RETURNING TO DUTY AFTER MAJOR LIMB LOSS AND . -

Care of the Combat AmputeeFitness for duty is evaluated as a function of the reasonably expected ability to perform the duties of the soldier’sprimary MOS.13(p14) To get to this point, the Army mustutilize the medical evaluation board (MEB) and physicalevaluation board (PEB). The MEB determines “retention,”per Army Regulation (AR) 40-501, Chapter 3.14 The PEBdetermines “fitness,” based upon MOS. This distinctionis extremely important, because the medical treatmentfacility (MTF) does not and should not comment on the“fitness” of a soldier, but rather whether the amputeemeets retention standards, regardless of MOS, basedsolely on AR 40-501, Chapter 3.14If the soldier’s medical condition could potentiallybe found to not meet the medical retention standards,as outlined in AR 40-501, Chapter 3, it is the treatingphysician’s responsibility to refer the soldier to theMEB. The MEB physician, who receives specializeddisability training, then reviews all clinical and administrative evaluations. The MEB physician (civilianor military) is directly employed by or assigned tothe MTF, working under the authority of the MTFcommander, through the deputy commander forclinical services. The MEB physician’s key role is todetermine whether or not the referred soldier’s medical conditions meet the retention standards of AR40-501, Chapter 3, regardless of MOS. If the soldierfails to meet retention standards and cannot satisfactorily perform his or her military duties, he or sheis referred to the PEB. The PEB, under the authorityof the US Army Physical Disability Agency, whichmanages the Army’s PDES and acts on behalf ofthe secretary of the Army, will consider the recommendations of the MEB and make the determinationof fitness or unfitness, rendered with the soldier’sMOS in mind.14Developing and implementing a system to bestbenefit the soldier, while providing for the overallgood of the Army, whose “paramount mission isto maintain a fit fighting force,” is a difficult anddaunting endeavor. 15 A pilot program was established in November 2007 to streamline the process,improve overall customer satisfaction, and rely onthe VA for disability rating purposes.16 This jointeffort was born out of the President’s Commissionon Care for America’s Returning Wounded Warriors [Dole-Shalala], which provided an “agendafor moving forward.”17 The goal of the pilot is tostreamline and improve the disability evaluationprocess by providing one medical examination anda single-sourced (VA) disability rating, making fora seamless transition from the care, benefits, andservices of the DoD to the VA system, measured bycustomer satisfaction (Figure 4-1).16 The PDES JointPilot Program was first put into practice at the three56Washington, DC-area triservice facilities: WalterReed Army Medical Center, National Naval MedicalCenter, and Malcolm Grow Medical Center. The planhas been to expand the pilot program throughout theDoD, worldwide. Army-wide rollout of the pilot hasbegun with Fort Meade, Maryland, and Fort Belvoir,Virginia, on October 1, 2008.Medical Evaluation BoardCurrent Legacy SystemTo understand the Army’s proposed changes to thePDES, a closer look at the legacy system is necessary.Currently, an Army infantry soldier with major limbloss found by the MEB to not meet retention standardsis referred to the PEB for a fitness determination. Whenthe PEB determines that the limb loss renders thesoldier unfit for his or her infantry MOS, a disabilityrating is generated by the PEB using the VA Schedulefor Rating Disabilities (VASRD).15 Soldiers who receiveat least a 30% disability rating from the Army, whichis often the case with major limb loss, and do not wantto continue in service are medically retired, eithertemporarily or permanently.15For the now retired soldier to receive disabilitycompensation from the VA with the same limb lossdiagnosis already rated by the Army, he or she mustrestart the medical evaluation process with a new setof clinical examinations by the VA medical providers.After reexamination, the VA, using the same VASRDcriteria used by the Army, rates the soldier’s serviceconnected disability, often at a higher percentage.Soldiers may be left wondering (a) why they receivedtwo separate and different ratings, one from the Armyand one from the VA, for the same impairment, and(b) why the process takes so long. These two problemswith the legacy system deserve further discussion.First and foremost, the legacy system allows for adiscrepancy in the final disability rating, rendered byboth the Army and the VA, irrespective of one another,on the exact same diagnoses. The primary reason forthis discrepancy is that the two departments followdifferent rules. The Army is tasked with rating eachdiagnosis that the MEB found “unacceptable” or “notmeeting retention standards” and the PEB also found“unfitting,” preventing the soldier’s performancewithin his or her specific military job training.15 Furthermore, the Army rates an “unfitting condition forpresent level of severity,” much like a snapshot ofthe soldier’s condition, at the time the MEB is conducted.15 The VA, on the other hand, rates any andall “service-connected conditions,” keeping in mindfuture progression of the disease or injury process,

