Reflections On The Children's Prosthetic Program
John C. Allen, M.D.
In the nine years that a children's prosthetic service has been in operation on a formal basis at the Newington Hospital for Crippled Children, our experience with the clinic team approach to this complicated area of children's disability has been singularly rewarding. Nevertheless a review and evaluation of our experience seemed in order. Our goal was the probable modification and strengthening of the program at Newington to provide better performance and service. It is hoped that our findings and suggestions might be of interest and value to the other clinics affiliated with the Children's Prosthetic Program.
The program has enabled us to offer a constantly improving service to child amputees. Specific benefits that we have observed are:
The publicity given this program at its inception and subsequently has attracted to the services patients who might not otherwise have been under definitive care.
The philosophy of early referral, fitting, and training has minimized disability to a considerable degree.
In certain cases the long range experience of the participating clinics has supported early surgical reconstruction or modification of congenital deficiencies - particularly in patients where multiple deficiencies are present - to provide more effective use and easier handling of prostheses.
The team approach to treatment has provided significantly more complete services and better management of the problems of the whole child.
The training of all members of the clinic team has been of major significance in up-grading individual skills and has resulted in improved prosthetic prescription, fabrication and training.
Acceptance of the principle of follow-up and overall responsibility for each individual patient on a continuing basis has led to represcription, resizing, refitting and re-training appropriate to the patient's changing circumstances.
Information concerning treatment techniques for the limb deficient child has significantly contributed to the education of orthopedists, pediatricians, physiatrists, residents, medical students and paramedical personnel.
The continuing effort in research has produced better components and techniques of fabrication and fitting.
By the exchange of information among clinic teams across the country each clinic is able to profit from the experiences of others to the benefit of all.
Suggestions for Improvement
The nine years that we have been associated with the program have spanned a period of growth and evolution. In the process, it is inevitable that some problems - either actual or potential - should have arisen. In the following paragraphs we present some of these difficulties as we see them, in the hope that areas of weakness may be strengthened.
1. Processing of Research Items
It is recognized that research can be extremely involved and consequently more time consuming than most of us can appreciate. Nevertheless it does seem that in at least one instance, that of the Size No. 1 Hand, the time required to develop, test, and market the item was inordinately long. This delay may have been due to circumstances beyond the control of the agencies concerned, but we would hope that future items can be processed more expeditiously.
2. Inter-Disciplinary Seminars
At the Newington Hospital the problems of child amputees have been presented to the entire staff and to students in periodic teaching sessions. We feel that this approach has contributed much to the children's prosthetic program in our locality. We have also tried to reach out on a state level to the general medical profession, as well as to the paramedical groups. We have presented our experiences at the State Medical Society Clinical Congress, and at the Seminar sessions held in conjunction with this Congress. Papers concerning various aspects of the program have been published in the State Medical Journal and demonstration clinics have been held for specialty groups within the medical and paramedical professions.
The value of these inter-disciplinary seminars has been amply demonstrated over the years and their general use is recommended, since we are of the opinion that some instances of congenital limb deficiencies are still not being reached.
3. Increase in Clinic Teams
Looking back through these nine years we are pleased to note the increasing numbers of clinic teams which have been activated. This extension of services for the child amputee should be of further value to these youngsters and their parents. However, some possible weaknesses as well as advantages can be detected in this pattern of growth:
Not every group interested in treating the child amputee has the facilities or experience necessary to manage some of the multiply involved or atypical problems which are seen.
In given geographical areas "competition" for a limited number of available patients is possible. Thus two or three clinics may share the case-load which is adequate for only one, thereby diluting the materials available for the teaching program and acquisition of experience.
Certain categories of personnel, for example, prosthetists and occupational therapists, are in relatively short supply. The development of competition to acquire members of these professions would be unfortunate.
Differentiate "Amputation Clinics" and "Amputation Centers"
To avoid or minimize these potential problems, it is suggested that consideration be given to the classification of facilities either as "amputation clinic" or "amputation center", with differing functions and requirements.
In this thinking the "clinic" would be defined as a clinic-team facility, which is essentially an out-patient service handling the simple amputation or limb deficiency problem which can be treated prosthetically without surgical revision.
The "center" would provide the clinic team approach in a children's hospital setting. The "center" would be qualified to treat the "complex" case; that is, one involving multiple deficiencies in a given youngster, or the existence of a deficiency which required surgical reconstruction or revision, or called for unusual prosthetic techniques. The management of these complex cases would imply the need for considerable experience and competence on the part of all members of the clinic team, the availability of facilities for surgical revision or reconstruction, and the opportunity for concentrated in-patient training.
This plan would provide effective care for the "complex" case and would have the additional advantage of reducing the competition for those categories of personnel in critically short supply. It would tend to concentrate cases of varying types in appropriate training centers and would operate not only for the benefit of the patient, but also for the education of all types of medical and paramedical personnel.
To effect such a change as suggested here would necessitate some means of establishing authoritative definitions of the "clinic" and "center", and the facilities and types of patients appropriate for each. A certain amount of education of those involved, such as Crippled Children's Services and various medical groups, would also be required. Further, it would be necessary to create a central group to establish acceptable standards and to assure maintenance of these standards.
These thoughts are offered in the form of a critical review. It is our hope that they will trigger discussion leading to the possible improvement of services as we have known them.
John Allen is Co-Director of Amputee Clinic, Newington Hospital for Crippled Children, Newington, Connecticut