IFrorn the@ Medical Director I hiouah the Waist by Douglas G. Smith, MD

t Though the outcome of amputation in that it involves loss of functions other dealing with the bladder and kidneys, surgery can be amazing, with people than walking, grasping and touch. The and a plastic surgeon for managing the living renewed lives as they move beyond waist-level amputation also means the complex closure of the surgical site. the injuries or disease that led to their loss of the organs for reproduction, blad- Getting five surgeons and surgical teams amputations, we should acknowledge der and bowel functions and the loss of to coordinate this complex and staged and understand that sometimes the out- sitting ability. procedure is indeed quite a challenge. come isn't optimal, and sometimes none of the choices are good. Occasionally, A Difficult Decision decisions are made that, to others, may The decision to have or not to have a not seem right. People may choose not to waist-level amputation is a life-changing have a particular surgery, even if it means decision. The person loses everything their disease will progress. But I think it's below the waist. In addition to bones, important for patients, their families and musclcs and tendons, the urethra, colon, friends, and healthcare professionals to rectum and sexual organs are removed, recognize that some decisions are indeed and ostornies are, therefore, needed for uniquely individual. There's just not a bowel and bladder function. The surgi- universal "right answer" for everybody cal procedure can last up to 13 hours, This is especially true with amputations and survival is not certain. In addition, at the waist. recovery and rehabilitation involve major The waist-level amputation, which is life adjustments. When making a deci. also called the translumbar amputation, sion about this type of surgery, therefore, transabdominal amputation, or hemicor. Because so many bodily structures patients understandably want to consider porectomy (HCP), is the most extensive and functions are affected by transab- it carefully, primarily because of quality- and extreme of all amputation levels in dominal amputations, a large surgical of-life issues. terms of structure and function. This team is required. Though most amputa- Though this amputation level was type of surgery is described in one text tions are performed by one surgeon with pioneered in 1960, there are fewer as a "heroic effort to save the patient's a team of assistants, transabdominal indications for it than there used to be, life in the face of severe trauma, infec- amputations can require the skills of an and it is rarely performed today. Diagnos- tion or cancer." It can also be an option orthopedic surgeon, a neurosurgeon, a tic techniques have improved since the for spinal-cord injury patients who have general surgeon, a urology surgeon, and '60s, and chemotherapy and radiation a long history of debilitating backside a plastic surgeon. An orthopedic surgeon treatments have become more effective, ulcerations and bone infections when no is needed for the muscles and skeleton, leaving fewer people with the need to less-extreme medical or surgical options a neurosurgeon for dividing and manag- consider this difficult choice. for treatment remain. ing the spinal cord, a general surgeon for Even when it is an option, with This amputation level is unique, too, managing the colon, a urologist for thorough education and the

