By Judith Philipps Otto

The figures have been frustratingly hard to find. While detailed statistics are kept of U.S. military casualties in the Iraq and Afghanistan war zones, the toll of wounded and killed civilian contractors is not so closely monitored—nor so carefully recorded and publicized.

According to never-before-released statistics recently reported in the New York Times (May 19, 2007), the total number of contractors killed in Iraq is 917, with more than 12,000 wounded in battle or injured on the job. American military death casualties total nearly 3,400. Do the math, and the statistics show that the ratio of contractor to military deaths is greater than 1 to 3.




Joe Williams completes his first day in therapy following his amputation with therapist Sandy Fletchall, OTR/L, CHT, MPA, FAOTA.Joe Williams represents just one of those thousands of cases. Williams left his own Memphis, Tennessee-based trucking company and family life behind in 2003 to sign on with KBR Inc., a global engineering, construction, and service company headquartered in Houston, Texas, which supports U.S. government ventures in Iraq.

Why take on such a high-risk job? As Williams points out, the hazardous-duty compensation was attractive to a man whose family of nine depended on his support. It was also a way to serve his country and make his father proud.

After rising rapidly through the ranks from truck driver to convoy leader, Williams was serving as a civilian contractor commander of 50 drivers leading a 20-truck convoy in northern Iraq when an improvised explosive device (IED) changed his life and future forever.

Civilian drivers operate in the same areas and under the same conditions as military drivers, Williams explains. That amounts to driving primarily at night, with headlights off, at full speed.

"You jump curbs, you hit potholes, and you hope there's no IED there," Williams remembers. "The European-made BMW and Mercedes trucks we used there are built for small people—not for Americans with long legs and big feet, who tip the scales at over 200 pounds. Americans cannot hide in those trucks."

Especially not if you're the commander, whose record-keeping duties require him to leave the interior lights on as he maintains a log and completes reports, Williams adds. "I was talking to the man on the satellite, and I was keying everything in on the computer while we were going down the road at 90 mph. Did you ever run down the road with your lights off, but your cabin lights on and the dome lights on? Those people know you're coming!"

Conditions have improved since his arrival in Iraq in 2003, when a convoy of as many as 100 white civilian trucks was escorted by only three green military trucks with limited armament and orders not to fire unless fired upon, he says. Now, green and white trucks alternate in even numbers along the length of the convoy and are led by a military vehicle carrying a 50-caliber machine gun. Few of the convoy drivers feel completely secure, however.

"It's so easy to get lost over there, even in the daytime, because the roads are poorly marked and drivers must rely on landmarks," he explains.

Parts of the convoy frequently become separated and get lost. It only takes a moment's inattention to miss a turn or take the wrong fork. In such cases, says Williams, the entire convoy has to be stopped, waiting in an exposed position while efforts are made to locate and recover the missing trucks, which are not always found.

As his convoy was heading back to Camp Anaconda (north of Baghdad) late one night in April 2005, Williams, in the lead truck, spotted what appeared to be an old flare alongside the road. Within another two miles, he saw a second flare.

"About the time I got on the radio to report to the commander," says Williams, "that thing went off, and suddenly everything was in slow motion—gunpowder, dust. I could see everything in the truck coming apart and shaking. Couldn't find my glasses, couldn't find my radio microphone. I had to stop the military first. They didn't know what had happened. I was all bloodied up, couldn't see, but I had to find the phone in the dark and tell the commander to stop—that I was injured and needed assistance.
"The next thing I know, they had blocked the roads off and everybody was sitting still. My driver wasn't moving at all. He was in shock. I had to yell at him and make sure he was okay and get him to give me his belt so I could make a tourniquet around my leg to slow down the bleeding while the medic was working his way forward from the middle of the convoy.

"I was whipped away in a Humvee to a field hospital, and the next thing I knew, I was in Germany."

Williams reports that surgery first was done in the field to remove the shrapnel and stabilize him—and again in the German hospital where he stayed for two weeks, preparing him for the 15-hour flight home to the United States in a hospital plane.

His wounded leg was secured with a protective "birdcage" device, which fit over the entire leg, he recalls, and was affixed to the bone with screws. It was designed to stabilize and immobilize the leg during the flight.

