Colonel Jennifer Menetrez sympathized with the man on the hospital bed. She knew his status: lower spinal cord injury. Lower leg amputation. This man would never walk again.
At least, that was what he had been told by caretakers, shortly after a 7.0 earthquake had rocked Haiti and killed 220,000. The region’s limited resources would be directed elsewhere. Menetrez, however, believed in this man. She knew he might someday walk, if only someone took the time to work with him.
A few beds down from the nameless man was a nameless woman: pregnant, paralyzed, and unable to speak. Outside her room sat a man-made wheelchair with a dirty, plastic lawn chair attached as seating.
This is the situation Haiti faced, and still faces.
Menetrez had been deployed to Haiti to lead the combined US military medical response. She had arrived on the USNS Comfort, an 894-foot floating hospital commanded by the US Navy. The ship saw 820 surgical cases during immediate Haiti relief efforts. The estimated total of amputees resulting from the Haitian earthquake is generally accepted at 4,000, but Menetrez says approximately 1,500 amputees were surgically treated after the earthquake, 37 of whom were on the USNS Comfort.
Whatever the true numbers of those afflicted, post-earthquake conditions in Haiti remain less than ideal. The already-low life expectancy of Haitians has been compounded by sanitation problems resulting from the earthquake and associated injuries. Amputees face the nearly impossible task of keeping their wounds sterile, although Haitians continue to take great pride in cleanliness and presentation.
Throughout Haiti, the emergence of tent cities (formally known as Internally Displaced Persons Camps) fostered additional health complications. Amputees struggled to use their prostheses while traversing rough terrain and, without the benefit of running water, trying to keep their skin clean and healthy.
For those people still facing rehabilitation, hope often seems slim. A primary rehabilitation center near Port-auPrince is only accessible via dirt stairs that run up one hillside and down another. Amputees gather near hospitals in the hopes of being treated. For those with prosthetic limbs, there is no time for, or inclination toward, therapy. Patients begin using their new legs from the moment they try them on.
“Life in Haiti is rehab,” Menetrez said. “This is the type of environment in which they try to live.”
Living in Haiti with a disability is often seen as a curse— a sign that a family did something worthy of punishment. Voodoo is very much still alive in the small country, and people with disabilities have no rights and grim futures. They aren’t offered jobs. They’re taunted in schools. Structural adaptations are virtually non-existent.
On a global scale, these challenges are not uncommon. “Haiti is a good example of what goes on in much of the rest of the world,” Menetrez said. “It’s really survival of the fittest. It’s a very hard life.”
And yet, some measure of hope remains. This November, Menetrez delivered the keynote speech at Neuroprosthetics 2010, an international conference on artificial limb development at Worchester Polytechnic Institute. She spoke of her experiences in Haiti, but also of her day job as director of the Center for the Intrepid at Brooke Army Medical Center (BAMC), a rehabilitation hospital for injured American veterans who have returned from Iraq and Afghanistan.
The achievements made at BAMC draw a sharp contrast with the struggles Menetrez witnessed in Haiti. As of October, BAMC has treated a total of 1,097 amputees, 20 percent of whom had upper-limb amputations. Another 20 percent had multiple amputations.
The Center for the Intrepid is a four-story, 65,000 squarefoot facility built from donations from more than 600,000 people. It showcases an impressive team effort by a multitude of specialty departments including, but not limited to, physical medicine, physical therapy, occupational therapy, burn therapy, prosthetics, and case management.
Research and clinical departments at BAMC are housed within the same building, a rarity among many large hospitals, and provide a powerful bridge between design and practice. At BAMC, an amputee isn’t just fitted with a specific prosthesis—he’s fitted with one that may allow him to run a marathon upon completion of rehabilitation. Veterans are led on full horseback riding excursions through the countryside, participate in sled hockey, and make full use of the Flowrider: a recreational water device that simulates wakeboarding and surfing.
As part of occupational rehabilitation, BAMC engages veterans in a firearm training simulator that re-establishes their comfort with weaponry. Additionally, an “Activities of Daily Living” apartment—which, by design, is not accessible—forces veterans to overcome daily hurdles they may face outside of BAMC.
The rehabilitation center’s hottest ticket, however, is its driving simulator, which allows veterans to get back behind the wheel and become re-acclimated with motorized vehicles. But Menetrez notes that even this activity presents a range of challenges.
“Our patients were in a war,” Menetrez said. “They were blown up. So sometimes you get them in the driving simulator and find they actually swerve away from things on the side of the road or zoom under overpasses without even realizing that’s what they’re doing. Daily activities are really important aspects of rehab. It’s not just about regaining physical ability.”
That’s not to say, however, that physical rehabilitation gets short shrift at BAMC. Through participation in the Gait Lab, which utilizes 26 cameras and eight force plates, veterans can traverse an uneven surface through which an instrumented treadmill allows them to improve ambulatory performance. Within moments, a flat walkway can transform into a set of stairs at a 40- degree incline, allowing researchers to collect important data on a patient ‘s progress and capability.
But for a number of veterans, social engagement might provide the most useful therapy of all. In the BAMC computer lab, injured veterans can reconnect with their units and swap experiences and memories. Menetrez says this aspect is vital for a patient’s psychological recovery.
“When our patients were injured overseas, they tend to feel a lot of guilt,” Menetrez said. “Many of them want to go back. Meanwhile, their units are worried about what happened to them. So it’s very important that everyone has the capability to reconnect. We even have to pay attention to the anniversary of the patient’s amputation. We often find that as he approaches that date, something doesn’t seem right in his behavior. It’s not even a conscious thing. But it’s something that needs to be taken into consideration.”
Despite the success of BAMC therapies and technologies, Menetrez is quick to warn that the challenge of recovery ultimately falls on the medical provider. Even amidst its slew of fancy machines, facilities and state-of-theart prosthetics, the key to the success of BAMC remains its ability to place focus on the patient. And thousands of miles away, in the unsanitary environment of Haiti—its rigged equipment, dirty hospitals, and overcrowded wards—the same truth holds. If a patient isn’t being helped, the equipment means nothing.
“Can that upper-extremity prosthesis help wipe a butt?” Menetrez asked. “Can it help perform transfers if you’re someone who has lost both arms and maybe your legs? What does it do to improve someone’s function? That’s the bottom line. We can never lose sight of the patient.”
by Josh Pate