From Land Mines To Lawn Mowers Prosthetic Rehabilitation Proceeds One Foot at a Time by Dale Berry Nothing can cure an amputation. The wounds are devastating and are life altering to anyone who survives the trauma of amputation. Especially in the case of children, it will change every aspect of their future. When Angela and Ahsad were 3-years-old they both led typical energetic and fun-loving lives. If they had lived next door to one another, there is little doubt that they would have been best friends and enjoyed the fun of just being kids. Normally, Angela and Ahsadís lives would have continued on separate paths, sharing little in common because of their cultural separation--one living in Iowa and the other in Iran. As fate would have it, though, Angela and Ahsad would experience and survive an event that would change every aspect of their future--the trauma of having a leg amputated above the knee. Angela and Ahsad required the use of an artificial limb or prosthesisóas do all amputees who want to learn to walk again. The styles and types of prosthetic devices available today are varied and numerous depending on where you live in the world. As technology advances, so do the abilities and capabilities of individuals who survive amputation. A case in point is that the worldís fastest amputee runs the 100-meter dash in 11.09 seconds, a mere second slower than the fastest runner with two sound legs. Todayís prosthetic developments and rehabilitation treatments make it possible for amputees to lead full and productive lives, that is of course if they have access to the technology and quality care. Ahsad wasnít so lucky. He is the innocent victim of a fate no child anywhere should endure. Ahsadís life as an amputee began while playing soccer with his brother and some friends in a field not far from his home. There was no reason to assume there was any danger that day. It was a sunny and warm afternoon, a typical day for Iran. Ahsadís older brother recalled that he kicked the ball to his little brother, who ran after it into some tall grass. He heard a loud pop, saw a puff of smoke and then heard his brother crying. Ahsad had stepped on a mine, obviously one that had been laid years earlier to protect the village from enemy soldiers during the Iran-Iraq War. This tragic event happened years after the war ended and the fear of enemy soldiers had subsided. But the mine stayed behind to deliver its devastation on the very individual it was intended to keep safe. Ahsadís brother ran to his side where he was lying in pain, covered in blood and now missing a leg. Neither boy had any idea what had just happened or what to do. Both were very afraid and knew they desperately needed help. Halfway around the world in Iowa there were no land mines for Angela to be concerned about, but the danger of trauma was still present. Angelaís day started out like any other day for an American 3-year-old energetic child full of adventure. In the backyard, her father was getting an early start on the weekend and mowing the lawn. Wanting to help, Angela ran out the door to join him and help with chores. As Angela approached her father, he moved to protect her from getting close to the lawn mower, but she slipped on the grass that was still wet with morning dew and her foot slid under the machine. Her father picked up the still running lawn mower off his daughter. He threw it over the fence where the engine and spinning blade slowly came to a stop, leaving the sound of his injured daughterís voice to fill the air. He knelt by her side and applied pressure over the deep wounds on Angelaís leg to prevent the overwhelming loss of blood. They were both very afraid and knew they needed help. Fear of the unknown is the initial emotion experienced by any survivor of amputation: What am I going to do now? How will I get around with an amputation? Will I survive as an amputee? One of the main reasons for these fears is that most people donít know anything about amputation or life as an amputee. Typically, all that people know about amputation is what they read, such as a story like Angelaís in the newspaper. Most people naturally believe that trauma, as in Angelaís case, is the leading cause of amputation. The truth is that the number-one cause of amputation is not trauma but disease. Approximately 85 percent of amputees in the United States have lost their limbs because of diabetes, hardening of the arteries and other circulatory diseases. The majority of these amputations are scheduled surgeries and the resulting residual limbs are healthy and the amputees respond well to prosthetic rehabilitation. In the relatively rare instance of a traumatic amputation such as Angelaís, the American medical community, at least, is prepared and capable of providing the highest quality emergency and rehabilitation services. In developing countries, however, amputation statistics are significantly different. Brett Norton of the Land Mine Survivors Network (LSN) described the stark statistics of amputation victims in war-torn countries such as Cambodia, Iran and Afghanistan. "In