Psychological Rehabilitation on a Patient with Breast and Arm Amputation: A Case Report

We define amputation as a removal of totally or partial part of an organ. Amputations can be caused by chronic diseases as cancer, infection and diabetes, or by a traumatic accident. Where, we discuss the differences between the two types of amputation. This paper is a case report on an amputee patient, the consequences in short e long term. We suggest possible interventions for psychological professionals and multidisciplinary healthcare team. Also, we discuss the lack of academic production about traumatic amputations.


Amputation: An Overview
Amputee surgeries refer to the removal of totally or partial part of an organ. Currently, this type of surgery is considered reconstructive surgery because the final objective is to restore the organ (Gabarra, 2010;Seren & Tilio, 2014).
There are few illnesses that can lead to an amputation: cancer, diabetes, infections and traumas. About this last type of amputation, it's necessary to highlight the sudden break with the "normal" life before the trauma and the need to quickly adapt to a completely new form of living (Paiva & Goellner, 2008).
We should stand out about the traumatic amputees' patient's profile: young, on working age and with no previously known disease (Perkins et al., 2012;Shankar et al., 2020).
In the United States of America, are estimated 185.000 amputations per year which 45% are provoked for traumatic accidents (Kratz et al., 2010;McKechnie & John, 2014). It's estimated that by the year of 2050 the total number of amputees will reach about 3.6 million people (Ramos, 2012). That makes the attendance and follow-up of amputees a public health issue.

Psychological Reaction in Amputation
The experience of amputation brings physical and psychological changes (Melo et al., 2020). It's important to highlight that these changes are called "adjustment reactions" and they are not considered pathological reactions. This adjustment reactions involve feelings like anger, fear of the future, sadness, self-esteem change and anxiety. Therefore, it's important that the patient receive psychological treatment as soon as possible (Srivastava et al., 2011;Tenner et al., 2018;Melo et al., 2020).
Despite the vast report of these symptoms the number of studies publications is still very low (Boccolini, 2000;Kratz et al., 2010;Shankar et al., 2020).
It's possible to didactically divide two moments post amputation: (a) acute phase, immediately after the surgery, when the principal mission of the patient is to survive with the necessary adaptations; (b) chronic phase, the moment when the patient must lead with the characteristic of its new physical limitation, the pain, the meaning of loss, quality of life and, eventually, the fitting on a prosthetic.
In both phases-acute or chronic-the limitation imposed by the absence of a member result in serious daily life changes; impacting social, work and sexual life (Galván & Amiralian, 2009;Milioli et al., 2012;Sahu et al., 2016).
Authors defend that follow-up of psychological intervention in medium and long term (to six months to a year) it's important to follow the evolution of the adaptation of the adjustment reaction (Kratz et al, 2010;Perkins et al., 2012). According to these authors, the first year after an amputation brings emotional symptoms, being the most frequent depressive and anxiety symptoms'.
This important to discuss that negative symptoms are not necessarily negative reactions-they can be the adjustment reaction. These reactions can lead the patient to treatment motivation. Some patients understand the amputation as a chance to "live a new, health life" (Melo et al., 2020, p. 326).
Given the above, it is essential that an amputee patient be evaluated and monitored by a psychological professional (Boccolini, 2020).
Just to explain to the reader, a systematic literature review was carried out by this author to screen the number of studies that address psychological aspects of amputees. Descriptors used were "traumatic amputation" and "psychological trauma". Were found a total of 143 articles. Of these, 14 were were excluded for treating revascularization surgeries (where, we can understand, that the patient was not amputated). 25 articles were excluded because they discuss penile amputations (which, for this review would bring low contribution). Seven articles were excluded for treat about complications of non-traumatic amputation. Three articles were excluded because they did not mention psychological aspects.
On this survey, 110 articles were excluded; being considered only 31 articles.
Based on the survey above descript, we can note that studies about traumatic amputation are rare. Just in front of that fact, we need to develop studies with traumatic amputees.

The Case Report
The patient, here named as P. for maintenance of confidentiality, was a 19-year-old girl with a normal life. At the time of the accident, P. worked on a restaurant, was engaged to her boyfriend, had a good circle of friends and no major conflict with her family.
One night, on the end of her work shift, P. was sought by her fiancé to go home. On the highway, a drunk driver ran over P. and her fiancé who were on a motorcycle. After running over, the drunk driver dragged P. for 2.5 miles.
During all this period, P. was conscient, trying to get loose from the car hood.
Unfortunately, P. couldn't get out from the car hood and this episode end with her left arm-that was stuck on the car hood-dropping for her body. Long story short: by this time, P. was amputee. P. was rescued by a team of firemen and was directed to a trauma reference hospital. Once in the hospital, P. stayed on very serious health condition. She remained on the ICU for more than a month.
After the medical care and with the stabilization of the health chart of P., the psychologist started the sessions to work on post traumatic stress symptoms, self-image change and depressions/anxiety symptoms.
The first sessions happened yet on the "acuate" phase, when P. was hospitalized in the ICU. At this moment, the main objective of the psychological intervention was to help the patient to elaborate the accident and to develop strategies to face the traumatic situation.
After hospital discharge, P. remained accompanied by the psychology service of the hospital. When P.
returned to home, the phase where we expect better adjustment reactions, P. had a lot of family disagreements, including jokes about her amputation. Adds to this fact, the engagement was over, according to P. because the fiancé did not was interested in helping her on the health care treatment. P, lost her job and, until now, is not entered into the labor market.
On more than one situation, P). though and tried suicide. On her words "because I could not support more of this situation".
It's important to say that on the moment when I write this case, more than one year is passed over the accident and P. is still in psychological follow-up to handle the symptoms above describe. By now, the suicide thoughts are not present and our (mine and P.`s) goal is to adjust the social, work and affective life of P; even if it means resignification and great adjustment on her reaction in face of unfavorable events of life.
Also, at this moment, the medical team is starting to work on the reconstruction of both breast with silicone implants. This treatment is costed by the Brazilian healthcare system-also known as Sistema Único de Saúde (SUS). However, the arm prothesis cost about U$ 28.000,00; this is not a treatment offer by the SUS and is way out of family conditions to acquire.
Probably, P. should fit her new life without the arm. The absence of her arm is a very important thematic on the psychological sessions and it's one of the most traumatic impacts that this accident brought to P. As psychological professional, is my duty to work on developing functional coping strategies. Also, interdisciplinary work is developed with a physiotherapist for possible physical adjustment for P. daily life.
The communication with the multidisciplinary team is essential for the better health care for P.

What Psychologist Could Do in those Situation
The first conclusion this case report bring to discussion is the lack of studies and publication on the traumatic amputee area. This reinforces the importance of offering conditions for researchers to develop innovate studies.
Another conclusion on this case report is the importance of psychological intervention on both phases: acute and chronic phases; therefore, which one has their specificities. More than "patients" the psychological professional should stare to the amputee as a person who need all the effort on the healthcare team. An amputee will need help to relearn the simplest things and activities in their live and, this, should motivate the healthcare team.