In San Antonio, Wounded Troops Find Treatment

Retired Master Sgt. Todd Nelson, Brooke Army Medical Center patient
Lt. Col. Maria Serio-Melvin, critical care nurse specialist
Col. Evan Renz, MD, director, US Army Institute of Surgical Research Burn Center
Col. James Ficke, chairman, Brooke Army Medical Center Department of Orthopaedics and Rehabilitation

The San Antonio Military Medical Center is home to a cutting-edge prosthetic clinic and the military's only advanced burn unit. The center treats some of the armed forces' most severely wounded troops, and the state-of-the-art medicine developed there often helps civilian doctors provide better care.

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NEAL CONAN, Host:

This is TALK OF THE NATION. I'm Neal Conan in - well, I was supposed to be in San Antonio today, but a snowstorm shut down the airport last night. Long story, but we planned out a show on military medicine with our partners at Texas Public Radio. So I'm in Studio 3A, in Washington. Our guests will join us from the studios of KSTX in San Antonio, which is home to the Brooke Army Medical Center at Fort Sam Houston.

Over the past 10 years, it's become an increasingly important center for military medicine. The specialties there include prosthetics - more on that later in the program - and burns, which can be among the most painful injuries and something very difficult to treat.

If you suffered burns while in uniform, give us a call, tell us about your experience, the physical and the psychological scars. Our phone number is 800- 989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

And we begin with retired Master Sergeant Todd Nelson, who served as a senior logistics supervisor in Afghanistan. He lost his right eye and ear in a car bomb explosion there. And nice to have you with us today.

M: Thank you. It's good to be here.

CONAN: And how are you doing?

M: Oh, it's been a great day. Thank you.

CONAN: And your injuries, are they OK?

M: Yes, sir. Yes, sir. I've managed to kind of reach the end of medical advances to this point. We've done just about everything there is to do.

CONAN: And are you comfortable with the way you look now?

M: After you get used to it, after a year or two - there's kind of an exponential amount of comfort that you go through over the period of a year or two after you've been burned.

CONAN: How bad were your burns?

M: Technical jargon, 18 percent total body surface area. In people- speak, that's my right arm and almost my entire head.

CONAN: Did the explosion that caused those burns, did it knock you out?

M: Absolutely. I was knocked completely out. So it was good in that sense that I don't have any traumatic - or excuse me, post-traumatic stress disorder from it.

CONAN: But what was it like when you finally woke up?

M: It was six weeks later when I finally woke up. Whether that was from the narcotics or the traumatic brain injury is yet to be determined, but I still remember looking in the mirror for the first time, and my personality dictated what to do. And that was - my response was: I can live with that.

CONAN: You can live with that?

M: That's about it, yeah.

CONAN: It's one of the hard things that - a lot of people say, it's anticipating how other people are going to react to how you look.

M: That's right. And so, becoming comfortable with how you feel about yourself is just as important as how other people are going to react to you.

CONAN: We're going to be talking about doctors and nurses, about some of the medicine involved. We wanted to ask you, though, about learning to accept who you are now. Are you any different than you were before?

M: I'd like to say no, that character defines you as opposed to your skin. I say that but maybe strong character, strong moral character, can get you past it. If you have any weaknesses in your character, they may be unfolded by a disfigurement.

CONAN: What does your right eye look like now?

M: Without the prosthetic or with the prosthetic?

(SOUNDBITE OF LAUGHTER)

CONAN: With the prosthetic.

M: Yeah, without, it's pretty freaky looking. But with the prosthetic, you couldn't tell the difference. I was just in class a minute ago, and I told the gal sitting next to me it was a prosthetic. And she'd been sitting next to me for several weeks now, and said she had no idea.

CONAN: It tracks with your left eye, it moves?

M: Yes, to a certain degree.

CONAN: Obviously, you can't see out of it, though.

M: No, no, there's a bit of a blind spot. I've overcome that - say, with driving with spot mirrors and that type of stuff. And yeah - but otherwise, it's really not as significant as some would think it would be.

CONAN: And your ear - is this a question of cosmetics, or is this a question of hearing, or is it both?

M: No, amazingly enough, I didn't lose any hearing out of this. But - so it was cosmetic. But it's kind of funny. They said, we can fit you for a new ear. Would you be interested? And how would anybody respond if they can give you a body part? Of course. So that was an easy choice.

CONAN: And did you get an ear that was the mirror image of your other one?

