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Sudden Impact

Chris Hartlove

Sudden Impact (continued)

Some four weeks, three continents and several hospitals later, Major would do just that, when he awoke from a drug-induced coma at Walter Reed Army Medical Center. After 19 blood transfusions, he was stabilized and transported stateside, where he soon lost his other leg to an infection. Later, as he became conscious of his surroundings in Ward 68, there came the moment when the neck brace was removed and he could finally lift his head off the pillow.

 What he witnessed shattered him.

“It wasn’t the pain that affected me,” Major says. “But seeing the amputation was like a stab to the heart.”

 His legs gone above the knees, he thought of the man he was and despaired over the man he might be. He had defined himself through his body—the challenges it could meet, the sports it could play, the movement in which he gloried. But now?

 “How will I do that without my legs?” wondered Major, his mind asking the same question that hovered, like a shadow, over all the soldiers in Walter Reed facing a similar fate.

 And who, if anyone, could show him the way back?

It could be a bad pun or karmic poetry.

Either way, Ellen MacKenzie, PhD, is the first to admit she discovered trauma research quite by accident.

As a student in the 1970s, MacKenzie, a biostatistician by trade, was studying Susan Baker’s work. Baker, MPH ’68, a professor of Health Policy and Management (HPM) at the School, had developed the Injury Severity Score, or ISS, which would become the standard measurement for predicting injury mortality. MacKenzie wondered if similar scales might predict non-mortality outcomes such as the ability to perform everyday activities. Her advisor, pioneering public health researcher Sam Shapiro, told MacKenzie, “I’m sure there’s a lot of research out there.”

When you get out of the hospital, “you have a lot of time alone with your thoughts and your ‘new’ body, looking different, covered in scars.” —JR Black

There wasn’t.

Shapiro, an HPM professor, quickly helped her secure a Robert Wood Johnson grant. Of such efforts careers are born, and, in the case of MacKenzie and colleagues, clinical practice changed. MacKenzie spent much of the ’80s burrowing into the world of trauma treatment. Her work focused on quantifying all aspects of trauma care, from the cost of treatment to how pre-existing disease affected the length of hospitalization.

But those findings were the end product of something far more important and lasting. MacKenzie’s true genius was building research partnerships with frontline trauma surgeons and other trauma-oriented physicians—so much so that she spent a sabbatical in 1995 at University of Maryland’s Shock Trauma Center.

“Here I was doing a lot of work in trauma, yet I’m not a clinician, I’m not a survivor, I’m a biostatistician,” says MacKenzie in explaining her choice for the yearlong sabbatical. “And so I wanted to spend time with trauma surgeons to learn what they do, to be closer to them. I went on rounds with them every morning, I sat through surgeries … I really became part of that family and got access to a lot of information and got a better feel for their work.”

MacKenzie realized that the high-pressure, high-volume work of trauma surgeons left them little time for research. They understood the importance of outcomes research but needed a colleague who could find the grants and carry out the work.

It wasn’t easy—trauma, despite being the fifth leading cause of death, has never had a Lance Armstrong-like celebrity spokesperson to raise awareness and funds. But MacKenzie was motivated. She recognized that trauma surgeons had the power to move the needle, if she could spur them into action. Her opportunity was a study that she and her colleagues called LEAP, as in the Lower Extremity Assessment Project. LEAP was one of the first multicenter trauma studies, featuring 601 patients drawn from eight Level I (highest-level) trauma centers.

With no existing national consortium for trauma research, MacKenzie needed plenty of charm and persistence to organize some of the country’s top orthopedic surgeons to design and carry out the study.

LEAP’s ostensible goal was determining whether leg amputation or limb salvage provided the best functional outcomes. But, as MacKenzie notes, “there’s no way you could ethically do a randomized control trial, where some people would get their leg cut off and some wouldn’t, so we had to convince ourselves and others that doing an observational study with trauma centers that handled a lot of both patients would answer the question.”

Working with Carolinas Medical Center trauma surgeon Michael Bosse and orthopedic surgeons from seven other major U.S. trauma centers—as well as her own team led by researchers Melissa McCarthy and Renan Castillo—MacKenzie published initial results in 2002 in the New England Journal of Medicine that shook the world of trauma orthopedics. It turned out that neither group fared well, for reasons that went far beyond their initial injuries and surgical treatment.

The study, which included asking trauma patients to self-assess how they were faring since their injury, found that barely half returned to work after two years. Some of their explanations for poor outcomes—poor social support networks, low self-confidence to resume life activities, pain and lingering mental health issues including depression, anxiety and post-traumatic stress disorder (PTSD)—could well be addressed in the clinical setting, but had not been. The result: needless suffering for trauma victims.

“We learned that there were elements of the patient’s assessment of the outcome that we weren’t really appreciating well as orthopedic surgeons,” says Andrew Pollak, MD, professor of Orthopaedics at the University of Maryland School of Medicine and chief of Orthopaedics at the R Adams Cowley Shock Trauma Center. “[We’ve] looked for years at whether the fracture healed as the primary outcome measure. There’s no question it has to heal, otherwise everything else fails. But there’s a lot about patient satisfaction that’s driven by something else”—notably treatment of psychosocial concerns.


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