Orthopedic Surgeon on the Front Line in Syria
While much of the country may have “Syria fatigue, ” Robert Loeffler, M.D. does not. An orthopedic surgeon with the Lower Keys Medical Center in Florida, Dr. Loeffler recently returned from the war zone where he was the only American doctor…and the only orthopedic surgeon.
“I did a nine week mission with Médecins Sans Frontières (MSF) on the border of Syria and Jordan. There were 10 ‘expats’ and 100 ‘nationals’ working in the hospital, and we were surrounded by a steady stream of physically and psychologically traumatized patients. The closest town, Dara, was constantly bombed—and we could feel the explosions.”
Sleeping in a walled compound at night and performing amputations during the day, Dr. Loeffler was struck by the differences in his work in the U.S. and his work in Syria. “Under normal conditions, the amputations I perform are elective; for example, the leg is not getting enough blood and it’s impossible to repair. Working in Syria, however, the patients arrive with legs and arms blown off. My job was to complete the amputation or turn the limbs into functional stumps. Kids are stepping on mines or are getting bombed. It does tend to be children because they are out playing during the daytime. A lot of medical personnel leave after a few weeks because the trauma these kids endure is too much to bear.”
“Aside from amputations, I had to fix quite a few fractures. In such an environment you can’t put in rods, plates, and screws—all we had were external fixators. And we had to get it right the first time…there was no going back to the OR another time. Fortunately, there is a rehabilitation facility that is part of the nearest refugee camp (a place, which, by the way, houses roughly 100, 000 Syrian refugees).”
“On a lighter note, after arriving, I met two of the Bedouin kids that lived in a tent next to the walled compound the expats stay in. They were very friendly and were very happy to show me their large tent and animals (sheep, goats and camels). The little girl saw me jogging one early morning as she was herding the sheep to a new field by the border. She insisted I take her stick and proceeded to show me how to herd the animals, including the sounds and whistles.”
“I am able to keep in touch with the psychosocial worker from the hospital via WhatsApp. In particular, I check in on my first two patients. Five boys—ages seven and eight—were playing outside when a bomb struck. Two died immediately and the other three were brought to us. One died in the ER, one had severe nerve damage, and the other required a below the hip amputation. Yet another boy had an amputation at the hip as a result of a landmine. He had no family, and he was never quite right after the surgery. I do my best to keep track of their progress.”
“I worked in Haiti after the earthquake, but this was my first wartime experience, ” says Dr. Loeffler. “I would say 99% of doctors do not go overseas to work—and 99.9% are not going to a war zone. When I come back here I see negativity towards refugees. I want people to know that the vast majority of these individuals are nice, resilient and just want to live their lives like the rest of us.”
Patient-Reported Outcomes: New Methods on the Horizon
Two studies just published in the Journal of the American Academy of Orthopaedic Surgeons describe the benefits of the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) to objectively and quantifiably assess and track patient symptoms over time. Darrel S. Brodke, M.D. is a co-author on the study and professor and vice chair of the Department of Orthopaedics at University of Utah School of Medicine.
Dr. Brodke told OTW, “Over the last 10 years patient-reported outcomes have been an increasingly important part of the orthopedic surgery universe. We have traditionally used X-rays, range of motion (ROM), and other measures to determine outcomes. Traditionally, two types of outcome scores have developed: disease-specific outcomes (Knee Injury and Osteoarthritis Outcome Score, aka, KOOS, or Oswestry Disability Index for Low Back Pain) and generic outcomes (such as the Short Form Health Survey 36). One issue is that subspecialists have trouble understanding the precise meaning of one another’s data. As a spine surgeon, for example, my knee colleague might tell me that someone’s KOOS score has improved from X to Y, but that’s not something I necessarily understand.”
“We had always assumed that these disease specific measures were sensitive and broad for the diseases we treated because they had been validated. Because patients were burdened by spending a lot of time doing paperwork on outcome measures and because of the inconsistencies of the many measures used, the National Institutes of Health (NIH) became interested in transforming patient-reported outcomes. They set out to develop a new style of measure, using item response theory and computerized adaptive testing to shorten the process of data collection and increase the accuracy.”
“Instead of looking at disease specific measures which have lead to many, the test designers decided to break up the measurements into domains of health (physical, mental, and social). This means that you no longer measure hip function you measure physical function, something that could be diminished because of hip pain or spine pain. Now spine—and other surgeons—can relate to that.”
“The process at our institution is such that patients complete a survey on an iPad when they check in. There are a couple of demographic questions, the PROMIS measures, and a couple of legacy scales (such as a numerical pain rating scale).”
At present, says Dr. Brodke, there are only two other academic centers using PROMIS in a way similar to the University of Utah: Washington University in St. Louis and the University of Rochester. “PROMIS was first used in oncology and psychiatry. Four years ago our department began the process of determining how to use it on a daily basis in Orthopaedics—and how it could be used not only for research and quality improvement, but during patient encounters.”
“It is challenging to figure out how to use the data in conversations with patients. But essentially we need to say, ‘You were here in the healing process. Now you are here, and this is where you are likely headed.’ This can provide an element of objectivity to the discussion.”
“I usually have these scores in my clinic notes and can say to the patient, for example, ‘Your score is consistent with patients who have tried all nonoperative treatments’ or ‘Your score is better than most patients who need surgery so let’s try this nonoperative treatment first.’
“We still need to do work on comparing PROMIS the to the ‘legacy’ measures because this is what is still widely used. Thus, we need to understand its use in, for example, knee arthritis patients versus other kind of knee patients. Then we can begin publishing this work alongside classical outcome scores.”
THA Improvements Are Specific to Sex
In the rehab facilities, will it now be some version of, “ladies to the left and gentlemen to the right?” Perhaps, say researchers from the University of Illinois at Chicago (UIC). This group of scientists studied 124 individuals before and one year after total hip arthroplasty (THA), and found that outcomes such as pain, function, range of motion, and strength are different for men and women.
Kharma C. Foucher, Ph.D., is assistant professor of Kinesiology and Nutrition at UIC and the study’s senior author. Dr. Foucher told OTW, “Psychosocial factors have received more attention in the literature, but biomechanical differences can also contribute to some of the differences in clinical outcomes seen in men and women.”
“The fact that we found any sex differences was interesting! More specifically, based on previous work from our group and others, we expected that hip abductor function would be important, but it was interesting that some secondary roles of hip abductor function predicted both pain and functional recovery in women.”
“First we need to do prospective studies to make sure these findings hold up, as well as more research to understand why these associations are different (is it simply pelvic geometry, or something else). Down the line, we are interested in using these findings to inform new rehabilitation interventions that will improve care for both men and women.”