some areas 80 percent to 85 percent of the amputees are land mine survivors. The mines are responsible for 22,000 amputations per year and have produced 300,000 amputees worldwide." The Land Mine Survivors Network is a non-profit organization devoted to the international crisis involving land mines. "The LSN goals are to clear the existing mine fields, ban the future use of the weapon and to help the victims of land mines," Norton said. "The land mines are designed to injure and maim, and they do not differentiate between a soldierís boot and a childís sandal." "The challenges faced by the survivors are both physical and social," said Norton. "The physical challenges are obvious. They are missing a leg, and there are typically no services in underdeveloped countries to provide them with an artificial limb. From a social standpoint, before the accident, the individuals were a productive part of the family unit. Now that they are disabled, they are considered a liability and a burden to the family." A significant number of children injured by land mines end up in orphanages or are abandoned. Even worse, many are left on their own to fend for themselves. If they do stay with their families, they become second-class citizens within their own communities. As amputees without a prosthesis, they are unable to contribute to the family by working in the fields or factories. Norton also noted that land mines affect a countryís economy. Fields that were once fertile are now left untouched for fear of injury. Villages are without crops to sell or eat because people are unable and rightfully afraid to farm the fields. Those who do venture into the fields become mine victims. The ones who survive are left to deal with limb loss. To compound the tragedy, the majority of these countries are unprepared, unable and ill equipped to care for the survivors. "The prosthetic technology that is commonly seen in America is impressive but is simply not a reality for most land mine survivors. It is estimated that fewer than 10 percent to 15 percent of land mine victims are ever fit with a prosthesis or are provided any rehabilitation services whatsoever." In comparison, the majority of American amputees receive prosthetic care, and there is a significant contrast in their rehabilitation success. Angelaís prosthetic experiences clearly demonstrate the extraordinary clinical outcomes achievable with todayís latest technology. It has been 25 years since her accident and she is now married with an 18-month-old son and she works full time. She describes her amputation as more of a major inconvenience than a disability. Angela is one of approximately 350 amputees in the United States wearing a newly designed state-of-the-art computerized knee mechanism. The C-Leg is a prosthesis with an on-board miniaturized computer that analyzes every step she takes and makes adjustments 50 times per second to ensure the knee is in the optimum setting for each step. She doesnít have to worry about falling, slipping or stumbling with her prosthesis. She has the freedom of walking without having to think about each step. Ahsad, in comparison, had no prosthetic experiences for the first five years after his land mine encounter. Getting around was accomplished by using a set of hand-made crutches that he constructed with his brotherís help. Ahsadís introduction to an artificial limb was when he joined hundreds of other amputees in his area. They all congregated to meet at a regional medical clinic. A rumor spread that a visiting group from the West was giving out free artificial legs as part of a medical relief program. Ahsad was there to see if it was true. It is very common for the volume of amputees at a relief prosthetic clinic to be overwhelming. Few if any of the amputees have any experience or knowledge about wearing a prosthetic device. As for the typical profile, Ahsad and his brother stood in the hallway shoulder to shoulder with other amputees in need of prosthetic care--and the number of people far outnumbered the resources or supplies at the disposal of the relief team. "The prosthetic supplies and resources are limited, but it appears the source of land mines and their victims is unlimited. Land mines have claimed more lives and caused more injury in the second half of the 20th century than both nuclear devices exploded in Hiroshima and Nagasaki combined," said Jeff Fredrick, a recent delegate from the State of Florida to the U.S. Campaign to Ban Landmines Legislative Action Conference. Fredrick has first-hand knowledge and experience concerning land mines. In 1968, while serving with the U.S. Army in Vietnam, he lost his leg to an enemy mine. He has since become a certified prosthetist to design and fit other amputees with artificial limbs, and he is a strong advocate for the elimination of land mines. "Land mines are neither a logical or reasonable weapon for todayís military," said Fredrick. "The mines deliver damage to both military and civilian targets alike. The limited potential military benefits are far outweighed by the long-term political and