Matters of life and limb

At Headley Court in Surrey, seriously injured service people are being nursed back to health. The process is long and painful but it’s a joy to behold, says Steve Smethurst

From Legion Autumn 2009

"Joe! Was that you?” says Matt, accusingly. Joe looks innocence personified. “Was what me?”

“Was it you who put all those tampons in my leg?”

“I have no idea what you’re talking about,” says Joe with a smirk, before adding a little mischievously: “So, is that the only place you’ve found them?”

Welcome to Headley Court. The Defence Medical Rehabilitation Centre is a Ministry of Defence hospital set in 85 acres of grounds near Epsom in Surrey. It’s the place where seriously injured members of the armed forces come to recover from their wounds. The former Elizabethan farmhouse was the headquarters for the Canadian forces during WWII, but since then it has been used by the RAF, and then the joint-services, as their main rehabilitation centre.

That a seriously injured pair of Royal Marines from
40 Commando, Lance Corporal Matt Kingston (pictured left) and Marine Joe Townsend (above), can share a joke about their false legs is testament to their resilience, the relaxed atmosphere at Headley Court, and the skill and devotion of the teams that are nursing them back to health.

Matt, 24, is still receiving treatment after being shot in the ankle during a skirmish in Afghanistan in November 2007. Following a year of trying to live with the injury, he succumbed to a below-the-knee amputation to give him a greater range of movement.

Joe, 21, was much more seriously injured. In February last year, he was walking across fields just 800 yards from the safety of his base, when he stepped on an anti-tank mine hidden just below the ground. The blast tore off both his legs.

Joe allows us to take photographs as he continues his attempts to walk unaided. He walks back and forth between parallel hand-rails, while a physiotherapist and prosthetist look on and make suggestions and adjustments to his new limbs. Despite his huge biceps and the fact that he makes it look relatively easy, it soon becomes clear that walking is exhausting work.

“A double amputee requires 300% more oxygen consumption just to stand up than someone with their own legs,” explains the physiotherapist, Kate Sherman, “so it is really hard for them, and the less residual leg that you have left, the harder the prosthetic limbs are to control.”

After the mine blast, Joe was flown to the operating theatre at Camp Bastion and underwent 12 hours of surgery before being evacuated back to Selly Oak military hospital in Birmingham. While there, he spent five weeks in a critical-care ward. In total, his treatment lasted for more than four months. It was only once he had fought off several infections and his wounds were healing, that he was transferred to Headley Court. He still spends a lot of time here, although he is now allowed home regularly on leave.

Joe’s experience is typical, says Sergeant Neil Bellamy, supervisor at the RAF prosthetics workshop. He says that Headley Court will usually get a few weeks’ warning of a new admission, and that patients only come down from Selly Oak when they are stable and their wounds have healed.

New patients will typically visit this area of Headley Court on their second day, after they’ve been through the admissions process. They’ll see a prosthetist, be assessed, informed about the rehabilitation they’ll go through, then be measured up for a limb. A cast will be taken to produce a representation of their residual limb and the workshop will produce what is known as a ‘check socket’ to act as a bridge between the patient’s stump and prosthetic.

“When the socket is fitted, a prosthetist checks the weight bearing is in the right place and ensures it’s not pushing onto any wounds or scar tissue,” says Neil. “Once a patient has the socket, we might even give them a temporary knee or a foot. From that we’ll make their first definitive socket within five working days. Then they’ll be up walking between the bars.” Sometimes, it’s important for a patient’s psychological welfare to get them up and about quickly. “Imagine you’ve been in bed for five or six weeks, your muscle tone has gone, you feel light-headed when you stand up, so the quicker you’re up and about the better,” says Kate.

To make life easier for bilateral (double) amputees to get around, they are also issued with ‘stubbies’, the equivalent of small stilts without kneejoints – just a socket and short feet in order to get them upright and stable with a low centre of gravity. However, by the time they are ready to go back to work, they will have a main limb, spare limb, shower limb, sports limb, and if they are a keen rower, say, one for that too. There are also ones for boxing, cycling, skiing or any other activity they pursue.

“The more activities they do, the more specialised their legs have to be,” says Neil. “All the hardware they need is provided by Headley Court, just as long as it’s a reasonable  ‘clinically appropriate’ request.”
Prosthetist Mark Thoburn is a civilian but, following a motorbike accident 18 years ago, has a below-the-knee prosthetic himself. He explains that amputees will put extra socks over their stumps to achieve a good fit with the socket. “The most important aspect is the fit, you need good control of the limb. If not, the limb is a waste of time. It takes a bit of adjustment to get them right as residual limb volume changes very quickly in the early stages of the rehabilitation process.

