Teaching Prosthetics in Iraq: Performing Under Fire

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By Judith Philipps Otto

Editor's note:  All persons photographed in this article, other than US Military, have been de-identified by a black box covering their eyes for security purposes

As allied healthcare professionals practicing here in what is arguably the most civilized country in the world, we are inclined to complacency. The most intense pressures we face daily deal with cash flow issues, documentation dilemmas, insubordinate subordinates, malfunctioning equipment, or fussy patients.

To experience real on-the-job stress, however, try fitting prostheses in a war zone in an office that is shelled by the enemy on a fairly regular basis.

1st Lt. Joe Miller, CP, MS
1st Lt. Joe Miller, CP, MS

Just ask 1 st Lt. Joe Miller, CP, MS, and US Army Reservist, who recently returned from a five-month assignment in Iraq, where he and his team of therapists instructed Iraqi nationals in the art and craft of prosthetics-despite the challenging conditions faced daily in that country.

"This is the first time the US Army has ever put together a team like this," said Miller. "This unique level of commitment to working with prosthetics is certainly a significant philosophical change."

Miller recalls that it took six to eight months of planning before their January departure. "Myself and the other two officers, including team leader Capt. Matthew Scherer, were involved early on in helping to develop the mission, determining who would go and what the mission objectives would be, etc. We had a lot of questions, and there were some gaps in information, due to personnel in the theater being deployed back home."

Miller was the only reservist member of the team-and had some understandable misgivings, since he had not been on active duty for nearly 20 years. "The idea that your first activation is going to be right in downtown Baghdad raises a number of concerns, primarily with safety and security."

The mission, conceived and masterminded by retired Col. Charles Scoville, US Armed Forces Amputee Patient Care Program manager, evolved from requests from senior leadership-level military personnel who had served in Iraq.

"These individuals had toured Walter Reed and seen what we were able to accomplish here with our amputee patients. They wondered if it would be possible to provide this level of care for our allies," explained Scoville.

"There are two ways to provide this care for Iraqis that have had limb loss: One is to bring them all here to the United States, providing care at Walter Reed Army Medical Center and various other facilities. The other is to build the capability in-country to provide the care. It's much less complicated to provide care in theater for Iraqis than it is to bring them to the United States."

Scoville developed his plan and presented it to the Surgeon General. "The Surgeon General was supportive of it from the beginning, and it was actually the higher levels of command in the theater that said, 'Hey, we like this program; and we really need it!'"

His concept was based on the Walter Reed model, including its philosophy of care: "We treat individuals with limb loss as elite athletes, and strive to return them to the highest possible level of function, applying the appropriate level of technology in order to do so. Instead of identifying walking as a goal in itself, and developing new goals only if the amputee manages to reach the walking stage, the Walter Reed philosophy regards walking as merely a starting point-and we help set their goals for a considerably higher ultimate level. Walking is just one step along the way."

Scoville's plan provided for highly qualified and well-prepared individuals to perform a train-the-trainer mission. His hand-picked team was sent to train the Iraqi providers in how to provide the appropriate level of care, and how to train others to also provide that level of care, thus creating a self-sustaining program.

The team included Miller, a physical therapist, a physical therapist technician, an occupational therapist, and an occupational therapy technician. "Before they went over, we had the technicians work in the prosthetic shop to learn some of the skills so they could assist Joe in his job, thus enhancing the team's capabilities without increasing their number-and their risk," said Scoville.

In a scenario that gives real meaning to the term "hostile environment," Miller and his team arrived in Baghdad's Green Zone at 2 AM on January 30, after nearly 48 hours of air travel, from El Paso, Texas, by way of Bangor, Maine; Ireland; and Kuwait. At Kuwait, military transport took over and amenities disappeared. The helicopter that carried them over the last leg of their journey made several stops at "hot spots" to airlift personnel, and provided a grim introduction to the realities of survival in a war zone, Miller reported.

"It was a little bit unnerving," he admitted. "It's the middle of the night, you see tracer rounds flying around, and two door gunners are just frantically watching for incoming rounds."