social chaos created in the country where the mines are buried." Because of the volume of amputees in a medical relief project, a triage or ranking procedure is commonly implemented to identify the patients to be treated. The patients with the simplest and easiest amputations are given first priority. The ones with the most debilitating amputations are often sent home without care. To maximize the success and impact of a relief effort, it requires treating the greatest number of individuals who will get the most use with a new prosthesis. A patient with multiple amputations combined with complications will arguably need help the most, but it would take excessive resources and expertise. In the time it would take to fit and care for one patient with complications, four or five patients with less serious or complicated amputations can receive care. Ahsad had a simple and straightforward amputation. He was young, strong and eager to give up his homemade crutches for something better; he fit the criteria to receive a new prosthesis. The prosthetic goals when providing relief care are significantly different from delivering a prosthesis in a country with a developed health care system. For countries affected by land mines, prosthetic services are nonexistent or marginally acceptable by modern standards. "In the United States, the level of care is determined upon the amputeeís ability to pay or the level of insurance coverage they may have," according to Craig Gavaras, executive director of Limbs for Life. "New advancements in technology are expensive and are typically only available to those who live in countries that can afford state-of-the-art care." "But these new breakthroughs also provide a trickle-down effect that benefits amputees in third-world counties," said Gavaras. Limbs For Life is a non-profit organization that collects used and unwanted prosthesis from amputees in the United States and then redistributes the components to third-world countries. "We collect 1,200 to 1,500 prosthesis per year," he said. "As American amputees receive the latest technology with their new prosthesis, they donate their old legs to Limbs for Life. About 25 percent of the legs received are in good-as-new condition." Gavaras--an amputee from an injury in the line of duty as a Dallas police officer--wears the same new style of computerized prosthesis Angela wears to pick up her son and walk down a set of stairs. What is significant is that she can hold her son with both arms and does not require handrail assistance. Angela says she smiles when she reaches the bottom step. "I would never have thought it possible to walk with such confidence and security." The computerized prosthesis with its carbon-fiber components and custom-designed socket provides the ultimate marriage of science and art to allow an above-knee amputee to run, go up and down ramps and walk on uneven surfaces without having to look down and watch every step. "This is the greatest freedom I have felt with a prosthesis," says Angela. But she is also quick to point out that she does not take for granted how lucky she is to wear such an advanced system. "The world has suddenly become a much bigger place for me. I no longer have to worry about watching every step. I now get to look around and see what I have been missing for the past 25 years." Back in Iran, the type of prosthesis worn by Ahsad is vastly different and the technology is worlds apart from the high-tech C-Leg. What is the same, however, is the joy and gratitude visible in Ahsadís smile. There is no question he is equally appreciative of his new artificial limb. The foot, ankle and knee are all used parts from a discarded prosthesis previously worn by another amputee. The components had served their use in the United States, and now Ahsad is eager to put them to the test in his new prosthesis. Ahsadís older brother was by his side to hold his hand as they took their first steps together. By the next day, the two boys were playing in the clinicís courtyard and Ahsad was learning to kick a soccer ball with his new prosthesis. Through an interpreter, Ahsad said that he wanted to thank everyone in America for his new leg and that he would walk tall and make people proud. The advancements in prosthetics continue to make a powerful impact in the lives of individuals who wear them. "New technology allows amputees to walk, run and live a full, active life," Gavaras said. "The challenge that needs to be overcome is providing access to the technology. It really does not matter how you lost your limb, whether you are here in the U.S and do not have insurance or a land mine victim in Turkey. You just need assistance to literally get back on your feet again." Dale Berry is a practicing certified prosthetist in Minneapolis, Minn. He is the author of "RESULT, Thereís No Such Word as Canít," and a member of the American Orthotic and Prosthetic Association (AOPA). He has made numerous trips to various countries to provide prosthetic care to land mine victims. For further information, contact AOPAís office at (703) 836-7116, ext. 213.