that Doty would most like to change is making surgeons more accessible to prosthetists. "[Surgeons are] so heavily guarded, protected, and very busy that it's just not always convenient for them to have a conversation with us. And when we want to follow up, it's difficult to get in touch with them as well. Once you have established a relationship with a surgeon, access is easier and more frequent. If we could just have their cell phone numbers available to us, wouldn't that be great?" So how might one go about building bridges between prosthetists and surgeons? Baty's relationship began serendipitously, when he was called in to fit a doctor-prescribed, post-operative prosthesis that another prosthetic group could not provide for the patient. Baty promptly provided what the doctor ordered, beginning with good patient relations. "Then I started showing the staff what we could do better. I took the approach that the hospital was nationally known, and if I could improve the prosthetic service, it would reflect positively on the hospital." "The whole key to this is the fact that everything I've talked to them about has worked out very well. I pick what I think is a good product, or things that I knew to be true, and I recommend them, and I steer them away from other things. I've been helping this particular hospital's staff with its amputee population for seven to eight years. Now, when I offer options that could possibly impact the patient, the surgeons will listen to me. But it has taken a long time." Doty agrees that to earn the trust of surgeons, you must be reliable and knowledgeable. "You must bring a good base of knowledge to any discussion that you're initially going to have with the physician. You have to be able to deliver what you promise, and you have to maintain a strong relationship with the patients that you're being given an opportunity to work with because that's the reason the doctor is going to send someone back to you again-because you did a nice job with a previous patient." And it is always wise to be prepared. "Certainly," says Doty, "when you call physicians to say you're seeing their patient and you need a prescription for a particular prosthesis or component, and they say, 'I don't even know what that is,' of course you need to pounce on those opportunities to educate them, as they occur." Judith Philipps Otto is a freelance writer who also has assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

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