By Rebecca St. Andrie

In 2004, Chris Cummings was working in his central fabrication lab in Ft. Lauderdale, Fla. when his Army Reserve unit was called up to active duty. So he shut down his business, stored his equipment with a friend, and headed over to Iraq. But despite the change in location, Cummings found that the best way he could serve was to continue doing the work he was doing.

Meeting by chance
it all came about serendipitously. Cummings was originally deployed with the Civil Affairs battalion, which was attached to the First Cavalry Division out of Texas.

Civil Affairs units are liaisons between everything in the combat zone and the Army. As part of it, Cummings would evaluate community needs, and then go back to the Army to see what it could do. Many times that meant starting reconstruction projects on hospitals or police stations, or just finding work for military-age men to do “so they wouldn’t be planting bombs on the roadside.”

But in the course of this work, a higher-level officer got to know Cummings. When he found out Cummings was a prosthetist, he introduced him to another one, Steve Lindsley of Louisiana.

The start of a good thing
“The officer put us both in a room to see what we could come up with [for] a feel-good project,” says Cummings. As a result of their shared background, they came up with a plan to start seeing prosthetic patients in their spare time. But once they got started, “the project just snowballed—in a good way.”

To start with, Lindsley’s hospital donated a large amount of prosthetic materials. Then Cummings called the friend who had stored his equipment in the U.S., who agreed to ship many of Cummings’ tools over to Iraq.

Word of mouth
With those basic beginnings, Cummings and Lindsley set up a makeshift operation in the basement of one of Iraq’s palaces. It had originally belonged to one of Saddam Hussein’s sons. Since the kitchen had a pizza oven, it became a good place to set up their first prosthetic lab. And once Cummings and Lindsley opened up the lab, the patients started coming.

“It was more word-of-mouth than anything,” Cummings says. “When I would go out to the streets on a foot patrol or a mission, I would meet an amputee and give him a number to call me. Then I would pick him up at the checkpoint and take him over here.

“One of our first patients was a fourteen-year-old boy who was begging on the side of the street. He was a through-knee amputee, and I turned the convoy around and said ‘Let’s go back and get this kid!’ I think he got a little scared when he saw all these Humvees coming toward him.”

Then the Civil Affairs command, which operated an Iraqi assistance center, started giving out contact information. “Amputees were lining up out the door,” Cummings remembers. Back then, he was working by himself with only an interpreter to help. “Some days there would be 10 guys there [looking for a prosthesis],” he says.

Meeting the right people
More funding started coming in as well. The first large grant came about due to a Civil Affairs officer who knew what Cummings was doing.

Because the officer’s unit was about to return to the U.S., the officer had a fair amount of money left in an equipment fund designated for the Iraqi people. So he asked Cummings “What would be your dream list for the clinic?”

“There are a lot of things I can think of!” Cummings replied.

"Have a proposal on my desk by 7:00 a.m. tomorrow,” said the officer.

Cummings pulled it off. He put together a 20-page “dream list” of equipment for the clinic, including a CAD/CAM system.

On his own
However, although the money got approved, the contracting process took a long time. And during that time, Lindsley redeployed back to the U.S. But having asked for the equipment, Cummings decided to extend his tour, eventually staying 20 months total.

While that meant he had to watch his battalion go home as he stayed behind, Cummings says he really enjoyed what he was doing. “I was taking care of people who otherwise wouldn’t get that level of care,” he says.

But then he started to get short on materials. He heard about a woman at the American embassy who ran a gift shop and donated the proceeds to local charities. “I went to her door, begging. It turned out she was General Petraeus’ secretary,” says Cummings.

At that time, Gen. Petraeus was in charge of training the Iraqi Army. “He got word of it, and things really started to snowball after that,” says Cummings. The clinic was now fully up and running.

Prosthetist training in Iraq
During his first tour, in addition to running the clinic, Cummings would also train Iraqi prosthetists in the use of the equipment and in more sophisticated techniques than what they had learned in school.

Cummings says there is a technical training school for prosthetists in Baghdad, much like one of our vocational colleges, but the training is different. “They learn all the basics about alignment, but they don’t get good, hands-on practical training,” Cummings says. “In their two years there, [people studying to be prosthetists] would complete one device.”

