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Physical and Psychological Impact of Limb Loss Among Haiti Earthquake Survivors. Clinician Outreach and Communication Activity (COCA) Conference Call . March 3, 2010. Continuing Education Disclaimer.

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Physical and Psychological Impact of Limb Loss Among

Haiti Earthquake Survivors

Clinician Outreach and Communication Activity (COCA) Conference Call

March 3, 2010

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Continuing Education Disclaimer

In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.There is no commercial support.

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Accrediting Statements

CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1 contact hour.

CEU: The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. The CDC is authorized by IACET to offer 0.1 CEU's for this program.

CECH: The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I contact hour in health education, CDC provider number GA0082.ACPE: CDC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  This program is a designated event for pharmacist to receive 1.0 Contact Hours in pharmacy education.

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Today’s Presenters

Terrence P. Sheehan, MD

Chief Medical Officer and

Director of Amputee Rehabilitation Program

Adventist Rehabilitation Hospital

Rockville, Maryland

Medical Director

Amputee Coalition of America (ACA)

Chair, ACA Medical Advisory Committee

Stephen T Wegener, PhD, ABPP

Director, Division of Rehabilitation

Psychology and Neuropsychology

Associate Professor of Physical Medicine and


Associate Professor of Health Policy and

Management, Bloomberg School of Public

Health, Johns Hopkins University  

Baltimore, Maryland

Moderator: Mary Helen Witten, Project Officer for Amputee Coalition of America in the National Center on Birth

Defects & Developmental Disabilities at the Centers for Disease Control and Prevention

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At the conclusion of this hour, each participant should be able to:

Describe epidemiology, physiology and classifications of limb loss.

Compare and Contrast the incidence and management of limb loss in the United States with Post Earthquake Haiti.

Identify amputee pre-operative predictors of outcome for rehabilitation and lifelong follow through

Discuss essential information for the management of psychosocial issues following limb loss.

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Physical Issues Following Limb Loss:Adapting in the Context of a Natural Disaster

Terrence P.Sheehan, MD

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Physicians For Peace

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  • In the US, there are approximately 1.9 million people living with limb loss

  • Congenital Amputations: ~ 5%

  • Tumor: ~ 5%

  • Traumatic: ~ 15%

    • Males > females

  • Vascular and Diabetic: ~ 70-80%

    • Over half of these are diabetic

    • 82% of discharges are vascular related

      NLLIC ACA Fact Sheet

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  • Rate of major amputations because of vascular disease has decreased

  • 75% of all amputations occur in those older than 65yrs

  • Amputations in the geriatric population in the U.S. will probably double by 2030

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  • Peripheral Vascular Disease

    • Risks:

      • Diabetes Mellitus

      • Smoking

      • Hypertension

      • Hyperlipidemia

      • Obesity

      • Inactive Lifestyle

      • Family history of CAD or PVD

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Every Day in the U.S.

  • 225 people have amputations due to the complications of diabetes

  • 55 people with diabetes lose their eyesight

  • 120 people with diabetes get end-stage kidney disease

  • 580 people die from diabetes and its complications


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Don’t Neglect Your Diabetes – don’t be a statistic

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should not be thought of as a failure of treatment, but as a treatment of choice.

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Pre-Operative Evaluation and Amputation Surgery

  • Physiatric Pre-operative Evaluation

    • Co-morbid factors

      • Three “unaffected” extremities

        • Opposite foot

    • Affected extremity

      • Range of motion

      • Strength

      • Sensation

  • Vocation

  • Avocation

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Prior to Earthquake, most limb loss from trauma and infection


Motorcycle, gunshot

Post earthquake

Estimates of 2000 to 3000 people with limb loss

Majority are women and children

Majority below knee amputations

Numbers will grow over the next months to year because of poor infection treatment from trauma


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Major Differences When Thinking About Upper and Lower Extremities for Salvage

Lower Extremity:

  • Weight bearing Mandatory

  • Functions poorly w/o sensation

  • “Assistive” limb not useful

  • Needs to be relatively pain free

  • Needs durable skin and soft tissue coverage.