M: Absolutely. It's incredible. I look at myself in the mirror, I can't believe it's a fake.

CONAN: And do you take it off at night?

M: Oh, yes, yes. I'll take it out periodically through the day, just like you would take your headgear off or whatever - just to kind of, you know, massage it or whatever, and then put it right back on. It's magnetic.

CONAN: It's magnetic. And you said earlier you were in class, just coming from class. What are you studying?

M: I'm attempting to get my bachelor's of science in my occupation, which is the equivalent of business management in automotives.

CONAN: And you look forward to graduating in - how soon?

M: I plan to be graduating by Thanksgiving, this Thanksgiving.

CONAN: Well, congratulations. And good luck with that.

M: Thank you.

CONAN: And Master Sergeant, thanks very much for your time today, appreciate it.

M: You're welcome.

CONAN: Army Master Sergeant, retired, Todd Nelson, with us from San Antonio and the studios of our member station there, KSTX.

Also there with us is Lieutenant Colonel Maria Serio-Melvin. She is a critical- care nurse, specialist in charge of improving nursing practices for the 16-bed intensive-care unit at Brooke Army Medical Center. Nice to have you with us today.

CONAN: Thank you, Neal.

CONAN: And I have to ask you, is the kind of attitude you heard from Sergeant Nelson, is that normal?

CONAN: For the most part, with our wounded warriors, many times. It's absolutely amazing how much the wounded warriors who've come through have inspired me to continue to do the work that I do, to continue to encourage other nurses to do the work that they do - to do everything we can to help these guys and gals endure the hardships of burn care and rehabilitation, to move on to their new normal.

So, yeah, Todd actually is quite unique. He's an awesome, inspiring individual, but there's many folks like him. And the other thing I've known Todd to do is through his leadership, which are some of the skills he learned in the military, in helping to motivate other wounded warriors to drive on through their challenges secondary to their injuries, and to continue to try to look forward to their new life. So I think more so the norm than not.

CONAN: We want to hear from those who, men and women, who have suffered burns in the military, 800-989-8255. Email us, talk@npr.org. We want to hear your stories about your treatment and - well, how - your physical and mental scars. So please give us a call.

But Lieutenant Colonel Serio-Melvin, I wonder, you talked about the difficulties of treatment. What's involved?

CONAN: Well, from a nursing perspective, a big part of what we do to care for these patients involves wound care and pain management. And we spend many, many hours with these patients, taking their dressings down, bringing them to the shower, cleaning their wounds, putting them in new dressings, and then helping get them back and forth to the operating room so that my colleague, Dr. Evan Renz, and his fellow burn surgeons can continue to do surgery on them.

And then we will recover them from the anesthesia and continue to care for them post-operatively, doing everything we can to help their grafts heal and then continue to clean their wounds.

We also spend a lot of time with the emotional support component. You know, the nurse is at the bedside from eight to 12 hours a day when he or she works. So we develop pretty close relationships with our patients and with their families.

So sometimes, the first time that a person sees themselves in a mirror, it's when they're with the nurse. And you know, we're the person that they may confide in, or we may see tears because it's the first time that they've seen themselves, and that reality has kicked in after all that they've been through up to that point.

So I would say wound care, pain management, and a significant portion of that psychological, emotional support is a big, big part of what we do. And then from a critical care perspective, we're the eyes and the ears for the physicians as well.

So we're monitoring these patients 24 hours a day, looking for any little, subtle signs and symptoms that something may be going right - or wrong, excuse me, and then letting the physicians know so that we can work together to help that patient out, to help them get better.

CONAN: And one of the main things that can go wrong is infection. And keeping the wounds clean, that has to be a never-ending task.

CONAN: Absolutely.

CONAN: There are showers involved, hydrotherapy, I believe it's called?

CONAN: Yes, very much so. Sometimes we'll do what we call bed- bath, in the bed, especially in a critical care arena. But most times, as soon as we can possibly get them to the shower, they'll actually be put on a vertical shower cart, and we will bring them to a big shower room and put them in the shower, just as if you and I would take a shower. It's the same type of concept, except that the patient could be on the ventilator and be very ill, and they're on a monitor. So we make sure that their vital signs are OK, and we clean their wounds, and they're laying down at that same time.

So we do that quite a bit. And that's been a very big key to our success in preventing burn wound infection.

CONAN: You also mentioned pain management. Burns can be excruciating. Doesn't that, doesn't water on them make it hurt even worse?