At the time Cummings left in October 2005, he had trained two Iraqi prosthetists to work at the clinic. The Army also provided some extra support. A few months after Cummings left, a prosthetist named Joe Miller, who was working at Walter Reed at the time and was also in the reserves, was deployed to the clinic. He provided a little more detailed education for the Iraqi prosthetists.

An unstable situation
But the situation in Iraq does not often make for stability. After Miller left, the Iraqis who were working there either quit the job or fled the country. While the clinic continued to operate, it was not being used to its potential.

“There was this great clinic and nobody was trained on how to use the equipment, or, specifically, on modular prosthetics,” says Cummings. “In the Iraqi system, they use the more traditional ICRC polypropylene prosthesis. So these guys weren’t trained on modular components and they weren’t trained on a CAD system.”

The Army called Cummings up. Would he, they asked, be willing to come back and train the Iraqis working there—this time as a civilian?

Cummings agreed. In July 2007, he returned for a one-year commitment.

Challenges for the clinic
“Things are going pretty well now,” he says. “I’ve got seven guys with formal training in prosthetics, and right now they’re working semi-independently with the CAD/CAM system.” He recently took a vacation, and when he came back, he found that everything had gone smoothly.

There have been challenges. The Iraqis working at the clinic when he returned didn’t have any computer training, and very few are able to speak much English. Likewise, Cummings’ Arabic is limited to “Are you feeling pain?” “Take it off,” “Put it on” and “Walk.” He gets over the language barrier with a translator most days; right now, his most recent translator, a medical student, has left to start his own residency.

Security is the biggest problem. “My [original] translator, whom I worked with for the 20 months I was over here, was assassinated two months before I came back [because he was working with the Americans],” Cummings reports. “And all these guys that I work with right now return to their homes [outside the Green Zone] at the end of the day,” Cummings notes. So they are also at risk.

In the clinic, Cummings mainly acts as a coach. He has divided the prosthetists into two-man teams by experience. When a patient comes in, he grabs whatever team is free and assigns them that patient. He has the team do everything for the patient and coaches them as they go along. In most cases, they don’t make a test socket; they go to a polypropylene socket and modify it as they go along.

“It’s been really tough, because it’s not like the training is set-aside [time],” he says. “All of my training has been dictated by the patients coming through the door. If I see an interesting case, I grab everyone and I say, ‘Look, this is what happens when you don’t have total contact in a socket.’ It’s been really challenging, but it’s been great because it’s been rewarding.”

The caseload is another challenge. Cummings has each team work with an individual patient. Then, he says, he heaps all the backlog on himself. For example, on a recent Saturday, he cast four amputees, two of them bilateral, and fit two others. “Since I came back, we’ve seen about 200 patients in six months,” Cummings says.

Finally, it’s tough to get patients to come back for follow-up. Besides the security and travel difficulties—  patients can stand in line for up to an hour just waiting to get through the security checkpoint—patients are also reluctant to ask for any more of Cummings’ time, even when they have a problem.

 “The overall attitude is, when you’re done making [a prosthesis], you send a patient home, good or bad,” he says. “They’re grateful for what they’ve got, and they try to tough it out, so when they do come back to see me, it’s much, much worse than it should have been,” he says. “The patient care could be a whole lot better.”

The future in Iraq
Despite the challenges, the work is needed. While Cummings has heard estimates of everything from 20,000 to 300,000 amputees in Iraq (or roughly 1 percent of the population), he feels that these estimates are all too low.

And the clinic is thriving. When Cummings first got back, the clinic had five prosthetists working there, and it now has eight. With physical therapists and counselors, the total staff comes to 26.

In addition, they just finished construction on a new building outside the Green Zone and will make the transition there right before Cummings’ contract is up in July. Cummings was able to design the layout of the fitting rooms, labs and equipment.

Cummings has appreciated the experience. “I’m not even sure what I’m going to do when I get back to the States yet, and I’m typically a guy who plans things out fairly well in advance,” he says. “My mind is so full of what I’m doing right now.

“It’s given me tremendous experience. I can’t think of anybody who’s had this patient load that I’ve been dealing with,” he says. He’s also appreciated the extra experience he’s gotten with CAD/CAM systems, even talking about using that experience back in the U.S.

Whatever he does in the future, it’s clear that the people of Iraq have many reasons to appreciate the work he’s doing there now.

Rebecca St. Andrie is managing editor of the O&P Almanac.