    Base decision on limb that can tolerate weight bearing, have sensation to provide protective feedback, and have durable skin and soft tissue cover.

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  • Incision



  • Bone

    • Beveling distal end

    • Length

    • To bridge or not to bridge

  • Soft tissue

    • Securing the Muscle Over the Bone

    • Adequate coverage

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Limb Amputation SURGERY

  • Stabilizing the distal insertion of muscle can improve residual limb function and comfort.

  • Myodesis is the direct suturing of muscle or tendon to bone.

  • Myoplasty involves suturing of muscles to periosteum.

  • Myoplasty does not provide as secure a distal stabilization of the muscle as does Myodesis.

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Post Earthquake Haiti SURGERY

The Amputation Surgery Education Center

Dedicated to helping surgeons improve technique and patient outcomes

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Post-Operative and Pre-Prosthetic Management SURGERY


  • Wound care

  • Edema control

  • Therapy program

  • Pain control

  • Psychological issues

  • Disposition planning

  • Education

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Early Rehabilitation: SURGERYPost-Amputation Goals - Physical

  • Minimize muscle atrophy, maintain muscle strength in affected limb,

  • Maintain muscle strength in unaffected limbs

  • Maintain body symmetry

  • Maintain some two-handed function.

  • Adequate pain control

  • Decrease post surgical edema

    • Promote wound healing

    • Decrease pain

  • Mold residual limb

  • Prevent flexion contractures in surrounding joints

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Post-Operative and Pre-Prosthetic Management SURGERY

Wound Care

  • If the wound is clean and dry, protect it with non-adherent dry, sterile dressing daily

  • If the wound is moist or open, use saline gel or antibiotic ointment dressing twice daily

  • For burns or skin grafts, use xeroform or petroleum dressing daily

  • Staples usually removed after 2-3 weeks for trauma, or 3-6 weeks for dysvascular patients

  • Wounds heal faster if edema is controlled

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Post-Operative and Pre-Prosthetic Management: Edema Control Options

  • Ace Wrap

    • Compression dressing – ace-wrapping

    • 24 hr/d until staples out, then switch to shrinker

    • Must be wrapped correctly or it may make edema worse

    • Must be re-wrapped several times a day to change dressing or simply check the wound

    • Prefer shrinker garment once staples removed

  • Rigid Options

  • IPOP

    • Traditional IPOP is simply a rigid dressing with a pylon and foot attached for early mobilization (partial-weight-bearing only)

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Post-Operative and Pre-Prosthetic Management Options

  • Therapy Program

    • Strengthening of shoulder depressors, elbow extensors, hip extensors and abductors, knee flexors and extensors, ankle DF/PF

    • AAROM at hip extension, knee extension, ankle DF

    • Back program (lumbar mobs, core strength)

    • Early mobilization to wheelchair, then progressive ambulation

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Stretching Options

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Stretching Options

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Post-Operative and Pre-Prosthetic Management Options

  • Therapy Program

    • Residual limb care for shaping/shrinking, soft tissue mobilization and scar management if appropriate, desensitization

    • Education regarding edema control, limb positioning, exercise program, future prosthetic rehab program

    • Driving assessment and training when appropriate

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Residual Limb Pain Options

  • Post-surgical

  • Edema

  • Infection

  • Neuroma

  • Bone spurs

  • Prosthetic related

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Post-Operative and Pre-Prosthetic Management Options

  • Pain Control

    • Distinguish surgical pain, phantom pain, phantom sensation

    • Surgical pain requires narcotics, but short-term only

    • Phantom sensation requires no meds, just re-assurance that it is normal

    • Phantom pain may require meds, but try to avoid narcotics

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Common Examples of Phantom Sensation Options