CONAN: Yes, it could, but you have to choose risk-benefit, as we say in the medical world. So if we don't clean their wounds and they get an infection, then they can die. So you have to bring them to the shower in order to clean those wounds.

So what we try to do is give them an appropriate amount of medication to help the patient tolerate the pain, so they don't - and sometimes we can't make that pain go completely away, but we do all that we can through talking with them, providing that emotional support, and giving them the medications in order to help bring that pain down so they can at least tolerate the shower.

CONAN: You've been at this for a while. You didn't get to the rank of lieutenant colonel without some experience here. How much have things improved, and how much are they still the same?

CONAN: I've had the opportunity to work as a captain - so back from 1994 to '98 - in burns. And then in coming back, some of the biggest changes I've seen is in wound care management, actually. So some of the dressings that we use now were not available over a decade ago. And so that's been a big improvement.

And then some of the technology that's occurred, one of those things being continuous renal replacement therapy - or as we call, CRRT. And that helps with patients who end up with renal failure, or kidney failure. So that's been a nice change in technology over time that's made a huge difference in burn care.

CONAN: We're talking with Lieutenant Colonel Maria Serio-Melvin, and she mentioned Colonel Evan Renz, a surgeon. He'll be joining us in just a moment. They're both with the Army Burn Center at Brooke Army Medical Center. And we'll get to your calls in a moment, too.

If you suffered burns while in uniform, give us a call. Tell us about your treatment and about the scars, physical and psychological; 800-989-8255. Email us, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan.

We're broadcasting today in partnership with KSTX, Texas Public Radio in San Antonio, the city that's home to the Brooke Army Medical Center at Fort Sam Houston, a level one trauma center that houses the military's only burn center.

They treat some of the worst injuries from the wars in Afghanistan and Iraq. More than 800 members of the military have been treated in that burn center since 2003.

And joining us is Lieutenant Colonel Maria Serio-Melvin, who oversees the nursing unit at the burn center, and joining us as well is Colonel Evan Renz, a trauma surgeon who directs the U.S. Army Institute of Surgical Research Burn Center at Brooke Army Medical Center. Good of you to be with us, sir.

D: Thank you, sir.

CONAN: And if you suffered burns while in uniform, give us a call. Tell us about your experience, 800-989-8255. Email us, talk@npr.org. And you can join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

And Colonel, I don't know whether to call you Colonel or Dr. Renz.

D: Either is more than adequate.

CONAN: Either will do? OK, well, we'll call you Dr. Renz, since you're the surgeon here. When you operate on burn victims, how much - well, this can be a lengthy process. It could be several surgeries.

D: Yes, sir. Most of our patients who are admitted to the burn center undergo multiple operations throughout a course of weeks, months to even years.

CONAN: And some of that at the beginning, then, is dealing with the extent of the injuries themselves?

D: Most of our patients suffer from multiple injuries in addition to their burns because of the frequency that the extremities are injured. So it's not uncommon for a patient with severe burns from an explosion to also have - extremities to the lower extremities or their upper arms, etc.

CONAN: And the burns can be anywhere?

D: Absolutely anywhere because the mechanism that we have seen since Iraq and Afghanistan started has involved, primarily, explosions. And therefore, we try, as a military, to provide good protection for the entire body. But there are always places that can be affected.

CONAN: And what is the treatment, the preferred treatment? Obviously, if you can save somebody's skin, that's priority A. But if you can't, then how do you replace it?

D: Well, that's one of the good news stories as far as advances in burn care over the last one or two decades, and that includes the ability to utilize materials such as biosynthetics or even cultured cells - which can be grown in the laboratory - to help close the wounds more rapidly, which until their development limited us to using either the patient's own skin, known as autograft, or we can use - temporarily, at least - cadaver skin or allograft.

CONAN: Allograft or - that's provided by people who donate their organs. We don't think of skin as an organ, but it sure is.

D: Actually, the skin is the single largest organ system in the human body.

CONAN: And too much damage to that organ, as too much damage to a liver or a heart, and you can't recover.

D: And again, that's another thing that people are surprised by sometimes - is the connectivity between the skin and all of the other organ systems. As Colonel Serio-Melvin mentioned a moment ago, the support of the kidneys is a project that takes a lot of our energy as well as support of the lungs, in many cases.