Returning to Duty After Major Limb Loss and the US Military Disability SystemReserve component member entitlement to VA disability compensation begins upon release from active duty or separation.1Figure 4-1. Disability evaluation system Joint Pilot Program timeline overview. This graphic is part of the mass briefingprovided to WTU members at Walter Reed Army Medical Center by the physical evaluation board liaison officer. Note thatthe treating physician, who generates the permanent “3” or “4” profile, which initiates the PDES, is distinct from the MEBphysician, who administratively helps process the MEB.AC: active componentDES: disability evaluation systemDoD: Department of DefenseMEB: medical evaluation boardPDES: physical disability evaluation systemPEB: physical evaluation boardRC: reserve componentVA: Veterans Administrationwith respect to the condition’s “adverse impact onemployability within the civilian job sector.”15 Thesedistinctions in laws and regulations allow for significantly different rating values. The final disabilityrating is expressed as a percentage rating between0% and 100%, resulting from all types of diseasesand injuries encountered as a result of, or incidentto, military service.18Second, the legacy MEB/PEB process may involveconsiderable delays for soldiers and their families.For soldiers suffering from multiple and complex“unacceptable” conditions, each requiring a disabil-ity evaluation from a separate MTF specialty clinic,delays become inevitable. US Army Physical Disability Agency guidance requires that the disabilityevaluations of unacceptable conditions be performedno more than 6 months (30–45 days for psychiatricconditions) before submission to the PEB.19 If the MTFdisability evaluation of an unacceptable conditionextends beyond the 6-month window before the casereaches the PEB, the soldier needs to be seen againby the particular MTF specialty clinic for an updatedassessment and comment on whether or not thecondition remains unacceptable. This reevaluation,57

Care of the Combat Amputeea repeat of clinical work, places a tremendous strainon the specialty clinics.Proposed Pilot SystemRegardless of whether they enter the pilot programor remain in the legacy system, wounded soldiersreturning from the battlefield are assessed by theirinpatient treatment team prior to discharge from thehospital. During transition to the outpatient setting,the soldiers are placed into an established WTU to becared for safely outside the hospital, since they arenot well enough to return to their units. A physicianmember of each soldier’s interdisciplinary treatmentteam, serving as a competent medical authority, mustdetermine whether the soldier’s conditions are medically stable.20 Once medically stable, the soldier maybe considered for referral to the MEB. For referral,the soldier must have a permanent “3” or “4” profile.20 A “3” designator signifies that the individualhas “significant limitations”; whereas a “4” indicatesthat his or her “physical defects are to such a severitythat performance of military duty must be drasticallylimited.”14(ch7) For PDES purposes, the “3” and “4”designators are synonymous, meaning the soldier willnot receive additional disability benefit in having apermanent “4” versus a permanent “3.”Once the permanent profile has been generated bythe treating physician and signed by the designatedapproving authority, the soldier is recommended forreferral into the Joint Pilot Program.21An MEB physician reviews the permanent profileand ultimately determines if the soldier is a suitablecandidate for entry into the pilot program, based on acompletely new referral standard:When a competent medical authority determines aservice member has one or more condition(s) which issuspected of not meeting medical retention standards,he or she will refer the service member into the DES atthe point of hospitalization or treatment when a member’s progress appears to have medically stabilized(and the course of further recovery is relatively predictable) and when it can be reasonably determined thatthe member is most likely not capable of performingthe duties of his office, grade, rank, or rating. Referralwill be within 1 year of being diagnosed with a medical condition(s) that does not appear to meet medicalretention standards, but may be earlier if the examinerdetermines that the member will not be capable ofreturning to duty within 1 year.20A condition is unstable when it has the potential,within 1 year of treatment intervention, to improveto such a degree that the soldier meets medical reten58tion standards.19 Examples of treatment interventionsare condition-improving surgery or medication titrations, warranting a trial of duty prior to stabilizationdetermination. If the MEB physician believes that amedical treatment intervention may improve the soldier’s condition to such a degree that he or she willmeet retention standards, then the soldier should bemaintained on a temporary profile, valid for 3 months,and extendable up to 12 months, prior to considerationof permanency.14(ch7) The MEB physician must reviewall conditions for determination of medical stabilitybefore the soldier enters the MEB pilot program. Underno circumstances should any soldier with major limbloss be issued a permanent profile within 4 months ofthe amputation, per AR 40-501, Chapter 