Painfully twisted

Terrible cramps


Sherman, Richard A.  Phantom Pain.  New York: Plenum Press, 1997

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Post-Operative and Pre-Prosthetic Management Options

  • Phantom Pain

    • Most common choice drug now is gabapentin, dosage range 300-3000/d

    • Tri-cycles still used as adjunct meds

    • TENS is worth trying and provide home unit if it works

    • De-sensitization by tapping, rubbing, massage of residual limb

    • Compression with prosthesis or shrinker helps

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Towel Pull Options

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Other Accepted Physical Treatments Options

  • Heat/cold

  • Topical applications

  • Increasing muscle tone in residual limb

  • Maintain well-fitting prosthesis

  • Stretching,

  • massaging,

  • Isometric exercises

  • TENS

  • Acupuncture, Acupressure,

  • Chiropractic

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Heterotopic Options Bone

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Heterotopic Options Bone

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Heterotopic Options Bone

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Prosthetic Fitting Options

Determining factors in choice of prosthetic


  • Length of limb

  • Condition of skin

  • Strength

  • Range of motion

  • Cognitive & physical ability

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Patella Tendon Options

Medial Flare

Medial Shaft of Tibia

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Trans Femoral Suspension Options

  • Belts and Straps

  • Liners with Locking Pin

  • Suction Liner

  • Vacuum pump

  • Total Suction

  • Wet Fit

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Foot and Ankle Systems Options

  • SACH

  • Single Axis

  • Multi-Axial

  • Dynamic Response

  • Hybrid

  • Adjustable Heel Height

  • Microprocessor

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Technical Barrier to Productivity Options

  • Need custom socket

  • Customized alignment

  • Time-consuming

  • Restoring functional gait to the amputee

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Prosthetics Options

  • Monolimb-Socket, pylon, and foot unit form one unit

  • Single episode of alignment

  • Wide tolerance of acceptable alignments

  • $20 foot

  • Single Sheet Polymer

  • Lightweight

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Correct surgery, immediate rehabilitation/training, and a well-fitting prosthesis are all equallyimportant!

Rehabilitation should be both:

  • Physical

  • Psychological

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Amputation Levels Options

  • Disarticulations tend to provide more serviceable levels in the upper extremity.

  • Shoulder

  • Elbow

  • Wrist

  • Carpal-Metacarpal

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Upper Limb Amputation Options

Surgeon needs limb

  • sufficient sensation to provide protective feedback

  • durable soft tissue cover

  • used to interact with environment

  • function with modern prosthetic

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Upper Limb Amputation Options

New Techniques

  • Myocutaneous transfers

  • Skin expansion and bone lengthening

  • One stage procedure better than multi-step procedure

  • Early prosthetic fitting (1-4 mths)

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Upper Limb Amputation Options

Levels of Amputation

Trans-humeral amputation performed at three levels:

  • long, medium, short residual limbs

  • long-arm residual limb is preferred for optimal prosthetic restoration

  • prosthetic components can be externally powered, body powered, passive, or a combination of these

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Upper Limb Amputation Options

Levels of Amputation

  • Shoulder disarticulation and forequarter amputations seen less frequently

  • Most difficult to fit with a functional prosthesis

  • Surgical techniques – soft tissue handling is critical

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Upper Limb Amputation Options

Prosthetic Fitting and Training

  • Prosthetic restoration of the upper limb is an extremely challenging task in view of the variety and complexity of available prosthetic components (prosthetic terminal devices, wrists, elbows, and shoulders), socket fabrication techniques, suspension systems, and sources of power and control.