CONAN: We want to get some callers in on the conversation. We're talking with Colonel Evan Renz. He's a surgeon at the Brooke Army Medical Center's Burn Unit. Also with us, Lieutenant Colonel Maria Serio-Melvin, critical care nurse who specializes in the burn unit at the critical care center; 800-989-8255. Email us, talk@npr.org. Kurt's(ph) on the line, Kurt calling from Suffolk in Virginia. Kurt, you there?

KURT: Yes, I am. How are you today?

CONAN: I'm very well, thanks.

KURT: I just wanted to give a quick call. I listen all the time, and I just heard Brooke Army Medical Hospital. My son was wounded on his second tour in Iraq. He was burned and sent to Brooke Army Hospital. And I don't think anybody has an idea of how much work those folks do down there.

They handle some severe injuries and, as the doctor just mentioned, multiple injuries, head injuries as well as burns, limbs damaged. And the staff, the medical staff and the volunteers and everyone at Brooke Medical Army Hospital have got to be some of the finest people, some of the most caring people I have met in my lifetime.

CONAN: And how's your son doing, Kurt?

KURT: He's fine. He's on another tour. He's in Afghanistan, currently, right now. His burns were not severe. They did a great job. He was not there - he was not injured nearly as bad as many of the young men and women that I saw there. But he's doing fine, and he's back on active duty.

But the staff and the surrounding community are tremendous. I was also able to go on a wounded warrior trip with my son, and the entire community turned out with parades and flags, and really did an awful lot to support these troops morally and emotionally.

So thanks to the staff down there, and the community around Brooke Army Hospital - super people.

CONAN: Thanks very much for the call, Kurt, and we wish your son the best of luck.

KURT: Thank you.

CONAN: All right. And Colonel Serio-Melvin, families play an important part in treatment, do they not?

CONAN: Absolutely. We spend a lot of energy supporting those family members because without a good support network, the success of that wounded warrior being able to accept their wounds and continue to move on through rehab and integrate into the community - if you don't have a strong family to help you with that, it makes that journey all the more difficult.

CONAN: And that first glimpse of somebody after they've come out of surgery from their family members, that's - you must have to prepare them for that sometimes.

CONAN: Absolutely. But not only coming out of surgery, Neal, but the first time that the family ever sees their loved one after they've come back. They haven't seen them, many times, for months, sometimes almost a year, because their family member was deployed to Iraq or Afghanistan.

They get that fearful phone call from whomever to let them know that their loved one was seriously injured, burned, and at the burn center in San Antonio. And the first time they come from the waiting room to walk into either the ICU or onto our acute care ward that we have, we spend a lot of time emotionally preparing them for what they are going to see.

There's many instances of where you cannot recognize your loved one whatsoever, and they look very scary because of the extent of their injuries and the swelling that they will have as a consequences of the fluids they received to resuscitate them through the initial burn phase.

CONAN: Let's get another caller in. This is Ed(ph), and Ed's calling us from Traverse City in Michigan.

ED: Yes.

CONAN: Ed, you're on the air. Go ahead, please.

ED: Yes, I was just calling to make a point. I had a - I was in the Army for 12 years, and I had a traumatic brain injury in a crash, actually, and one of the - my recovery process, going through that, was watching these young soldiers be injured, get back up on their feet with prosthetic limbs and the such, gave me the inspiration to go on and recover, and not feel too sorry for myself.

CONAN: And not feel too sorry for yourself.

ED: Yes, with a traumatic brain injury, unfortunately - or I guess fortunately - you cannot see the injury. So therefore, people look at you as though you should be normal, and you're not. And so you have a long recovery process. So you have a head injury that you cannot see.

CONAN: It sounds, Ed, as if you're raising a family now.

ED: Yes, I'm going to step away from that young one because he's making quite the noise. But that's the other process of that second chance in life - was to raise a family.

CONAN: Well, Ed, good luck with that, and thanks very much for the call. We appreciate it.

ED: OK, thank you.

CONAN: This is an email we have from Sandra(ph) in St. Charles, Missouri. You might want to look at the Army's telemedicine program. My father's the office manager of it. The only time he isn't checking the computer is when he's overseas on vacation. They work with all five armed services around the world, military and some civilians.

Doctors send photos of a situation via email. Another doctor gives a response on proper treatment. Many soldiers - and some civilians - have been treated and saved.

And I wonder, Dr. Renz, have you had experience with that?