A second helicopter taxied them from Baghdad International Airport to the Green Zone surrounding the US Embassy and the state department, where they found themselves on their own inside a concrete-walled airfield beside a mountain of luggage and supplies. ("Between us five guys, we had over 20 bags.")

The zone is heavily fortified, Miller recalled, with concrete barrier walls, sandbags everywhere, multiple entrance checkpoints with a lot of tanks, and armed posts with guards carrying M-16 assault rifles.

"Initially I felt more secure, because of all this heavy fortification, but as we learned, because it was the embassy and the hub of the state department, it was more likely to be a target for shelling. Baghdad is basically the epicenter of the Iraqi government, so having a strong hold in Baghdad meant that you controlled the nation. So symbolically it had a lot of meaning to the terrorist organizations as well as to us."

The Green Zone was shelled fairly regularly, said Miller. "We had two rounds that hit very close-one was 150 feet from the trailer that I lived in, and another one hit across the street from our prosthetic office. So those were unnerving."

Also unnerving was the newspaper account he read of a failed plot by 412 al-Qaeda members to take over the embassy by posing as multinational guards.

"I read that and thought, 'Wow. My 9mm pistol isn't going to do me much good!'"

"Although the loudspeaker would announce, 'This is not a drill. We have incoming rounds!' we always heard the actual explosion before the announcement. So we'd throw on all our gear, get away from the windows, and take other recommended security precautions. But as time went on, you started to think, 'Oh, well-that round wasn't that close.'"

"I will say, I continued to put on my gear, even in a building, although the other guys would harass me about it. We had these big desks in the office where we had to set up a classroom, and the back side of one desk was a flimsy metal panel. So when the guys would walk up to it and accidentally kick it with their boot, it would sound like an explosion. Initially, we were all pretty jumpy. We would hear this 'Boom!' and everyone would jump; and we'd say, 'Sorry, sorry!' After a while, we kind of got used to that sound."

Following the team's Monday morning arrival and subsequent in-processing, they were in their clinic and open for business by Thursday.

"We came prepared," said Miller, "with our course schedule fully laid out, ready to rock and roll. The following Monday, once we assessed the clinic, we started teaching.

"The Iraqi prosthetists had been working with our army predecessors, so they knew that another team was coming. They were very happy not only to have a new influx of US military, but now they were also going to be the clinicians. They were happy, they were attentive, they came to all the classes. We had quizzes, and they were very involved in hands-on. It was a very good experience for us as well as them."

Miller notes that some of his initial concerns were based on questions concerning the host country nationals themselves: "What were their backgrounds? Are there prosthetists? If so, what sort of training do they have in Iraq? Do they have security clearances to be coming in and out of the compound to work with us? How technical is their background? Are they used to thermoplastics? Do they have computer backgrounds? Do they know how to run CAD machines? We really didn't know.

"We found that there is a huge dichotomy of people that are educated, and then the very, very poor who have no experience on computers. Our fear was that we were going to be called upon to train folks who were basically off the street, and that trying to make them into clinicians was going to be somewhat impossible. Luckily, the people that were identified as prosthetists were two gentlemen who had previously been prosthetists in the old Iraqi army. They had 20 years of experience and they knew quite a lot.

"The two physical therapists were educated in Iraq and had the equivalent of a six-year degree-a masters level in physical therapy. They were active-duty Iraqi lieutenants, so they were well-attuned to the educational as well as the command and control issues.

"So we had an excellent team as well as an administrator who has a degree in computer science from Iraq-he was our office administrator. And all of them spoke English fairly well."

There was still, however, quite a bit of teaching to be done.

"They were used to performing the technical aspect of making a leg," explained Miller. "Our objective was to teach them to be clinicians. We had to address issues such as why everybody doesn't get the same style socket, and why you don't modify the same way for everybody. We taught them how to evaluate the patient for the right type of components. We also introduced some of the upper-extremity technology to them."

Upper-extremity prosthetics are not often done in Iraq, where they usually opt for a cosmetic type of arm. Miller's team brought in a conventional arm system and taught them how to fit it.

"They were very interested in that-and very open to new fabrication techniques such as simpler ways to laminate or better ways to pull the plastic so we get a higher-quality product."