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Post-Operative and Pre-Prosthetic Management Options


  • Introduce the Prosthetic Team members and clarify their roles

  • Discuss the rehab program, functional goals, prosthetic plans, and time frame

  • Show several prosthetic devices to prepare the patient for the prosthetic fitting process

  • Discuss long-term functional issues and potential limitations when patient is ready

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Psychosocial Issues Following Limb Loss: OptionsAdapting in the Context of a Natural Disaster

Stephen T. Wegener, PhD

Department of Physical Medicine and Rehabilitation

Johns Hopkins School of Medicine

[email protected]

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Responses to Stress and Loss Options

Stress Onset

Global Assessment of Functioning



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ICF Model: OptionsInteractive not linear/progressive

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Key Personal Factors in Psychosocial Adaptation Options

  • Medical including pain

  • Disability Status

  • Age

  • Body Image

  • Affective Responses

  • Interpersonal Factors

  • Coping Style

  • In addition- environmental & cultural factors-social context- family, community, access to care……

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Body Image Options(Rybarczyk et al 1995)

  • Must reconcile 3 images of self –before, after, with prosthesis

  • Early accommodation of body image/appearance predicts adaptation

  • Public self-consciousness (including the body in motion) associated with poor adaptation

  • Upper extremity amputation associated with poorer adaptation – reduced function, more visible, more central to body image

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Affective Responses- Overview Options

  • Rates of affective distress are higher than general population but similar to other medical populations.

  • Depression prevalance rates range from 20-35% in those with lower limb amputation

  • Anxiety prevalance rates are not well established, although higher in those with traumatic amputation.

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Psychological Distress-Depression Options

  • Inpatients - ~ 35-51% prevalence rate of major depressive disorder in a prospective study of inpatient amputees across etiologies .

  • Outpatient amputees- rates of depressed mood determined via standardized self-report measures are reported in the range of 21%-35%.

  • Point prevalence of major depression in the general population= 3.6%-10.6%9, and in medical/surgical inpatients = 6%-14%

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Risk Factors for Depression following Limb Loss Options(Horgan & Maclachlan, 2004)

  • Recency of amputation - < 2 yrs have higher rates

  • Younger age (in adults)

  • Activity restrictions

  • Social discomfort

  • Pain

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Psychological Distress-PTSD Options

  • Acute Stress Disorder (ASD) is among the first forms of psychopathology evident post-injury.

  • ~78% of persons with ASD following a motor vehicle crash (MVC) go on to meet criteria for PTSD within 6 months.

  • Prevalence rates of PTSD post MVC have been documented in the range of 24-39% with another 28.5% meeting subthreshold criteria.

  • MVC survivors with PTSD at 1 year follow up, 53% continued to maintain the diagnosis at 3 years follow up.

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Interpersonal Risk Factors Options

  • Perceived social stigma

    • Not all perception as there is documented negative bias in many cultures

  • Perceived vulnerability

    • More vulnerable to crime, less able to defend self

    • May be more victimized

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Potential Negative Coping Factors Options

  • Reduced social support

  • Avoidant Coping Styles

  • Catastrophizing – negative thinking style

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Potential Positive Coping Factors Options

  • Shift in values- self-worth is based on non-physical and intrinsic qualities

  • Downward social comparisons

  • Spiritual/Religious Practices and Beliefs

  • Benefit finding

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Mana Alexandre doing exercises with a physical therapist, Caryn Brady,

in Port-au-Prince, Haiti. By Deborah Sontag Published: New York Times

February 22, 2010

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Recognize Distress, Respect Resilience and Local Resources Caryn Brady,

  • Mental health and psychosocial problems in emergencies encompass far more than the experience o of (PTSD) or disaster-induced trauma, depression and anxiety.

  • A selective focus on these types of problems overlooks many other mental health and psychosocial support problems and ignores pre-existing problems as well as the assets or resources that communities possess to support their own mental health and psychosocial well-being.

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On the scene observations- Jeanne LaBlanc PhD Caryn Brady, Vancouver, British Columbia

“I very much heard a number of people really wondering if something they did or thought prior to the earthquake essentially marred their relationship with God, causing this to happen to them. ”“Also heard, a number of the things that you would hear anywhere, about concerns about what their wife (or husband or children) might view them now--are they less a man (or woman). 