64 inMotion Volume 15, Issue 4 July/August 2005 understanding of all involved, it has amputation levels, as you get close to the crutches ahead, leaning forward on the become very rare for patients and sur- core of the body, a socket looks less like crutches and then swinging the body and geons to decide to embark on this course. what we typically envision as a conven- prosthesis forward through the crutches. Education is extremely important for all tional socket. It is no longer a socket that Though walking in this manner is lim- concerned because even most healthcare fits onto the end of a limb; in the case ited, it does allow the person a bit more workers have never been exposed to of a transabdominal amputation level, it freedom and mobility. A few folks are this amputation level. Though the first encompasses the abdomen and lower nbs. even able to drive in specially designed instinct of physicians and patients alike A person typically won't use a trans- vehicles that allow them to use the accel- can be, "We're going to save life and abdominal prosthesis throughout the erator and brakes with hand-controlled that's the most important thing," with an day. While we can make a device that devices. understanding of the dramatic changes supports the abdomen, back and the ribs, that will occur in the person's quality of If You Can't Sit, Then What? most people choose not to use a prosthe- The Prone cart life, the decision-making process becomes sis because it pushes up on the abdo- much more complex. men and ribs, making it very difficult to breathe. Generally, it's not well tolerated Prosthetics: The Primary for more than short periods at a time. Goal Is Sitting This amputation level radically changes our concept of prosthetics, In other lower-limb amputations, the prosthesis is used to replace the foot or the leg and is designed for wallung. In upper-limb amputations, the prosthesis replaces the hand or arm and is designed for grasping, Because of breathing and comfort manipulating objects, and using tools. In problems associated with the socket and waist-level amputations, however, the ini- sitting up, many individuals with this tial prosthetic goals are simply for sitting. amputation level lie on their backs or Still, some notable patients were able to bellies. Unfortunately, there are problems successfully tolerate sitting and the pres- with this too. sure the prosthesis placed on their abdo- When you lie on your back, your men and ribs and then advanced to some For those individuals who do master arms and hands are in a nonfunctional level of walking. They would use standing sitting and can breathe comfortably with position for mobility. If you tip the bed prosthetic limbs with crutches or a the increased pressures on the rib cage, a up, the pressure returns to your ribs and walker and do a swing-through wallung few are able to advance to short periods abdomen, making it difficult to breathe. technique. This allowed them a bit more of walking. Wearing prosthetic limbs that The other option is to lie face down, independence and improved their ability to allow them to remain upright in a stand- which is called prone. For mobility, a reintegrate into life outside the home. ing posture, they walk for short periods person with a transabdominal amputa- To meet the initial goals of the waist- using crutches or a walker. The typical tion may use a device called a prone cart. level amputee, the socket and prosthesis walking technique is positioning the It's about waist high and has four wheels. are designed solely to get the person Lying face down, the person uses his or upright. Because sitting typically involves her arms and hands to move and guide the buttocks and backs of the thighs, the cart. Unfortunately, to look forward traditional sitting is no longer possible or from side to side, the neck must be because there is simply nothing to sit on hyperextended upward. But thanks to anymore. Since the buttocks and pelvis advances in technology, newer models are removed in a transabdominal ampu- can be motor-driven, with the operator tation, it becomes necessary to design propelling and guiding the cart using a a prosthetic system to get the person hand-held device. upright, which is, in a sense, sitting. Without a prosthetic support, the only When There Are No options are to lie face up or face down. Easy Choices As we discussed in our series on Most programs that performed waist-level the hip disarticulation and transpelvic amputations have stopped doing them

To support the ACA or tn become a member, call 1-8881267.5669 65 over the past couple of decades because say they don't want to die on the medical of quality-of-life issues. roller coaster in the midst of heroic pro- In my 16 years of surgical practice at cedures. I'm often intrigued when I meet Harborview Medical Center in Seattle, those in the late stages of life who show Washington, I've encountered five or six in their eyes that they know their time people who were possible candidates for has come. They want it to happen with transabdominal amputations. With each peace, dignity and respect, while they are patient, we discussed the complexities surrounded by understanding loved ones. of surgery, reviewed photographs, and But sometimes their families continue outlined rehabilitation and life with a throwing out words like "fighting," waist-level amputation. Each person said, "battling" and "winning the war." I often "I'd never want to live like that," and see terminally ill people surrender to the decided not to have this drastic proce- family's wishes and continue on this very dure. It's not unusual for a person facing rough and ragged medical roller coaster. a waist-level amputation to make an They give up their final dream to die with active choice not to do it. peace and dignity. Issues of death and dying are also a Relatives may believe they're rallying major part of the decision to have or not the patient. The attitude is, "We always to have a transabdominal amputation, as fight death. Never surrender." But they they are with many other medical condi- may not realize that they can be taking tions. For example, people in the latest away the final wish of someone they stages of severe diabetes may have to love. People don't dream about dying in confront incredible complications, which an emergency room, undergoing heroic can include circulatory and neurological measures that would give them just a bit problems in the extremities, heart and more time shrouded in illness and pain. stroke issues, kidney failure and dialysis, It's a difficult thing, but the best thing and loss of vision. For many people in a loved one can do is ask the person, these late stages, the event that often "What do YOU want?'' The answer may pushes them to make a decision about not be easy to accept, but it is the loving living or dying is a severe infection or thing to do. As noted science fiction gangrene. They must decide whether to writer Isaac Asimov said, "Life is pleas- have an amputation, often at the thigh ant. Death is peaceful. It's the transition level or higher, or to let Mother Nature that's troublesome." take its course and get their final affairs in order. Hospice Care With some medical conditions, there Dylng certainly is something nobody can be options. People with kidney looks forward to, nor do many of us even disease almost always choose to undergo care to ponder our own mortality. But it dialysis to extend life, hoping someday to is reality for everyone at some point. For receive a kidney transplant, even though many, hospice care under the guidance dialysis is very time-consuming and the of skilled and specially trained health- treatments must be done at least three care team members can be a preferable times a week and can last for four to nine alternative for the final days or weeks. hours per session. As wonderfully stated by Ralph Waldo The person spends that time hooked Emerson, "Our fear of death is like our up to a machine that removes the blood fear that summer will be short, but when from the body, cleanses it, and returns it we have had our swing of pleasure, our to the body, taking over the function of fill of fruit, and our swelter of heat we say the kidneys. It's not easy The person's we have had our day" whole life can soon revolve around the Hospice is a program designed to care continuous need for dialysis treatments. for the dying and their special needs. The Though the medical equipment American Academy of Family Physicians involved has improved in recent years recommends hospices provide the