Within Miller's prosthetic portion of the program, he emphasized four points:

1) Education

"We looked at their basic educational knowledge, and wanted to improve their basic skill. We wanted to enhance their technical capabilities, and so with that, we used their existing CAD/CAM, which they had basically learned one way to use. I taught them why we were doing these modifications in the CAD system, and what makes the leg better when it is done in a specific manner. They learned how to assess the patient and how that influences your socket design.

"We also wanted to improve the basic services within country, which is why the US Military had paid for the new laser digitizers. By acquiring all this technology, they could improve their capacity."

2) Business Practice

"We wanted to improve their ordering of components. They had some contracts in place, but they would buy 100 feet and 100 foam covers at a time. They really had no idea why they were ordering it-there was just a 'let's order stuff' mentality. We introduced a system of accuracy and accountability for what was being ordered, why it was being ordered, the need to track it-and generally encouraged thinking like a businessperson.

"One of the other things that we worked on was basically shortening the timelines for receiving components in country. That's a whole story in itself."

3) Workflow

"How were they getting their patients in?" Miller wondered.

"Patients had to come in from outside of the Green Zone, and so did our counterparts. Every morning they would get up at about 5 or 6 AM, walk or drive into the Green Zone, then go through the search, and get to the office at 9 or 10 in the morning. The key thing is that our counterparts and patients were putting themselves at risk because, in the real world, they were seen as working with the Americans, so they were targets for reprisals and attacks.

"And people were actually killed-it was no joke about that. We lost some patients-but we don't know if that was the reason. We had threats to patients; we had threats to a couple of our counterparts. Actually, one of the counterparts' neighbors was gunned down. He felt it was because they looked alike, with the same body build. One of the Iraqi lieutenants had to move his entire family from where they lived. So there were disruptions."

In addition to concerns about getting patients and practitioners to the clinic, Miller also addressed workflow issues by trying to reduce the fabrication timeline.

"Before we arrived, their procedure was to see a lot of patients, take a lot of molds and casts, and once they had 20 or 30 or so, then they'd start to work. They'd try to call the guy or get a hold of a family member to get him to come back into the Green Zone.

"Well, from the time of casting to the time of fitting could be three or four months, and, as you can imagine, that cast would no longer work. So we tried to speed the efficiency of getting things done and made quicker-within one or two days, or, if we could, try to get it done that same day-because we didn't know how much time before the patient could be back."

Not to mention the very real risk that the patient might not be back at all. As Miller observed, a bombing could close the roads on any given day. In many cases, the people would just camp outside the Green Zone and sleep on the dirt until they could come in the next day. But the longer the delay in calling the patient back for fitting, the greater the risk that he/she might never be able to return.

Time-consuming but unavoidable double-step process security measures further delayed workflow. Patients routinely went through a four-hour screening to check into the Green Zone and get day passes; then Miller or one of his colleagues had to drive to the check-in point, pick up patients, and drive them to the clinic, where another check-in at their compound gate was performed.

When work was completed, the patients had to be escorted back out of the clinic and back to the entry point, and their exit from the Green Zone supervised and ensured.

"It was not simple for them, but it was essential for us to maintain that security," Miller concluded.

Ways to improve quality also were scrutinized, as part of the workflow-improvement process.

"Although the Iraqi prosthetists had been taught to pull thermoplastics by our predecessors, every now and then they would get a fingerprint on the plastic, or they would pull it a little thin, but they regarded it as acceptable and ready for fitting. We'd have to recommend improvements to the work quality, in such cases."

4) Patient Care

Miller also focused on enhancing clinical skills overall and trying to improve patient outcomes, working closely with the rehab team. He also stressed increasing the number of patients being seen.

"We employed the business model of evenly subdividing patients into three categories: one third are on a waiting list to come in; one third actually being assessed or fitted, and one third accepting delivery of their finished prostheses. This one thirdone thirdone third model helped out with the flow of patients going through rehabilitation, it improved the promptness of delivery of legs and arms to patients, and it provided a better and more efficient overall education program."

Surprises?

What surprised Miller most about his Iraq experience?