D: The system you're referring to is literally connected to my belt as we speak. The teleburn consultation has been enormously successful. It's exactly as the caller described. It's very efficient. It's on 24 hours a day. And a provider deployed throughout the world can reach one of the consultant trauma surgeons pretty much instantly, to get either advice or just a comment about care. And oftentimes it's simply to coordinate the transfer of a patient back to one of the trauma centers.

CONAN: What's the most interesting question you've gotten by telemedicine?

D: I can't really describe them as interesting. They - there are some that are more technically challenging, where oftentimes the provider who is asking the question has very good resources and that sometimes - the point where the question is beyond the capabilities...

CONAN: Mm-hmm.

D: ...of the unit at the time, and sometimes there simply isn't a good answer.

CONAN: So you have to improvise something, if you can. But anyway, let's see if we get another caller in. This is Maggie. Maggie calling us from Denver.

MAGGIE: Yes.

CONAN: Go ahead, Maggie. You're on the air.

MAGGIE: Hello. How are you?

CONAN: I'm well. Thanks.

MAGGIE: I was just calling - I actually was in - did my combat medicine training at, you know, over there, and my first patient ever was at the hospital on the burn ward, and they made everybody who was going to go into the nursing portion after combat medic school do that. It made the biggest influence on my life.

CONAN: In what way?

MAGGIE: I'm now going back and getting a bachelor's degree and planning on working with burn patients and trauma patients. And I still remember my first patient, you know - a nice, Southern boy and he was about, you know, 21 years old, and his mom was there.

And I'm originally from a Southern town, and we just had a great time, and I mean, it was some of the worst burns you could imagine. And I spent 15 months in Iraq, and he was still, you know, some of the worst burns I had seen with a patient. And he was my first one.

CONAN: You would think...

MAGGIE: And I'll never forget it.

CONAN: A lot of people would think that might put you off and decide that obstetrics was a good way to go.

MAGGIE: Everybody is so positive there, though. Nobody ever comes in with a negative attitude, and you see that even deployed - you know, spending 15 months in Iraq, you see them come off - you know, lose a leg and wonder how fast they can get back out there, how fast can I get back with my friends, you know?

CONAN: Colonel Serio-Melvin, I wonder: Does that sound like your first experience, too?

CONAN: Well, my first experience was a bit different because it was back in 1994, and we took care of mostly civilian emergencies back then; we didn't have a war going on. But I can tell you through my experience in 1994, when there was a big explosion at Pope Air Force Base in North Carolina - it's connected to Fort Bragg, North Carolina - and I took care of my first wounded warrior back then. And yes, absolutely, the esprit de corps among staff, the spirit - and again, the character, like what Todd had mentioned, of the individual soldiers who were burned is an experience you will not get anywhere else, in my personal opinion. And it is totally - it's 100 percent inspiring. It makes you want to get up the next day, and you feel like you really make a difference each and every day you come to work.

CONAN: Well, Maggie, thanks very much for the call, and good luck on your next rotation.

MAGGIE: Oh, thank you very much.

CONAN: We're talking about military medicine. We're focusing on the burn unit, right now, at the Brooke Army Medical Center at Fort Sam Houston in San Antonio, Texas. You're listening to TALK OF THE NATION from NPR News.

And let's go next to - this is Skeet(ph), Skeet with us from Wilmington in North Carolina.

SKEET: How are you?

CONAN: I'm well. Thanks.

SKEET: Awesome, awesome. I just want to give out mega-mega chest thumps to all the doctors in the military, with - even with the VA. I've had - I'm a disabled vet myself, spent four years in the Air Force active, four years inactive. But the care that I got, it superseded the care that I got in the private sector.

I mean, I had a BlueShield - Blue - BlueCross/BlueShield card when I was living in Detroit, but it didn't compare to the care that I got in the Air Force because the doctors, they - the doctors were just a lot more accommodating. And everybody - from the person that shaved my leg for my first knee surgery, all the way to the recovery room - everybody treated me phenomenally, and I was really appreciative of it. And they do keep in touch with you about your follow-up.

And I just can't commend or give as much, you know, praise to everybody that's in the medical field - enough, because of how they do treat everybody. And they do make sure that you get out there in one piece, and they do care about what you're going to do.

CONAN: Well, thanks very much, Skeet, and good luck to you. Appreciate the phone call.

STEVE: Thank you. Yes, sir.

