New technology lets war vets with amputations get on with their lives

Comparing Scars

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Thursday, August 27, 2009

Photo Courtesy of The News Journal
Rob Kislow who says that "without his prosthetics he would have lost all of the qualities of his life..."

Rob Kislow who says that without his prosthetics he would have “lost all the joys” in life

For Rob Kislow, getting shot was a kind of relief. He remembers a moment of otherworldly calm as the percussive roar of gunfire and the voices of soldiers dissolved into white noise. He blinked back blood. He saw his limbs flailing weirdly, as though they belonged to some other body. The firefight had lasted nine hours, and Kislow was deliriously tired. He’d seen his good friend killed, riddled with bullets. But as he was finally dragged away from battle, he kept firing until the insurgent who had shot him was dead. They were mere feet away from each other. “I saw his eyes,” Kislow recalls. Later, another American solider snapped a picture of the Afghan’s body and gave it to Kislow as a memento.

But the photograph is not Kislow’s only reminder of that day. His right leg is gone, severed cleanly below the knee. He had been shot four times. Once in his elbow, nearly shattering his forearm. Once in the top of his head, slicing off a chunk of scalp and a piece of skull. Twice in his right foot, exploding his ankle.

Rob Kislow — who left for Khost, Afghanistan at age 18, just months after his high school graduation — is now 23 years old, living with his parents in Bethlehem, Penn. Today, the only vestiges of his head wound are short-term memory loss and hearing problems, and, after 12 surgeries, his arm has been reconstructed. He chose to have his right leg amputated in 2006 because he couldn’t bear the pain. “I saw amputees playing sports, riding bikes, all with prosthetic legs. I thought, I want to do that. I got my leg amputated so I could have that freedom.”

Kislow is one of almost 800 veterans who have lost limbs after being injured in Iraq or Afghanistan, according to the U.S. Department of Veterans Affairs. This number seems paltry in comparison with the scores of amputees who emerged from World War II, Korea and Vietnam; World War II alone saw 15,000 amputations. And due to new technology developed over the last few decades, the veteran amputee experience has changed drastically for the veterans of Iraq and Afghanistan. “These guys are coming back with traumatic injuries — they’ve lost limbs because of car bombings, IEDs, machine gunfire,” says Mary Lou Lauricella, a therapist at the West Haven Veterans Administration Hospital. “They just want to get on with their lives, and prosthetics are increasingly allowing them to do so.” While amputees of Korea and Vietnam were often forced to spend years in sedentary isolation, many of today’s veterans are active, impatient and pushing the boundaries of prosthetic technology.

The first time Rob Kislow had an artificial leg fitted, his doctors told him he wasn’t ready to use it. His stump needed more time to heal, they said. He smiled and nodded and waited for the physicians and nurses to leave. Then, he wheeled himself into the physical therapy room, grabbed his new leg and took it home.

His parents were not happy. His mother said: “Robert, you did not take that!” “Damn right I did,” he told her.

Then he took his first shower standing up since Afghanistan. He went archery hunting and drove his dirt bike. “I had the time of my life,” Kislow says.

Three years later, Kislow has already broken 14 prosthetic devices. One split in two while he was riding his motorcycle. One cracked and collapsed when he was carrying a buddy who had gotten hurt on a hiking trip. Another conked out after a day of snowboarding. A new prosthesis can cost between $6,000 and $12,000. Kislow currently has nine different prosthetic attachments — all paid for by the Department of Veterans Affairs — including devices for walking, running, motorcross, hunting, swimming and scuba diving. The artificial leg he uses to ride his bike is emblazoned with a slick silver skull on a black background. It has a hydraulic ankle joint that allows the foot to move naturally. His running leg is called a “Cheetah” — a blade made of carbon-fiber contoured to bend like a human ankle.

“Without all this technology, I would have nothing,” Kislow says. “If I had an old-school prosthetic, I’d have lost all the joys in my life.”

These “old-school prosthetics” were standard, sturdy models often made of wood or stainless steel and covered in flesh-like rubber. They were heavy, weighing 15 to 20 pounds. They bent crudely at the knee, and sometimes buckled spontaneously, causing the patient to fall.

The wars in Iraq and Afghanistan — by creating a demand for high-tech, durable prosthetics — have pushed the field toward a series of new advancements.

Now, instead of wood and steel, prosthetics are made of lighter substances like carbon graphite, titanium, aluminum, silicon and different types of gel. The suspension system is also different: Prosthetics are attached to the body by suction or vacuum as opposed to buckles and straps. Today, myroelectric arms can use muscles to move motorized hands, elbows or shoulder joints. Scientists are moving toward transplanting nerves into prosthetics to allow patients to use the same neurological pathways they had used to manipulate natural limbs.