3.14In a hypothetical example of the DES process, a malesoldier with a right above-knee (transfemoral) amputation has had his permanent “3” profile reviewedby the MEB physician, and is ready for the pilot program MEB entry. The soldier meets with his assignedphysical evaluation board liaison officer (Figure 4-2),who helps the soldier navigate through the disabilityprocess, helping him understand the procedural intricacies of the PDES. Next, the soldier is scheduledfor medical evaluation with the VA clinical examinersat the regional VA facility. The VA examiners evaluate all conditions claimed by the soldier as well as allchronic conditions and those that have the potentialto render the soldier militarily unfit.22 After the VAclinical examinations, VA worksheets are generated toFigure 4-2. PEBLO counseling session: Mr Aaron Clemmons(left), Senior PEBLO, meets with SSG Juan Roldan to reviewall MEB administrative documents and answer proceduralquestions, prior to forwarding MEB case file to the PEB.MEB: medical evaluation boardPEB: physical evaluation boardPEBLO: physical evaluation board liaison officer

Returning to Duty After Major Limb Loss and the US Military Disability Systemis involved in the pilot program. Soldiers found bythe MEB to have conditions that do not meet retentionstandards are referred to the PEB for determinationof fitness.Soldiers who do not agree with MEB findings havea new option for further evaluation. A policy memorandum, issued by the under secretary of defenseon October 14, 2008, describes the possibility of anindependent medical review of MEB findings, priorto submission to the PEB:Figure 4-3. MEB physician encounter: Dr Andrew Rhodes,CPT, MC, USA (center), resolves discrepancy in soldier’smedical record by examining SSG Juan Roldan (left), withconsultation from Dr Eric Dessain, LTC, MC, USA (right),Disability Evaluation Service Chief, before finalizing theDoD/VA consolidated narrative summary.DoD: Department of DefenseMEB: medical evaluation boardVA: Department of Veterans Affairsdocument focused subjective complaints and objectivefindings, resulting in a final diagnosis for each claimedcondition. The worksheets are returned to the MEBphysician, who then prepares a consolidated narrativesummary (NARSUM). The NARSUM must resolveany inconsistencies between the soldier’s electronicmedical record and the VA worksheets (Figure 4-3).The NARSUM also provides the physician with theopportunity to comment on each VA-generated diagnosis, with respect to whether or not the soldier meetsretention standards, per AR 40-501, Chapter 3.In generating the consolidated NARSUM, it isimportant that the MEB physician is knowledgeableabout retention standards.14 In the case of the soldierwith an above-knee amputation, the MEB has no discretion; it must find that the soldier does not meet retention standards, per AR 40-501, Chapter 3, paragraph13a(1b).14 Paragraph 12a lists the specific impairmentcriteria for upper extremity limb loss.14After the soldier with the above-knee amputationhas returned from the VA and met with the MEB physician to review his consolidated NARSUM, his caseis then officially referred to the MEB, an all-physicianpanel of at least two doctors, who review the entire caseand make the final determination as to whether or notthe soldier’s conditions meet retention standards, perAR 40-501, Chapter 3.14,23 The membership compositionof the MEB, PEB, and medical MOS retention board(MMRB) is the same, regardless of whether the MTFE3.P1.2.6.1.2. Upon request of a Service member referred into the DES, an impartial physician or otherappropriate health care professional (not involvedin the Service member’s MEB process) is assignedto the Service member to offer a review of the medical evidence presented by the narrative summary orMEB findings. In most cases, this impartial healthprofessional should be the Service member’s primary care manager (PCM). The impartial health professional will have no more than 5 calendar days to advise the Service member on whether the findings ofthe MEB adequately reflect the complete spectrumof injuries and illness of the Service member.E3.P1.2.6.1.3. After review of findings with the assigned impartial health care professional, a Servicemember shall be afforded an opportunity to request arebuttal of the results of the MEB. A Service membershall be afforded 7 calendar days to prepare a rebuttalto the convening medical authority. The conveningmedical board authority shall be afforded 7 calendardays to consider the rebuttal and return the fully documented decision to the Service member The fullydocumented rebuttal will be included with the MEBinformation sent to the PEB.24Medical Military Occupational Specialty RetentionBoardThere are a few instances in which a soldier withlimb loss can meet retention standards, including theloss of toes or fingers. In the case of amputated toes,to fail to meet retention standards, the impairmentmust preclude the soldier’s “abilities to run or walkwithout a perceptible limp and to engage in fairlystrenuous jobs,” as listed under 3-13a(1a).14 In thecase of lost fingers, to be considered as not meetingretention standards, the loss must be greater than orequal to: “a) a thumb proximal to the interphalangealjoint; b) two fingers of one hand, other than the littlefinger, at the proximal interphalangeal joints; [or] c)one finger, other than the little finger, at the metacarpophalangeal joint and the thumb on the same hand at59