When Williams arrived at the Memphis International Airport, an ambulance was waiting to transport him to the Memphis Regional Medical Center Burn Unit, where he was cared for alongside other high-risk patients requiring intensive care.

After a total of 13 operations over the next 17 months, during which Williams' sense of frustration, hopelessness, and helplessness grew, "very little success" had been achieved.

"As a patient, you really have no idea what they do to you during surgery," Williams says. "All you know is that you wake up in the hospital bed. And sometimes you aren't sure you're going to wake up."

On September 6, 2006, due to continuing problems with infection, Williams underwent amputation surgery on his leg.

"If you've never been through that procedure, you don't know what questions to ask," says Williams. "I was in No Man's Land. I didn't know what to ask [or] who could help me at all."

But Williams succeeded in choosing some effective champions for his therapy team. "I had a lot of choices, and after trying about five different places, I wound up at Capabilities for Living. It's the right place that fits me."
Fletchall looked at Williams' traumatic odyssey from a therapist's perspective. "Joe initially came to us with two legs, about four or five months after he was wounded," Fletchall recalls. "Even then, he was pretty deconditioned, and his trunk posturing and tone was very depressed. A surgeon had removed the rectus abdominus—the large stomach muscle—in order to achieve coverage on the leg, which had a huge hole with a missing section of bone."

The stomach muscle was used to cover the leg wound, with a rod inserted as a spacer, which rendered the leg non-weight bearing. Fletchall's early efforts concentrated on strengthening his hips and the remnant of the abdominal muscles, in conjunction with wound care.




Joe Williams concentrates on strengthening his trunk and lower extremities prior to receiving his prosthesis."Joe would call here frequently," Fletchall says, "because he'd get so depressed from sitting in the hospital. We figured out, even without any input from the physician, that his leg was probably going to come off. Periodically, he would mention in conversations, 'I guess they're going to just cut it off.'

"We told Joe that was not necessarily a bad thing and advised him to tell the doctors at which point the cut should be made. We also communicated with the case manager, telling her that Joe had called us to ask about the amputation and letting her know our recommendation if the amputation was done. So we did have some indirect input concerning residual limb length, which was helpful."

Fletchall and Tien Tran, CP, FAAOP noticed that things weren't going well. The rod was eroding his leg. "The next time we saw him was after his amputation, when he had pretty much convinced himself it was the end of the world."

After the usual delays for insurance authorizations and treatment of other health issues, Williams was fitted with a left transfemoral prosthesis with an endoskeletal hydraulic knee, multiaxial foot, and hypobaric suction socket in April 2007—two years after his original injury.

Today things are definitely looking up for Williams, including a February trip to Houston, where he was recognized as one of 20 wounded civilians to be awarded the Defense of Freedom medal, the civilian equivalent of the military's Purple Heart, for his overseas service and sacrifice.

Fletchall and her Capabilities team are pleased with his progress, noting that Williams has moved from resentment and resistance to acceptance and even delighted surprise at the things his prosthesis is enabling him to do as he gains strength, balance, and proficiency. He even shares his newly acquired skills and experience with other amputee clients at the facility.

"He has even talked about returning to work in Iraq although I don't know if that's possible," says Fletchall, gratified by his positive attitude.

"Before I got my prosthesis, I had already learned how to stretch, to walk on crutches, how to stand up and balance on one leg. That's a hard job; you ought to try that," Williams challenges. "Now, with the leg, I'm doing okay. It's something I've got to get used to. If I were younger, it wouldn't be any problem. I don't have a young heart or the energy I used to, but I'm getting around. It's a lot better than being on crutches 24-7!"

Most difficult for Williams now is the continuing adjustment process, as well as the uncertainty concerning his future plans. "When you have this kind of accident, it changes your whole perspective on life. You've got to adjust and try to control your nerves. It does something to you. It takes a long time before you get over that shock. You've got to be a strong person and control your emotions," Williams says. "I want to work so bad but don't know if I can, what I can do, and what they'll let me do. Waiting to get some answers is hard."

Determinations of Williams' level of compensation for his injuries and losses, as well as his prospects for future vocational retraining and employment, will ultimately depend on his condition and capabilities when he reaches a level agreed upon as "maximum improvement." ( See sidebar below "Winning Wounded Civilians Their Due" )

Williams' attorney, Gary B. Pitts of Pitts & Associates in Houston, specializes in Department of Defense civilian contractor casualty cases. He is keeping a close eye on Williams' interests, charting a careful course through the intimidating shoals and reefs of bureaucratic red tape and insurance issues that Williams must still navigate—possibly his greatest challenge yet.