Last year, the U.S. Department of Veterans Affairs spent almost $50 million on prosthetic devices and provided more than 4,000 new limbs to veterans.

Hanger Prosthetics, in Stratford, smells thickly of plaster and rubbing alcohol. Dr. Nathan Seversky strides purposefully down the hallway. His voice is clipped and businesslike.

“Let me see you walk,” he tells a man who has just been fitted with an artificial leg.

The patient staggers forward, arms outstretched.

“Good. She’s going to give you some nice thin socks,” Seversky says, gesturing to the nurse, “and if you need an adjustment, just let me know. See you in three weeks.”

Seversky became interested in prosthetics when he developed a bone infection in his ankle at age eight. His orthopedic surgeon showed him an array of prosthetic devices in preparation for his high-risk surgery. In the end, his ankle was fine, but Seversky was consumed by fascination with the rows of polished mechanical limbs.

The examination room at Hanger Prosthetics looks like a dance studio; it is paneled in mirrors so that Seversky can watch from all sides as patients learn to walk on their new limbs. One wall features colorful anatomy posters.

On the countertop is Seversky’s most prized possession — a wide computer screen with an attached sensor that looks like a barcode reader. Whereas sockets were once made by taking plaster impressions of a patient’s stump, computer technology is gradually digitizing this process.

The software — called Insignia — takes a surface scan accurate within two millimeters. After a patient has had one limb amputated, Seversky uses Insignia to scan the stump and then the other limb so that an impression can be made and a prosthesis created.

Seversky scans his own arm to demonstrate. He presses a small plastic sensor into the palm of his hand, then lifts the scanner and glides it up and down his forearm. Within seconds, a three-dimensional model of his arm materializes on the computer screen, first a delicate blue latticework and then an overlay of flesh-colored pixilation. The sensor sees every crevice and fold. It knows the bend of the elbow, the slope of the wrist.

But the workshop in the back of Hanger Prosthetics is still a testament to the crude corporeality of the business. There are two big ovens in which prosthetic limbs ossify in molds, plaster-dusted countertops scattered with screws and bolts, whirring bandsaws for grinding plastic, a wooden stand with artificial legs protruding like tree branches in all directions. There are big, husky legs and thin, knobby ones, slender female ankles and a man’s broad thigh. The floor is littered with various types of prosthetic devices: A skiing knee that has a coil over air shock to mimic what the hamstring does; a hydraulic joint topped by a clear plastic socket so Seversky can see how the stump fits into it. The place looks like a concrete battlefield, a sprawl of disembodied plaster casts.

“The human body is really adaptable,” Seversky says. He tells his patients they just have to set realistic goals. He assures them they’ll be able to do whatever they could do before the amputation; they’ll just do it a little bit differently.

“I have old prosthetic advertising booklets from the ’20s and ’30s that show amputees doing great things — running, skating on the old technology,” he says. “It’s interesting to me that people were still doing those kinds of activities, they were just working a lot harder. There are so many more options today.”

For Rob Kislow, the array of prosthetic devices he now owns is the key to his independence. “The technology is irreplaceable to me,” Kislow says. “It lets me be active. Otherwise, I might as well have been in Korea or Vietnam.”

Al Dupaul, a 78-year-old Korean War veteran from New Haven, answers the door of his apartment in a rickety electronic wheelchair that buzzes angrily as he moves. His right leg is a pearly, bulbous stump; his left foot, swathed in a sock, is amputated just below the ankle. He lives alone, except for a few nurses who bustle in to check his blood sugar and tend to a painful sore on his upper leg. Dupaul’s broad, bespectacled face is framed in a sweep of grey hair, and he wears blue shorts and a plaid shirt. (“The VA gave me this. Someone donated it — it had a tag and everything, brand new, which is good because I don’t get to shop much,” he says, fingering the buttons sheepishly.)

Dupaul was 21 years old when he went to Korea. “It was almost like a Boy Scout camping trip in the beginning,” he recalls. He was put on a contact team and charged with repairing optical sights and mounts. But after four months, the romance period had faded. The days were blisteringly cold, and the military-issued shoes were not well insulated. Dupaul’s feet sweated and froze onto the pad inside his shoes until he was walking on ice. The frostbite that ensued culminated in diabetes about 15 years later, Dupaul says, and his right leg was amputated shortly thereafter. He lost the left foot a couple of years ago, also to diabetes.