Care of the Combat Amputeethe interphalangeal joint,” as defined under 3-12a(1ac).14 An infantry soldier missing the trigger and littlefingers on the same hand, resulting from a traumaticblast injury, is by regulation, if no other impairmentsexist, still able to meet retention standards.14 Since thissoldier requires “significant functional limitations,”specifically being unable to fire a weapon, the soldieris issued a permanent “3” profile. However, becausethe soldier meets retention standards, he or she shouldbe referred to an MMRB.14(ch7)Soldiers may be referred to an MMRB if they haveat least a permanent “3” designator for a conditionthat meets retention standards.14(ch7) The MMRB has theoption of returning the soldiers to their units, placingthem on medical probationary status, reclassifyingthem into another MOS, or referring them to the MEB.25The MMRB consists of five members, some votingand some nonvoting. The voting members includea colonel, either in combat arms, combat support, orcombat service-support, serving as president; a fieldgrade Medical Corps officer or MTF commanderdesignated civilian medical doctor; and an additionalvoting member who, if possible, is in the same branch,specialty, or primary MOS as the soldier appearingbefore the board.25 The nonvoting members are apersonnel advisor and recorder.25 Treating physiciansshould be familiar with the options available for theirinjured soldiers.Physical Evaluation BoardThe Army PEB is composed of three voting members: a colonel, serving as the board president; a fieldgrade personnel management officer; and a seniorphysician, either a Medical Corps officer or an Armycivilian doctor. 24 The PEB first meets informally,meaning the soldier is not present, and also that therecommendations made at this meeting may later bechanged. The three board members determine fitnessby majority vote, taking into consideration the following: clinical evidence presented in the soldier’s MEB;performance standards of the soldier’s primary MOS;and the soldier’s personnel records, including but notlimited to his or her record brief, evaluation reports,and commanders’ statements.15 Under the pilot program, the PEB records its informal factual findingsfor each diagnosis, along with its recommendationfor fitness determination, on DA Form 199 (Election toFormal Physical Evaluation Board Proceedings).15 Norating determinations appear on Form 199; rather, forthose conditions labeled as unfitting, the form has anexplanation of the condition followed by a qualifier,signifying that the rating generated for the unfittingcondition is to be completed by the VA. The VA rating board then evaluates the soldier’s referred and60claimed conditions, providing a rating percentagewith rationale to the PEB within 15 calendar days ofnotification by the PEB that a soldier is unfit.22 At thistime, the soldier must request a copy of his or her VArating for each claimed condition (generated by a VAregional office).22In the pilot program, the Army is bound by theVA rating for those conditions found to be unfitting.In other words, if the Army finds the soldier unfitfor a particular condition, the rating for that condition is determined by the rating provided by theVA.22 For example, the soldier with the right aboveknee amputation, whose only condition is majorlimb loss, is found to not meet retention standards,per AR 40-501, Chapter 3, Paragraph 13a(1b).14 Thesoldier’s primary MOS is 11B, infantry. He is foundunfit for service, based on his injury and inability tosatisfactorily perform the duties within his primaryMOS. A soldier is physically unfit when a medicalimpairment prevents reasonable performance of theduties required of the soldier’s office, grade, rank, orrating.15 In this example, the soldier’s residual limblength, as measured from the perineum, is found tobe one-third of the distance from perineum to kneejoint, when compared to the left, unaffected side. Thus,the right above-knee amputation transects the upperthird of the femur bone. Per disability code 5161, asfound in the VASRD, the VA rates his condition at80% disability.18 Under the pilot program, the Armyis now bound by this 80% disability rating, whereasin the legacy disability system, the Army provides adisability rating independent of the VA rating.After the informal PEB has convened and renderedDA Form 199, the soldier is entitled to governmentappointed legal counsel (if not already obtained24) andhas the following election options: (a) concur with theinformal findings and recommendations; (b) request aformal administrative hearing, either with or withouta personal appearance; or (c) nonconcur and submita written appeal in lieu of proceeding with a formalboard.15 The formal PEB is administrative, fact-finding,and nonadversarial, meaning no gov

US Army Publication Directorate www.apd.army.mil Walter Reed Army Medical Center www.wramc.amedd.army.mil Amputee Coalition of America www.amputee-coalition.org Department of Veterans Affairs www.index.va.gov Disabled Soldier Support System www.ArmyDS3.org Disabled American Veterans www.dav.org Paralyzed Veterans of America www.pva.org