CONAN: Before we wind up, I need to ask you both - these are difficult injuries, and Colonel Serio-Melvin, you've talked about the, you know, the positive feedback you get and the sense of mission. Still, this has got to take an awful lot out of you.

CONAN: It does. It's an emotionally - sometimes emotionally draining, and then also emotionally invigorating. And it is labor-intensive. Only special people, in my opinion, can work at the burn center. Not anyone who can walk off the street or who has a degree, I believe - as a registered nurse, a respiratory therapist, a physical therapist, anyone, a doctor - not everyone can do this line of work. You just have to have something within you that allows you to be able to look at these wounds, support these families and these patients through this whole process, and get through to your next workday.

CONAN: Colonel Renz, would you agree with that?

D: I would agree and add that it is truly an honor and a privilege to work in our daily environment, and to meet patients like Todd and his loving and caring wife, Sarah, and getting to know families such as theirs. It's - it really is beyond description. It is more rewarding than a person can describe.

CONAN: Well, thank you both very much for your time today, and I know everybody in the audience hopes that you're soon back treating a lot of civilians again, that this won't be so necessary as it is today. Colonel Evan Renz, M.D., director of the U.S. Army Institute of Surgical Research Burn Center at Brooke Army Medical Center; and Lieutenant Colonel Maria Serio-Melvin, critical care nurse, specialist in charge of improving nursing practices for the 16-bed burn unit, intensive care unit at Brooke Army Medical Center. And they joined us from the studios of KSTX, Texas Public Radio in San Antonio.

Just down the street from the Army burn unit, the amputee care center. The doctors there do remarkable things to help members of the military walk, run and jump again. We'll talk about some of the ways they're transforming prosthetic limbs. Stay with us for that. If you've had a prosthetic limb fitted, give us a call; 800-989-8255. Email us, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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CONAN: San Antonio is also home to the Center for the Intrepid, an advanced military prosthetic clinic at Brooke Army Medical Center. Prostheticians and researchers there incorporate the latest technology to replace body parts, sometimes for function, sometimes to be nearly as lifelike as possible, sometimes both. If you've served in the military and wear a prosthetic, give us a call; 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Joining us now from member station KSTX in San Antonio is Colonel James Ficke, also an M.D. He chairs the Department of Orthopedics and Rehabilitation at Brooke Army Medical Center.

Nice to have you with us today.

D: Nice to be here, Neal.

CONAN: And prosthetics. This is something that has come along so far. How much of the changes that you've seen, in your experience, are the result of new kinds of materials that are available for the construction of these devices?

D: Well, Neal, the construction has changed by leaps and bounds. The carbon fiber prosthetics, the components are significantly different than they were even 10 years ago. One point I'd like to bring up - I think is very important - is that it's - while we have substantial advances in technology, we've also made tremendous advances in the approach. And we use teams to do this. Those teams are - involve rehabilitative specialists. They're the trainers, the prosthetists who work side by side with the patients, so they're - really consider themselves clinicians, and more than technicians. They actually are able to make moment-by-moment changes in the fitting or the adjustment of these artificial limbs. And that really makes a difference for the patients as they adjust, and as they try to really achieve their greatest function.

CONAN: Well, somebody comes in and is going to need a prosthetic limb, how soon will the prosthetician start working with them?

D: We do it as soon as we can get the injuries closed. As a surgeon, Neal, I work with the prosthetist, or the rehabilitation specialist, from the time that they're out of the recovery room in the operating room, from the time of their surgery on. Now, we don't fit a socket until that wound and that limb are stable so that they're not going to have infections...

CONAN: Mm-hmm.

D: ...or skin breakdown. But it may be a few - may be a few weeks before they're really putting weight on them.

CONAN: But are you already talking with the patient about, you know, this is the kind of thing that we can do, or you know, are there options to be presented?

D: Yes, sir. Actually, before they even have a socket, we get them up. You know, we have to - it takes training and strength and motion, and a certain degree of fitness. If some of these individuals have been laying in bed for - sometimes several weeks because of the very severe injuries, to get them out of bed takes energy. And so we start with, you know, with just transitions from the bed to crutches, even putting a socket on, to start with, before we have a foot that we attach to it.

CONAN: And these are, very often, very fit young men and women who are probably pretty eager to get back to what they were doing before.