Dupaul is still haunted by nightmares. His sleep is fitful and tense. “I blocked out the experience of being under fire, the dead bodies, the refugees,” he says.

But at night, he is back in Korea, huddled against the bone-chill of the air, hearing the gunfire pound in his eardrums.

After the war, he moved back in with his parents. “I was in limbo,” he remembers. He felt like he did not belong, and he didn’t want to talk to anybody. “When you left for the war you were part of America,” he says. “When you came back, you weren’t.” The isolation was consuming. He thought that no one understood what he’d been through. For years, he sat in his house and rarely went out. He was married, but soon divorced. As he got older, he developed a severe stutter, and he sees a therapist for post-traumatic stress disorder. “I wish I never went to Korea,” Dupaul says.

The prosthetic device for his right leg is gathering dust in the corner of his bedroom. It is a stocky, squat artificial leg, covered in a layer of rubbery synthetic skin, stuffed into a black sneaker. Dupaul never wears it anymore. “I look at it as an ornament now,” he says. His stump is too swollen from diabetes to fit into the socket, and he’s content with his electronic chair. “I never considered high-tech prosthetics. I don’t miss walking right now. I’m 78 years old. This is not a stage of life where I would want to go up hiking in the mountains or anything. In fact, for me, there never was. I have my PTSD to worry about. I don’t get out much.”

Dupaul’s saving grace, he says, has been a weekly support group for amputees at the West Haven Veterans Administration Hospital. Every Wednesday, 15 to 20 veterans — usually all men, although a woman whose arm had been amputated came to a few sessions — meet to share stories and complain about “amputee problems.” Sometimes, the veterans — many of whom use wheelchairs instead of prosthetics — commiserate about the fact that being an amputee means there are rarely opportunities to get out of the house. They discuss the nagging torment of phantom leg pain, how to choose a prosthetist, their depression and poor body image.

The group began meeting 13 years ago. Its first members were three veterans from Korea and World War II. “We had all these experts around telling the veterans what they could and couldn’t do,” says Mary Lou Lauricella, the therapist at the West Haven VA and the moderator of the support group, “but there was no forum for them to talk to each other.”

One older veteran, excited at the prospect of all this new technology, spent weeks researching artificial feet and watching videos of amputees running marathons on sleek, springy legs. But when he finally got his leg, it was too bouncy. He couldn’t use it because “it sent him flying,” Lauricella says.

Lauricella thinks the Korea and Vietnam vets could benefit from the perspective of some younger veterans, but the support group has not yet attracted anyone from Iraq or Afghanistan. Their youngest member is 50 years old. “A lot of the recent vets are in denial,” Lauricella says. “It’s a certain bravado. They tend to think, ‘I don’t need emotional support, I’m just going to get my prosthesis and get on with my life.'”

Dupaul recognizes that the new veterans need time. They have access to a host of opportunities that were never available to them, and for now, they are busy rebuilding their lives. “Our experiences have been different,” Dupaul says. “For the older guys — in Vietnam, you were in a jungle, fighting people you couldn’t see very well. In Iraq, you’re in a desert. You can see who you’re fighting. These are different kinds of wars. And now, the younger guys have all these new devices to distract them, to get them thinking about their lives here rather than what happened in Iraq. But I think when they’re ready, they’ll come here, to us, and we’ll help them through it as much as we can.”

While veterans like Dupaul — too old and too tired to take advantage of cutting-edge prosthetic technology — are still mired in the past, Rob Kislow struggles to focus solely on the present. “I’d never go to a support group,” he says. “I don’t want to hear someone else’s sob story. I have a hard enough time keeping myself motivated and strong. I don’t want to hear ‘poor me.’ I don’t want to go in there and compare scars.”

Today, Kislow is taking classes on business and welding. He plans to open up his own auto shop. He has never used a wheelchair, and insists that he never will.

And unlike Dupaul, Kislow claims that he has no regrets about serving in the military. “It was the best decision I ever made to go to Afghanistan,” he says. “I pushed myself 110 percent to follow something I believed in.”

With new legs and a new life, Kislow is fighting his demons the only way he knows how: through snowboarding and dirt biking, scuba diving and flag football. When the memories start to gnaw at him — the terrible racket of artillery, the sun burning over the hills in Khost, the eyes of the man who almost killed him — he slips into his favorite leg, the one with the acrylic skull printed on the front and the smooth hydraulic ankle. He revs up his motorcycle. He speeds down his quiet, suburban street. And he rides and rides until all he can feel is the wind on his back, in his hair, on his skin.

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