Meanwhile, as Williams says, the waiting is hard.

Note : As of June 19, 2007, according to U.S. Senate Armed Services Committee Hearings transcripts quoting Acting Secretary of the Army Preston Geren, there are approximately 128,000 contractor employees in Iraq, about 30,000 of whom are American.

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.Winning Wounded Civilians Their DueGary Pitts, of Pitts & Associates in Houston, Texas, specializes in U.S. Department of Defense civilian contractor casualty cases. He is currently handling more than 200 such cases, including that of Joe Williams.

The insurance benefits, compensation, and vocational retraining are there to be claimed, Pitts points out, but few people are aware of their availability, the patient's rights under the law, or the process for pursuing them.

"There is a statute of limitations," says Pitts. "Claims should be filed within a year of the person's injury or two years of their illness. If patients never file paperwork for their administrative claim with the Department of Labor, at some point they'll lose all their benefits. Insurance companies don't tell them that."What Patients and Practitioners Need to Know

All civilian contractors supporting troops overseas are covered by a federal workers compensation statute called the Defense Base Act (www.defensebasecomp.com). Pitts pronounces this federal workers compensation law as "very good-probably the best in the world."

By law, any worker who becomes ill or gets hurt overseas is entitled to the following:Reasonable and necessary medical care for the rest of his life, from the doctor of his choice. Weekly compensation (until he reaches maximum medical improvement) at a rate equivalent to two-thirds of his average weekly wage, up to a maximum amount that is adjusted annually. (In March 2005, the maximum was $1,047.16 per week, tax-free.) Compensation for any permanent disability. Free legal representation. If the attorney successfully prosecutes a client's claim and wins benefits for him, the attorney is reimbursed by the insurance company for his time only. (If he fails to win the case, the attorney earns nothing.)

"There's not a crush of lawyers wanting to take these cases," Pitts comments. "They can make more money doing almost anything else. Money is not the most important thing. I just greatly enjoy and am honored to have the opportunity to represent these guys. They need the help because there are about 15 ways that an insurance company can rip them off."Permanent Disability Compensation

Whether an injury is determined to be specific or general can make a huge difference in the amount of compensation awarded.

Congress has assigned compensation values to a complete list of body parts. The values are represented by the number of weeks of compensation received; e.g., the loss of a little finger is worth 15 weeks of compensation time; a thumb is worth 75 weeks, an arm is worth 312; and a leg 288 weeks. This compensation, for a specific injury, would be added to the amount already paid during the course of care for the original injury.

Since a specific injury that affects gait can often impact the torso, creating low back or hip problems, a specific injury can become a general injury, for which compensation is calculated differently.

"There is no set rate for a general injury," explains Pitts. "What we look at is the drop in the person's wage-earning capacity. To arrive at this difference often requires a trial presided over by a federal administrative law judge, who would decide what is the person's present wage-earning capacity."

From there, it's based on the number of weeks in the subject's expected lifespan (based on actuarial tables). If the payout received is a lump sum and the beneficiary is theoretically able to collect interest on that sum for the remaining years he is alive, the payout must be reduced based on interest rates for ten-year U.S. Treasury bonds, which are at about 5 percent currently.

It was a hot August morning in 1991 when Lee Shelby's life changed forever.

Then 28 and a lineman for Memphis Light, Gas and Water Division, Shelby was in a bucket truck that backed up to a pole to allow him to cut a secondary wire going to a house.
He was halfway through the job when his right hand touched a primary conductor and about 12,000 volts of electricity shot through him, burning his hands severely.

"I kept looking down at them, trying to get them to move," he said. "And when I picked my arm up, my wrists were just kinda limp. They wouldn't move."

Shelby spent 23 days in the burn unit at the Regional Medical Center at Memphis. Both hands, wrists and a portion of each forearm were amputated about three inches from his elbow.

He started rehab the day he was released.

"We went to therapy every day, just like work," Shelby said. "I got dropped off in the morning, picked up there in the afternoon."