"The most surprising thing to me was that Saddam had bought a lot of high-tech components while he was in power; but although the Iraqi prosthetists had exposure to them, they just weren't allowed to use them very much.

"'These are things that Saddam bought. We don't touch them,' they would say. They had clinics that I was not allowed to go to, but they told me that they have beautiful titanium parts on the shelf. So they have the technology, but if the opportunity to fit it on a patient arose, they would take it out of the box and just put it on-they didn't know how to do the fine-tuning of the knee units, for example. That was a hurdle we had to get over."

Miller also was surprised by how well they picked up using the computer system and the CAD system, and liked it. "They really thought that was a great benefit. Actually, when it went down for a few weeks they complained, and didn't want to go back to the old hand method."

It was a pleasant surprise to discover how organized the clinic was when Miller arrived, and how willing the Iraqis were to learn and adopt new methods. "They really wanted to make the system better for their country-and that was a big surprise to me. I stay in contact with them now all the time and I'm still involved with that program. Our two prosthetists also have tried to keep up with technology through the Internet."

Miller's living conditions were another welcome surprise. He was assigned to share (with two other officers) an air-conditioned two-bedroom trailer with its own bathroom and running water-a real luxury.

"We had TVs and DVD players, we had Internet capability within our trailer, and I was actually issued a cell phone because I needed communication; so my wife could call me from the United States. The embassy compound where we lived was nicely taken care of, with walkways, a swimming pool, and activities and entertainment every night.

"It was kind of surreal, living like this in a combat zone, eating our Baskin Robbins ice cream while other officers and enlisted members just a few miles away were living out in the dirt-in tents with latrines or porta-potties 100 yards away. It was not unusual for cobras to crawl up under the porta-pots and into the bath area, along with spiders and anything else you can imagine.

"We were very, very fortunate."

Measure of Success

Is it safe to say that the mission was accomplished? How does one measure the success of such an enterprise?

"Our mission was to train and transition at the clinic, and that's what we did, within our allotted time frame of six months," said Miller. "The end phase of the education program required that the Iraqi prosthetists had to develop a PowerPoint presentation on a topic to be presented to a few other prosthetists and therapists. We coordinated with the Ministry of Health to bring in this audience, and our prosthetists and therapists taught them."

It was arranged as a four-day course that the Iraqi practitioners actually taught as a part of their final validation, while Miller and his team critiqued them on their teaching.

"What made it difficult is that most people in Iraq know that the Americans have the new technology, and they only want to hear it from the Americans. We stepped to the background and said, 'Hey, these are your own people-they can teach you just as well as we can.'" Although ten prosthetists were invited, only a few came to the clinic for the class due to their fear of reprisals. Three who did not attend were themselves members of a terrorist group, Miller reported. The prosthetists who did come and the three therapists who attended were initially skeptical when they discovered they were not going to be taught by the Americans.

"But after the first day of seeing what these guys could teach and show them," Miller said with satisfaction, "there was a lot of camaraderie between them."

"Part of the issue is that prosthetics in Iraq is basically at the same level it was in the States in 1956-when it was a basement profession. Education was relayed by physicians, who would attend training and then come back and tell the prosthetist what to do. In Iraq, they still call prosthetic centers 'leg factories.'"

A Brief Recap of American Prosthetics in Iraq

Originally, said Miller, reserve army officer Steve Lindsley had been deployed to Iraq as a military policeman in 2003. "During his off-time, he would make some legs. He would treat patients using supplies provided by the hospital where he used to work in the States. That was the beginning of the clinical care program.

"He was succeeded by a civil affairs army sergeant, Chris Cummings, who was a prosthetic technician and who helped to grow the program. That's when a couple of Iraqi prosthetists were identified and brought into this quasi-program."

At that point, high-level officers began taking notice of the goodwill value of the program and made the request to the Surgeon General.

The rest is a history that continues to evolve. To date, it continues to be a true success story-from Lindsley's first efforts at making arms and legs to Miller's contribution to teaching and transitioning-to a clinic now managed and run by trained and qualified Iraqi prosthetists maintaining a collegial relationship with their compatriots on the other side of the world. Success, indeed.

Judith Philipps Otto is a freelance writer who also has assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.