66 inMotion Volume 15, Issue 4 JuIylAugwt 200. a toe, while I've seen others lose an entire leg and rapidly get on track and move forward. As I've tried to emphasize the challenges and difficulties related to amputation, it may have seemed that the tone of these discussions became more "negative" as the amputation levels moved higher. That certainly wasn't my intent, but the your physician and other seriousness of these challenges is a reality that all people with professionals. There are numerous hospice- these amputation levels and their families and friends must face. All amputations are serious, but as the surgical site moves closer hospicefoundation.org. A book titled Tne Cmfiof Home, by to the core of the body, we see that people's emotional response Maria N. Meyer, also details the various aspects of home care for to it becomes more and more pronounced. Survival and patients, their families and healthcare professionals. quality-of-life issues enter more and more into conversations between surgeon and patient. Some Concluding Thoughts on Lower0Limb But what I've also seen played and replayed in my years of Amputations surgical practice is that, frequently, wondrous and wonder- As we've taken thls surgical journey from toes to waist, what ful things happen for people as they overcome limb loss. I've emerges is that amputation of any kind is a challenging adjust- enjoyed seeing many people return to the activities they love ment. There are universal factors, whether a person has an and take on new challenges as their lives progress. I've also amputation of a toe or of an entire leg. The physical aspects are seen the best of human nature emerge as people overcome the challenges and become more insightful, compassionate and understanding about themselves and others. I've been blessed, for example, with opportunities to help care for a vast range of individuals, including seniors with vascular disease and diabetes, children who suffered traumatic injuries in lawn mower or traffic accidents, firefighters who lost a limb in the line of duty, workers injured while logging or fishing, and our brave soldiers fighting the war on terrorism. Recently, I've been privileged to assist in the care of soldiers injured in Iraq and Afghanistan. While at Walter Reed and Brooke Army medical centers, I've come to realize that we, as a country, are incredibly fortunate to have such dedicated, heroic individuals willing to put their lives on the line for the good of our nation. I have no doubt that I've seen many of our future leaders and I've come away feeling lucky and optimistic. These injured young men and women are inspiring individuals who are now and will continue to be great leaders. They make me feel very good about the future of our country. I

'fA person who chooses to die or risk death demonstrates that there are values, principles, maxims that are more valuable to him than is life itself. In short, he places his immortal self above his mortal self " - Henry David Thoreau

68 inMotion Volume 15, Issue 4 JulyIAugust2005