Racing With the Amputee
Thirteen-year-old Bryn Byers was one of a group of teen-agers, including her brother and friends, who were enjoying a particularly beautiful, 60 degree Labor Day weekend in 2003. They were riding their 4-wheelers across the rolling farm land of rural Wisconsin and celebrating the last days of summer before school started.
At an unmarked country intersection the machine Bryn was on collided with another—pinning Bryn between them. She was about to join the 1.6 million people in the United States who live with the loss of a limb. That Sunday in August was the last day she would walk without a prosthesis.
At first Bryn did not seem badly hurt—there was only a small hairline fracture in her left ankle. Hospitalized at the University of Wisconsin Hospital in Madison, she developed an infection that attacked her muscles. In an attempt to control the infection, doctors transferred her by ambulance to Children’s Hospital in Milwaukee and when that effort failed they amputated her left leg six inches below the knee. Bryn’s was one of the more than 185, 000 amputations performed that year.
Bryn’s next stop was the Madison, Wisconsin, branch of Prosthetic Laboratories, an ABC (American Board for Certification in Orthotics, Prosthetics and Pedorthics) provider of prosthetics and orthotics.
Based in Rochester, Minnesota, Prosthetic Laboratories is an institution that is totally independent of other medical institutions yet works so closely with orthopedic surgeons, physical medicine/rehabilitation departments amputee clinics, that patient receive a seamless experience while being fitted for their prostheses.
Mike Gozola, one of Prosthetic Laboratories two company founders and a certified prosthetist, said that members of the staff are called to pre-amputation consultations and are sometimes even in the operating theater after the OR team closes the amputation wound. Gozola credits this unique multidisciplinary approach for the fact that their services are sought-out by patients throughout the country.
“We do what is best for the patient, ” he said.” Do that and everything else will work out. That is what directs our existence. There are three departments but we all work together. The team is the orthopedic department, the physical medicine and rehabilitation department and our company.
“It is like a relay race, ” he said. “Once the patient is handed off by the orthopedic department to the physical medicine department, a whole new set of things start to happen. We are the linchpin. We are involved at each step of the treatment process. Patients see us with the doctors when they are undergoing surgery, then with the folks doing their rehabilitation. In this post-op management period we see the patient three to five times before they even hit the amputee clinic. We help give them an idea of what the care continuum is. We educate them about it from the beginning.
“I have been asked by many people, ‘Aren’t these patients emotionally overwhelmed and bummed out by what is happening to them?’ And I reply, ‘No, not in this practice because we have this multi-disciplinary approach that is so patient centered.’”
Gozola said it is important to work with “prosthetically aware” physicians. The success of a prosthesis depends in part, he says, on how prosthetically aware the surgeon is. By this he means that the manner in which the surgeon stitches the skin at the end of the residual limb affects the way the future prosthesis will function for the patient.
“How the tissues are treated, how the residual limb is fashioned by the surgeon makes a huge difference. Not just anybody can close. It is kind of like a plastic surgery, ” he said. Gozola hastens to add that while local staff surgeons are all prosthetically aware, he participates in the education of surgical residents to pass on the principles of the care model.
When the surgeon finishes his work and the wound is healed—after about six to eight weeks—the rehab team writes a prescription for a prosthetic device and sends the patient to Prosthetic Laboratories with an elastic bandage wrapped around the residual limb. The immediate task of the prosthetist is to remove the pressure bandage and make a cast of the limb before it swells up.
Moving quickly the prosthetist takes measurements and, using plaster of Paris, makes a cast of the residual limb. In the laboratory the cast is filled with more plaster to make an exact copy of the patient’s leg. From this is fashioned the “socket, ” the device that will fit over the end of the residual limb and to which will be attached the mechanics of the leg or the arm prosthesis.
It is the fitting of the socket that is the most difficult and painstaking. Steve Amundson, the other founding partner, explained, “There are two parts to it, a soft interface that goes inside and the rigid core structure. We need something solid that is going to transfer the weight between the socket and the foot. This part is made of plastic, heated and molded over the plaster model.
“The interface goes on the residual leg first, followed by one or more prosthetic socks that fill up the space created by the fact the patient’s leg is shrinking in size—the body is changing and muscles are atrophying. They are not attached as they used to be.”
Fitting the socket on the patient is a painstaking process. As Amundson said, “A lot depends on where they are in the rehab process, and the length of time they have been an amputee. We will make a lot of changes to the inside of the socket to make it fit. Getting the socket to fit is tremendously important. It only takes minutes, when things are not fitting properly, for the skin to become damaged and then the patient has to wait for it to heal.”
Amundson assures his patients that, though it is a long process, they will be able to walk and chew gum at the same time. But in the meantime they have a lot to learn: balance, proper shifting of their weight, adjusting to having no sensation in their foot, controlling a prosthetic knee as they are walking. “Some adjust faster than others, ” says Amundson. “Balance is a key issue as is trusting the prosthesis.” The average prosthesis, meaning the socket that attaches to the residual limb of the patient, lasts from three to five years.
Amundson says that they may have to change the socket on a new amputee several times during those initial three years. Though the components on the bottom of the prosthesis are still working, patients often need more motion as they become skilled using their prosthesis. “We recommend that patients use a basic foot as the first prosthesis, but after six months or a year, the patient may need more advanced components with more movement, more give. We don’t want to hold patients back with the prosthesis. The first year or two are very important for the rehabilitation of the patient, ” he said.
According to Gozola, diabetes drives their business, afflicting over 50% of their patients. When vascular ailments are added in, 70% of their patients’ amputations are caused by diabetes and related vascular disorders. Cancer accounts for the third highest patient count with trauma a distant fourth. Patients range in age from young children to patients in their 90’s. “The key is mental capacity. If patients cannot remember the proper sequence, how the prosthesis goes on, and then it is going to be very difficult to manage, ” Amundson said.
Where is the science of prosthetics going? Knees can now be fitted with microprocessors that, when connected to a computer, can program the patient’s walking ability. The knee becomes capable of independent thought; learning how the amputee walks, recognizing and responding immediately to changes in speed, load and terrain.
And then there is the Michelangelo Hand, a prosthetic hand with the electronic opposable thumb. Produced by Otto Bock, the hand alone sells for about $85, 000. Looking to the future, researchers like Dr. Todd Kuiken, an engineer and physiatrist, are working on prosthetic arms that connect to the user’s nervous system. Instead of learning how to move certain muscle groups in the upper body to control the prosthesis, the amputee thinks about moving his missing hand or elbow. Electrodes on the patient’s chest sense the muscle contractions triggered by nerves and send messages to the computerized mechanical arm to execute the command.
Active in athletics before her amputation, shortly after receiving her prosthesis Bryn Byers was once again participating in her favorite competitive sports—softball, basketball, downhill skiing. Today she is a college student and, since 2003, has been a camp counselor with the Amputee Coalition of America—helping both children and adults adjust to the loss of a limb.
It has been 28 years since Mike Gozola and Steve Amundson founded Prosthetic Laboratories in one of their garages. The company now employs more than 80 people, has 13 locations in three states, and houses a spacious patient care area and a central fabrication facility in a 21, 000 square foot headquarters building.
Clearly, in the race with the amputee, Gozola and Amundson have found a way to make everyone in the process a winner. For more information visit http://www.plor.net.