Independence was important for Shelby, who needed to be able to take care of himself and raise his daughter, LeAnna, now 15, who he's had custody of since his divorce in 1993.

In the nearly two decades since, Shelby has remarried and now has two stepchildren and a 2-year-old grandson.

He has gotten his pilot's license, gone skydiving, received a permit to carry a handgun, and hunted and fished -- all without the use of his hands.

"I can't tell you that I would have the same attitude if it were me," said his wife, Sherri Shelby.

Having the right prostheses has been a big part of his success, said Shelby, who admits not everyone is fortunate enough to receive prostheses that are a good fit.

Shelby has relied on body-powered prostheses which, with practice, have allowed him to go about his daily activities with little difficulty. Unfortunately, the devices require "socks" and a harness that puts pressure on the back over time.

But Memphis prothestist Tien Tran recently fitted Shelby with a set of myoelectric prosthetic arms that he designed.

The new arms, which cost $25,000 apiece, don't require socks or a harness and should make daily activities even easier.

Tran said electric impulses from muscle contractions help operate myoelectric devices.

Shelby has had myoelectric arms before but they were uncomfortable, less powerful and not as functional as Tran's newer design.

With his new arms, Shelby hopes to take on new challenges.

He resigned from MLGW last year to run his own business making inflatable moon-walks, jumpers and slides. He's thinking of writing a book and even toying with the idea of learning to ride a motorcycle.

Wanting to share his successes, Shelby travels the country speaking to other amputees who have lost limbs in electrical accidents.

He just returned from Alabama and plans to speak in North Carolina and Kentucky before the summer ends.

Shelby said his goal is to encourage, motivate and give hope to other amputees.

The 45-year-old is also working on his peer counselor certification from the Amputee Coalition of America.

Shelby said he can do any activity that anyone who has the use of their hands can do.

"I just have to do mine a different way," he said.

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Aug. 2 -- Tien Tran made some last-minute adjustments to a prosthetic arm Friday afternoon and slipped it onto Patrick Held, age 6.

"Good," was Held's judgment of the new arm and hand. Equipped with a touch-pad control and computer chip, he can grasp with the artificial limb and will test it in the first grade this fall.

Moments like these are the best part of Tran's job as a certified prosthetist. "The best part of the job is helping disabled people," said Tran. "That's the biggest reward."

It wasn't his first choice in careers.

In Vietnam, which he left as a political refugee in 1982 for the United States, he had earned a degree in economics and worked as an accountant, Tran said.

In Memphis, he began working as a technician in Prosthetics/Orthotics. He liked the work and decided to go back to college to become a practitioner. After graduation, he spent two years -- one to pass a written test and one for a practical test -- to become a certified prosthetist. The American Board for Certification in Orthotics and Prosthetics provides the certification, which must be renewed every five years, he said.

For a college degree in the field, Memphians must leave town, he said. Universities in Chicago and Dallas are among those offering the degrees.

Prosthetics is the term for artificial limbs that serve functions of missing ones. Orthotics is the term for devices used when a person still has the limb.

Bio-Designs Prosthetics, LLC at 748 Walnut Knoll Lane, Cordova, TN is outfitted with a wide range of technology used to produce the artificial limbs. They range from an anvil to computerized equipment used to help design devices.

It's all custom work. It may be years, Tran said, before he runs into a similar case that requires a  prosthesis like Held's small arm. Each Patient has individual needs and each limb is different from the last.

There are four basic steps: measuring and testing; fitting the socket that fits over a patient's limb; fitting the unfinished device and allowing the patient to test it for a time, and finally delivering the finished product.

Prosthetists work closely with other professionals in the health care field, including orthopedic doctors and physical therapists, Tran said.

Advances in technology are, not surprisingly, being driven by computers, he said.

Teresa Held, Patrick's mother, said her son has been seen by Tran since he was 6 months old. The family travels from Columbia, Tenn., to Memphis for each visit.

Born with no right arm, Patrick’s requirements for an artificial limb will progress with his age.

At age 6, he plays second base in T-ball, plays soccer and has learned how to swim, she said.

It was important that his new prosthesis bend at the elbow and at the shoulder, allowing him to place it on the desk at school and hold his papers in place.

Generally, patients count on health insurance to pay the cost of the prosthesis.