D: That's a great point, Neal. They have - they were, before their injury - and I think that's one of the points that makes it so inspiring to work with these young men and women because they, they - a few months or a few weeks or sometimes even a few days before we meet them, were in the peak of their health, in their young 20s. And now, they have a hard time adjusting to suddenly being in bed. And they're full of energy and full of passion to get that goal of being back up on their feet, or using their artificial hand again.

CONAN: And as you look at this, obviously, you don't want to get too far ahead of yourself. But on the other hand, young people can do amazing things.

D: Well, they have an expectation, that they want to get back to those amazing things. One of the points that you asked about was: How early do we start talking to them? We, as physicians, start talking to them immediately. We also have mentors that are individuals that have lost limbs or that - in some cases, have not lost limbs, but have had what we call limb salvage. And we - those individuals start talking, and become friends with the patients while they're still in the hospital beds.

CONAN: So they're very much a part of a community - a sort of a culture, then.

D: That's how I - I agree. It's a culture. They're - that community is somewhat different than the normal health care, where we respect everyone's privacy and they're very individual. We have an open floor, where all of the physical therapy occurs. And so one young amputee, or one young patient, may be able to inspire some person a little farther along or a little behind them. And so the progression or the community of their rehabilitation is, I think, a critical factor for advancement.

CONAN: So everybody's cheering everybody else on?

D: Or sometimes kicking them in the tail.

(SOUNDBITE OF LAUGHTER)

CONAN: I bet. I bet they are - 800-989-8255; email us: talk@npr.org. We're talking about advancements and fittings for prosthetic limbs. Give us a call.

Let's start with Karen, Karen with us from Provo in Utah.

KAREN: Hello, there.

CONAN: Hi.

KAREN: I just wanted to comment. I hope that the younger men now are - that it's been explained to them that those prosthetics, which work very, very when they're young, may cause a lot more problems as they grow older. My husband has two prosthetic legs - below-the-knee type, from Vietnam. And he was extremely active and could do, you know, lots of things when he was younger. And now, as he's older, his skin is much more fragile and infections crop up, you know, like, all the time. And it's getting much, much harder. He still tries to be as active as he can, but it's pretty difficult as you grow older.

CONAN: Karen, when you say the skin is much more fragile, obviously, the - there's a socket and the skin has to fit into the socket, and there's chafing. And this can become more of a problem.

KAREN: That's right. Absolutely.

CONAN: I wonder, Dr. Ficke, is this something you're aware of? Is this something you prepare people for?

D: It is. Even in the young individuals, the connection between the socket and their own limb or their own skin, just as the caller had mentioned, is our number one cause for complications, or cause for having to take that prosthesis off for periods of time.

And I'd like to - I think one of the points that she made that deserves highlighting is, it takes a lot of energy to use a prosthesis if you're an amputee. A lower-limb, below-the-knee amputation takes as much energy as it does to use crutches for us, for two-legged individuals. And so we really try to, when possible, salvage those limbs. And if we can get a person functional with both of their own feet, ultimately, as they get older, that energy expenditure is less of an issue than with a prosthesis, as she said.

CONAN: Karen, is that your experience? Your husband has to work as hard and...

KAREN: Yeah. It's energy. And more than that, it's the constant abrasion, I guess you would say. In my husband's case, his legs were - he has, literally, thousands of tiny pieces of shrapnel - you know, minute things - and gunpowder that was never burnt off. And so, I mean, his legs are filled with stuff. And the - when he was younger, you know, you get something moving around and you get a little infection, and in a day or two it was gone, you know?

CONAN: Mm-hmm.

KAREN: And now, you get little infection, and you might spend - he might sometimes has spent as long 12 weeks on PICC lines with really intensive antibiotics, and in wheelchairs. It's, you know, it's gotten pretty awful.

(SOUNDBITE OF COUGHING)

CONAN: Well, we wish, Karen, your husband the best of luck. Appreciate it.

KAREN: All right. Thank you.

CONAN: Thanks very much. And the materials, since - as we mentioned earlier, Dr. Ficke, the materials have changed enormously since the Vietnam era.

D: Yes, they have. Where - you know, from - we call it an energy- storing foot. In, you know, just as short of 20, 25 years ago, they would have a solid ankle. Now, we're actually working with developers to give motion and power in an ankle for that. So that - those are kind of on the front of scientific advancement. It's - you know, it's something that happens as a result of necessity for these individuals.