“After the amputation, there’s swelling as there tends to be a lot of fluid in the stump. You’re not using the muscles so there’s no muscle action to pump the fluid back around the body. Then, the shape of the stump changes as the muscles settle down.

Although, in the case of our severely injured patients, they tend to have lost a lot of weight, so in extreme cases, the residual limb volume will get bigger, rather than shrink.”

Mark compares the feeling of getting used to a prosthetic limb as being like wearing a pair of new hiking boots. “They’re not comfortable to begin with and you can’t take them off for a nice pair of comfy slippers. The slippers have gone and you’re stuck with the boots. They really do take some getting used to, but it’s uncomfortable rather than painful.”
It’s important not to get carried away with the technology, though, says Lt Col John Etherington, a consultant at Headley Court. While the ‘C-legs’ that are given to people like Joe are amazing pieces of kit – they cost up to £17,000 each and are computer compatible via a Bluetooth laptop to ensure the correct walking set-up – they are only part of the story.

“When rehabilitating somebody back to full physical fitness we rely on processes that we have used for many years. We use a multi-disciplinary team, working towards clearly set goals, decided between the patient and us, and we use the best technology available to facilitate that process.”

The teams are led by a consultant trained in both rheumatology and rehabilitation medicine. Team members include physiotherapists, occupational therapists, social workers and mental health nurses. There will also be a remedial instructor – a specially trained physical training instructor from the military.

“We also draw on psychiatrists, pain-management specialists and surgeons,” says John, “so it’s labour intensive.” The process hasn’t changed that much over the past few years. But what is different is that since the recent conflicts, Headley Court has had to increase its capacity and also the patient type has changed. “We’ve taken on more complex trauma cases,” says John. “We’re taking patients a lot earlier after their injuries, putting them into a nursed ward environment so that we can start their rehabilitation a matter of weeks after their first injury. Some patients will come to us within four weeks of their wounding.

“The quicker you get someone engaged in rehabilitation, the better it is in terms of their physical response, you can avoid things like shortening of muscles. But also from a morale and mental health point of view, it’s much more of a positive experience.”

Not surprisingly, injured troops are often very keen to leave Selly Oak and go into an environment which, although still military, is more relaxed and gives them the opportunity to mix freely with people who are going through a similar experience. “In many ways we are half-way between a hospital and normal accommodation,” says John. “We have just over 100 hostel-type beds here, so pretty much barrack accommodation that you would find anywhere around the country, but also we have more than 60 ward-based beds where we can provide nursing and meet all the usual requirements of a patient on a ward.”

The mental health of patients is also keenly monitored – although the relaxed and jovial environment seems to keep them all in high spirits more often than not. All patients who arrive as battle casualties are given a mental-health screen and undergo anxiety and depression checks.

“The interesting thing is that very few of them – certainly when they are with us – have severe mental health problems,” says John. “We can’t say what’s going to happen in 10 years’ time but I think that most of the evidence would suggest that positive support and informal debriefing among your mates is useful for preventing severe adjustment reactions to the trauma they have been through.”

Naturally, the patients at Headley Court do experience these ‘adjustment reactions’ and may suffer nightmares, for example, but the vast majority settle very quickly, usually within a couple of weeks.
“Going through a process of adjustment is common,” says John, “as we say to the guys, ‘it is normal, you are a normal person going through an extraordinary experience and therefore there is a time for adjustment,’ and most of the guys cope extremely well.” In fact, the treatment is so successful that at least three amputees have gone back to active service in Afghanistan – and they include an above-the-knee amputee. “I’m not sure how close they get to the front line,” says Neil, “but knowing the guys as I do, I’m sure they’ll be getting as involved as they possibly can.”

Certainly, Matt and Joe appear to be coping well. As Matt comes to the end of his account of what happened to him when he was shot in Afghanistan, he turns his wheelchair around to discover that his leg has gone missing. “Joe!” he shouts, plaintively. “Where’s my leg this time? I can’t believe it’s gone adrift again,” he says, although, clearly, it’s not the first time it’s gone AWOL.

“Thanks for coming down,” he says, ignoring the limb’s disappearance for a moment. “Oh, and if any Legion members want to visit, they’d be very welcome. I love talking to people and it’s nice to meet those who are helping the cause.”

He smiles. “It was nice to meet you,” he says, “but I’d better go and find my leg now...”