Cold Injury

 

NOTE: Dr. Jerrod E. Johnson, MD for the November 1998 publication of "The Scuttlebutt", wrote the following article. The Scuttlebutt was a monthly newsletter for the men of Ammunition Company, 1st Ordnance Battalion, 1st Marine Division, in which most are veterans of the Chosin Reservoir.

Dr. Johnson was at that time, a noted Doctor with the Reno, Nevada VA Medical Center in Reno, Nevada. He was in addition to being a authority on Cold Injury, but served as the POW Coordinator for the Medical Center. Our thanks to him and to Director Gary Whitfield, and Associate Director Debra Hershman, of the Medical Center for making this article possible.

 

Cold Injury

By: Dr. Jerrod Johnson

Cold Injury has a long, military medical history. Of particular significance, is that both Napoleon and Hitler made tactical mistakes trying to take Russia, and lack of planning put them deep into Russia as the weather turned cold. Their armies suffered as much from freezing to death as anything else.

Medicine is still in the learning process about Cold Injury. Longitudinal studies of WWI, WWII and Korea survivors, and more recently the war in the Falkland Islands, have given better insight into the initial injuries, and the long term consequences. During WWII and the Korean War, thousands of United States military personnel suffered Cold Injuries including frostbite, in other words a Freezing Cold Injury, and immersion foot which is also called Non-freezing Cold Injury. The winter of 1944 and 1945 in Europe, when the Battle of the Bulge was fought, was one of the coldest on record.
The winter of 1950/51 in Korea was bitterly cold, and the veterans of The Chosin Reservoir in Korea was recognized as having suffered especially high rates of severe Cold Injury. It was during WWI, that Non-Freezing Injuries were distinguished from those of freezing of tissues. Freezing Cold Injuries are designated as frostbite, whereas conditions usually referring to Non-freezing Cold Injury include: trench foot; immersion foot; paddy foot, which is described in soldier's whose feet had been immersed in warm water for long long periods, such as in Viet Nam; and shelter limb, which occurred in Londoners taking refuge in WWII, whose feet were neither cold or wet, but remained in a dependent or "hanging down position" for long periods of time. Many soldiers forget that they actually had frozen feet, and some of them never had their shoes of to recognize the frostbitten changes. Generally, it has been easier to connect frostbite with the later symptoms that develop over the years. On the other hand, in Non-freezing Cold Injuries where there is no freezing of the tissues, the afflicted soldier would not been aware of that anything had happened other that he had been miserable.
Later, when the symptoms develop, neither they nor medical personnel have been able to make a connection between their Non-Freezing Cold Injury and the later symptoms that happen. Consequently, these patients often have long careers following a progression from seeing a vascular or blood vessel surgeon, to a neurology specialist, and often end up with a psychiatrist.

Frostbite, on the other hand, goes through stages similar to a burn. In the first stage, the feet are cold and white. Then it goes to moderate, where people develop blisters as though they were burned. There can be clear fluid filled blisters, such as you see after a sunburn. And finally, if they had severe frostbite, they would have blood blisters in addition to toes turning black. But all this is very obvious, very miserable and easy to connect. Generally speaking, our military soldiers who have been exposed to cold injury can expect resolution or disappearance of their symptoms in anytime from three months to 12 years. But many of them never get well, and as they get older have greater problems. Because Cold Injury is damage to the small blood vessels, this is a similar type of damage that would occur with both diabetes and smoking. Consequently, smokers and diabetics will have exaggerated results from their having had a Cold Injury many years before. One other thing that doesn't occur with Non-Freezing is that those who suffer frostbite can not only lose toes, and have problems with their feet, but suffer loss of fingers, earlobes, and the tip of their nose. It is important to remember that even though the immediate effects of having had a cold injury can heal of appear healed, it does not prevent the development of a severe disability many years later. Veterans with a history of Cold Injury can have the following signs and symptoms:

In other words, in a person who has had frostbite the foot would be shiny, white, devoid of hair, and cool. They can also develop excessive pain, which is called peripheral neuropathy. They may develop skin cancers in the skin at the site of the scar from a cold injury. They develop arthritis, or other bone abnormalities, which appear as deformed joints, and osteoporosis which means thinning of the bone. There's no really good treatment for long term effects of Cold Injury, other than to keep feet dry, warm and clean. It is essential to take good care of toenails, stop smoking, and maintain good diabetic control.

A blood pressure medication called Nifedipine can cause blood vessels to open up or dilate. This can be useful in people who have Raynaud's phenomena, where the toes or fingers turn chalk white when they touch a cold surface. To control chronic pain in the feet, an anti-depressant drug called Elavil in doses of 25-150 mg at bedtime can be helpful. Another anti-depressant drug called Nortryptilene also works well.

Veterans suffering from long term, and delayed effects of Cold Injuries, frequently require continued medical care, as well as specialty consultations and periodic reevaluations. These patients, or veterans should enroll in a VA Primary Care program, and they should be encouraged to see a Veteran's Benefits Counselor to discuss submission of a benefits claim, if appropriate. Veterans, who already have some service-connected for the residuals of Cold Injury, may wish to reapply for additional benefits because extremities are now evaluated separately. There can be additional service -connection for arthritis and development of cancers at the site of the Cold Injury.

 

In summary, the Veterans Administration recognizes that greater attention needs to be given for Cold Injury, and that sufferers are entitled more adequate compensation.

Unfortunately, as with a lot of other things in medicine, we do not have satisfactory cures. Control of diabetes, stopping smoking, and keeping feet warm and dry can go a long ways towards adding to an effected veteran's comfort.

Jerrod E. Johnson

 

For more information regarding Cold Injury, enter the below address in your browsers location (URL) box.
http://www.va.gov/oph/cold/studyoutline.cfm

 

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