February 2007 • Vol. 3, No. 1
	Advancing Orthotic and Prosthetic Care Through Knowledge

Raising the Standard of Patient Care for Iraqi Amputees

Members of the Iraqi security forces who have lost a limb now have an opportunity for faster, better treatment, thanks to a unique U.S. educational mission that spent five months in Baghdad in the first part of 2006. The five-person team, organized jointly by the Pentagon and the U.S. Armed Forces Amputee Patient Care Program, included Joe Miller, MS, CP, who served on the Academy’s Board of Directors before resigning to join the mission. “It was the first time the military put a rehab mission together to serve in another country,” Miller explained. “The war has shed light on what we prosthetists do. But there’s a different feel working in an actual combat area.”

When he left for Iraq, Miller—a first lieutenant in the Medical Services Corp of the Reserves—was working at Walter Reed Army Medical Center (WRAMC) in the Amputee Care Program, which he had helped overhaul so that it offered topnotch care and rehabilitation to wounded soldiers returning from Iraq. In addition to Miller, the military educational team included a physical therapist, occupational therapist, physical therapy aide, and occupational therapy aide.

After arriving in Baghdad in mid-January, the team began treating Iraqi soldiers and police in a clinic that had been started by two American soldiers (a prosthetist and prosthetic technician) and laying the groundwork to expand and improve treatment through intensive education of selected Iraqi prosthetists, PTs, and OTs. The goal of the mission was to help the Iraqis build a self-sufficient prosthetic treatment infrastructure by focusing on four primary areas: education, business practices, workflow, and patient care.

Miller and his colleagues worked closely with two Iraqi prosthetists who had several years of experience as well as previous training in a Fillauer course in Jordan. The Americans taught a four-month course designed to broaden the Iraqis’ technical knowledge and capabilities, enhance their clinical skills, and improve patient outcomes by integrating PT and OT into the rehabilitation process. Mornings were filled with classroom instruction, and afternoons were devoted to treating patients.

To streamline workflow and increase the number of patients served, Miller introduced the 30-30-30 service model, where at any given time, Iraqi prosthetists would be seeing 30 new patients, working on fabricating prostheses for 30 patients, and delivering 30 completed prostheses. “Traditionally, the Iraqis saw a lot of patients, then did castings, then made the prostheses. That meant it could be several months until the first patients received their limbs,” Miller explained. In addition to reducing the fabrication timeline, it was crucial to minimize the number of patient visits, since coming to the clinic required risking their lives to enter the Green Zone.

The U.S. team also provided guidance on ordering supplies more efficiently, shortening the timeline for receiving components, and developing accuracy and accountability systems, as well as meeting the special challenges of working directly in a combat zone. For example, it was critical to arrange a way to get components safely to the clinic in a timely manner—not simply delivered to the airport.

With an eye on the long-term goal of developing a network of prosthetic facilities staffed by highly trained Iraqis, the Americans collaborated with Iraq’s Ministry of Defense and Veteran Affairs agencies. They hosted a three-day, short-term prosthetics course. The Iraqi prosthetists in the four-month training session recruited their colleagues and taught the course, gaining valuable training experience. Miller and the other mission participants provided support and feedback.

Since his return to the United States, Miller helped arrange additional training for the Iraqi prosthetists at a Fillauer course in Sweden. He remains in e-mail contact with them. Actively involved with the Academy during most of his 20-year career in prosthetics, Miller views his work in Iraq as a logical extension of the Academy’s mission to advance the standards of patient care, both domestically and internationally. “It goes hand-in-hand with the educational component,” he noted. “By providing a basic level of training, we can create and sustain programs in other countries based on first-world models versus third-world models.”

Throughout his career, Miller has focused on promoting the field of prosthetics and the highest standards of patient care, both within the military and beyond. In November, he moved from WRAMC to become deputy chief clinical prosthetics officer with the Department of Veterans Affairs (VA). He directly supports Fred Downs, head of the VA’s Prosthetics and Sensory Aids Service (PSAS), which is responsible for providing all prosthetics, orthotics, and sensory aids to disabled veterans across the country. In his new position, Miller plans to continue to build awareness for the need for additional research and high-tech care in both the military and private sectors. As always, he appreciates having the support and expertise of the Academy behind his efforts. “It’s very beneficial to have an organization like the Academy out there to help expand our influence,” he said.