But you know, one of the points that we see with technology is that it's only applied as well as the people who not only create it, but place that on and train the individuals to use it, and then the individuals who give us, you know, inspiration because they're asking for more. Their goals are higher. Their expectations are to be normal. And I don't think that was different 25 years ago, either, but it certainly is something that we're closer to. But we're not there yet.

CONAN: We're talking with Colonel James Ficke, M.D., who's the chairman of the Department of Orthopedics and Rehabilitation at Brooke Army Medical Center, and orthopedic consultant to the U.S. Army Surgeon General.

And you're listening to TALK OF THE NATION, which is coming to you from NPR News.

Some of the advances that we look at down the road, I mean, there's - you talk about giving power to the ankle. The idea that one's own brain can manipulate, well, prosthetic hands and prosthetic feet - is that all that far away?

D: It's there now, for the hand. We - the normal electricity that makes your muscle work to close your hand is what our prosthetists use to control the fingers and thumb on a hand of a prosthesis. What we don't have yet is the ability to feel the - your foot or your fingers. And we're getting close to that. There are - some work around the country towards sensation, because that ability to feel is critical to - and really makes the critical difference between a prosthesis and your own hand or your own foot.

CONAN: Because it's the biofeedback that lets you know how much power to apply, how much dexterity you might need.

D: Yes. Otherwise, you have to look and see - if you don't have the sensation, the sensibility.

CONAN: Let's see if we can get another caller on the line. Let's go to Billy, Billy with us from Little Rock.

BILLY: Hi.

CONAN: Go ahead, please.

BILLY: Neal, I wanted to ask the doctor if they ever considered incorporating gel pads into the socket area of the prosthesis, or have they considered it. And I'll take my answer off the air.

CONAN: All right. Thanks very much for the call.

D: Well, that's actually kind of a standard fit right now. We have gel socket liners. They hold on a whole lot better than the old leather straps that were used quite some time ago, or the neoprene straps that would cause the friction sores that another caller spoke about.

Those gel liners still have to - they interface with the end of a leg or an arm that is not necessarily designed for that. But that gel has advanced us quite a ways.

CONAN: As you look at the way ahead, what advancement gives you the most hope?

D: As we look ahead in some of the work that we're seeing right now, as we've said, the - if we're able to preserve a leg or a hand, that it doesn't hurt, that it can move, and it has that feeling that we don't yet have, we call that limb salvage or limb preservation. And in a young person, it's - they look for a life of increasing energy.

And so I think that the most promising or the most hopeful development that we're seeing right now is the application of this high-technology socket prosthesis development towards using orthosis, or a limb salvage prosthesis, one that will give a stiff, painful foot the ability to run or to walk without having that pain every step. A dynamic brace is right around the corner. We're actually working with that now. And I think that's one of the most promising aspects for what we term limb salvage orthosis, or limb salvage braces.

CONAN: Mm-hmm.

D: Within the prosthesis, or the limb loss or the amputation area, one of the areas that we're most excited about is beginning to get that sensation back, or some more - called targeted muscle re-innervation, where the muscles can give feedback from the end of the prosthesis, and give sensation back.

CONAN: Of course, we all regret the terrible circumstances that caused this extensive practice and this extensive experience. But these advances, I'm sure, you work to share them with civilian surgeons and people who do this, well, around the country with people who are the victims of car accidents or something else?

D: Oh, we do. Actually, we're very pleased about the Center for the Intrepid that - we like to think of the three missions that we have is to take care of those burns, those limb-salvage patients and those amputees directly. We also like to teach others what we do, and how we're doing that. There are three centers, Neal, that are important to know. There's the Military Amputee Training Center in Washington, D.C., and the Center for the Intrepid, and then in San Diego at the San Diego Medical Center, Military - Naval Medical Center. All of these have the same kind of goals. They're different facilities. But in order to train others to develop courses and all, and then outside of the military system, to develop research and publish that to extend our lessons learned, out to the community.

CONAN: Dr. Ficke, thanks very much for your time today. Appreciate it.

D: It was my privilege. Thank you.

CONAN: Colonel James Ficke, chairman for the Department of Orthopedics and Rehabilitation at Brooke Army Medical Center. He joined us from member station KSTX in San Antonio.

KURT: SCIENCE FRIDAY. Ira Flatow will be here with a look at political activists in North Africa who are logging onto Facebook to publicize their protests. We'll be back on Monday to talk with Bill Gates about the eradication of polio. Join us for that.

This is TALK OF THE NATION, from NPR News. I'm Neal Conan, in Washington.

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