“Also a great deal of concern (quite validly so) about how they will be able to support themselves or their families.”

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Normal Reactions to Crises and Loss Caryn Brady,

  • Grief, sadness, hopelessness and a sense of being overwhelmed

  • Emotional difficulties including anxiety, fear, anger, guilt

  • Behavioural problems such as lack of concentration, risk of increased use of violence or alcohol and drug use within communities

    • Social problems such as isolation, tension or violence in families, increased collective fear, anger and frustration regarding humanitarian aid

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Severe Reactions to Crises and Loss Caryn Brady,

  • People with the following severe reactions should be immediately recognized and responded to:

  • Are disoriented (e.g., not knowing where they are)

  • Not responding to conversation

  • Put themselves or others in danger

  • Threaten to harm themselves or others

  • Are unable to do basic activities of daily life (i.e., walking, talking, grooming, eating).


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Model for Providing Psychosocial Support Caryn Brady,

  • Well integrated mental health and psychosocial supports that build on existing capacities and cultural norms reach more people and are more likely to be sustained once humanitarian aid engagement ceases.

  • Affected community members are not viewed as passive beneficiaries but actors who have assets and resources.


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Model for Providing Psychosocial Support Caryn Brady,

  • Support is provided from within the community as well as by outsiders, respecting that people are affected by the disaster in different ways.

  • A layered system of complementary supports is put in place as expressed in the “intervention pyramid”.


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Key Interventions Caryn Brady,

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Psychological First Aid Caryn Brady,

  • A= Assess (assess for safety, obvious urgent physical needs, persons with serious reactions, and persons’needs and concerns)

  • B= Be (be attentive, respectful and aware)

  • C= Comfort (Comfort through your presence, through good Communication and by helping people to Cope)

  • D= Do (do address practical needs, do help problem solve, do link people with loved ones and supports)

  • E= End/Exit strategy (End your own assistance by referring the person to other supports as needed, End for yourself taking time for self-care)

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Cultural Competency- Highlights Caryn Brady,

  • In Haitian culture, as in many others, there is a stigma associated with experiencing or discussing signs or symptoms of mental illness or distress.

  • There are different and culturally appropriate ways to express grief, pain or loss- referraing to phhysical symptoms of stress.

  • There are specific customs to deal with the dead and for grieving that need to be respected.

  • For more details see resources that follow.

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Resources to Develop Haitian Cultural Competency Caryn Brady,




  • For a quick guide on cultural, community and family support in Haiti: Nicolas, G., Schwartz, B., & Pierre, E. (2009). Weathering the storm like Bamboo: the Strengths of Haitians in Coping with Natural Disasters. In A. Kalayjian, D. Eugene, & G. Reyes (Ed.) International handbook of emotional healing: ritual and practices for resilience after mass trauma. Westport, CT: Greenwood Publishing Group, Inc. This chapter is online at:

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References and Resources on Psychosocial Aspects of Limb Loss

  • Frank, R., Rosenthal, M. & Caplan, B. (Eds.) (2010). Handbook of Rehabilitation Psychology 2nd Edition. Washington DC. American Psychological Association.

  • Wegener, S.T., Hofkamp, S. & Ehde D. (2008). Psychological Interventions Following Limb Loss. In Gallagher, P., Desmond, D. & Maclachlan, M. (Eds.) Psychoprosthetics. (pp. 91-106), London, Springer Publishing.

  • Amputee Coalition of America -

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Thank You! Loss

Disclaimer: The information and viewpoints in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry."

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Continuing Education Credit/Contact Hours for COCA Conference Calls

Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits/contact hours (CME, CNE, CEU, CECH, and ACPE) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system

Those who participate in the COCA Conference Calls and who wish to receive CE credit/contact hours and will complete the online evaluation by Apr 03, 2010 will use the course code EC1648. Those who wish to receive CE credits/contact hours and will complete the online evaluation between Apr 03, 2010 and Apr 03, 2011 will use course code WD1648. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.