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thedrifter
09-17-06, 08:09 AM
Rebuilding limbs helps rebuild lives

Web Posted: 09/17/2006 12:28 AM CDT

Cindy Tumiel
Express-News Staff Writer

There are easier ways to build a leg.

But for John Fergason, the chief of prosthetics at Brooke Army Medical Center, the old methods still are the best.

"With skin like Damion's, I'd rather do it manually," Fergason says, arranging plaster bandages and water in front of Damion Jacobs, a Marine staff sergeant who lost the lower half of his right leg to an Iraqi insurgent's homemade bomb in February.

The Marine's shin is a patchwork of fragile skin grafts, where surgeons repaired flesh and muscle torn away in the blast.

Fergason is crafting a mold of Jacobs' limb — the first step in constructing a custom-made plastic socket that will cradle what's left of the Marine's leg and make it possible for him to walk on a prosthetic foot.

A nearby digital scanner could make fast work of this chore. With a simple sweep of the hand, Fergason could feed data about Jacobs' leg into a computer that then would guide a saw to carve out a model of the Marine's limb stump.

But that's not Fergason's way. Co-workers tease him for being "old school," and they're right.

Having learned the craft 20 years ago, he's a low-tech guy in a high-tech field whose tools include nothing more complicated than water and plaster, nimble hands and a ready sense of humor. But therein lies the secret of his success.

Considered one of the best in the business, he has earned a reputation not only for his skill with hardware, but also for his ability to motivate patients.

That part comes naturally. Fergason, a father who not so long ago watched his own children take their first steps, relives that feeling of exhilaration every time he watches a patient learn to walk again.

"As a dad with young kids, those first steps are very exciting," he said. "For these (soldiers), they are adults, but I get to be there for their first steps and to see hope on their faces. It never ever gets old to me."

"This is a gift of a profession, to be able to help people at this level."

Fergason, 45, came to BAMC almost two years ago when the military opened a specialized amputee center to take care of the growing number of troops who were losing limbs in Iraq.

Now he's a key component of a 40-person specialized team that listens intently as wounded troops plan for their new lives beyond the war. Doctors, therapists and nurses adopt the amputees' goals as their own.

Jacobs' goal is to get back to duty with his unit in San Diego, though he knows that fewer than a handful of Marines have returned to combat positions after suffering a loss of limb.

Fergason's thin fingers wrap several plastic and cloth liners over Jacobs' lower leg, then he draws blue lines and circles with a marker on the top layer, highlighting where bones are prominent and where grafted skin meets healthy tissue. The blue lines will transfer to the plaster model and mark areas where Fergason wants to shave or add material later for this custom fit.

Then he dunks plaster-coated bandages into water and wraps the fabric carefully around and around the limb, smoothing and studying his work as he goes, like an artist with a mental vision of a finished piece.

Jacobs' wife, Shannon, sits nearby and jokes with her husband about the new insights he is gaining into the struggles of women with their pantyhose.

They laugh.

Jacobs, 30, is a classic Marine, solidly built with close-cropped hair, square jaw and a matter-of-fact demeanor. The Ohio native went to a military school in junior high and decided then that he wanted to be a Marine. He signed up at age 17 and has relished the life of discipline, work ethic and public service.

With typical Marine grit, he says he has come to terms with the limb loss he has suffered. His rehab was slowed by troubling infections that kept him hospitalized for more than a month.

"Damion wants to stay in the Marines, and that is a high goal for him and will be a big motivation for him in therapy," Fergason said. "If that is what he wants, then I want to help him get there."

The goals of wounded troops follow Fergason home some days and linger as he has dinner with his wife and three small children. They bring him out on nights and weekends when wounded warriors test their new limbs in athletic events. The patients who are struggling, especially, are never far from his mind.

"I do take this job home with me," Fergason said. "I think, 'It is up to me to get this guy up or he's not going to walk.' That is a lot of pressure."

The art of the socket
Prosthetic legs these days are sleek and strong and crammed with cutting-edge technology that makes them more life-like than ever.

The newest models feature microprocessors that hum as they make a thousand calculations per second to analyze the wearer's gait and adjust to the terrain underfoot. Electronic signals transmit data across a room to a therapist who watches the leg on a laptop computer screen.

Even the more basic mechanical ankles have shock and torque absorbers and flex almost like the real thing, making it possible for wounded troops to dance, run, water ski or hike in the hills. Depending on athletic interests and needs, an amputee may leave BAMC with two or three of them, costing anywhere from $12,000 to $30,000 apiece.

But all this technology ends up sitting in the GI's closet at home if he or she can't get comfortable on top of the artificial limb.

That is the prosthetist's job — meshing sophisticated engineering with human anatomy. It comes together in a vase-shaped piece of hard plastic called a socket, which cradles the amputee's stump on top of the artificial limb.

Like shoe cobblers, the therapists craft each one individually for limbs that have been sheared by burns, shrapnel or explosions. It is a low-tech, laborious process, and it is Fergason's passion.

"The socket has the least amount of science to it. But for us, that is the artistry of it," he said. "The prosthesis is only as good as (the patient's) ability to stand on it."

A patient might go through five or six of them in the first year, as the remnants of a limb atrophy after amputation surgery. Severed bones have a natural inclination to grow, causing spurs that change the way a socket fits.

"The fact that it is dynamic is what makes it so challenging," Fergason said.

The nerve center of the prosthetics lab is a long open room, a cross between an industrial shop and a crafting center. A long, wooden worktable fills the center of the room and is littered with the tools of the trade: propane torches, heavy clamps, bags of plaster, carving tools, drills, specialized shoes and prosthetic limbs.

Four tall red mechanic's tool chests stand against the walls. Two industrial sewing machines occupy corners of the room.

Fergason and his staff of five always are moving about the room. Some troops have appointments, but others drop in casually when they need an adjustment. They sit in swivel chairs or wheelchairs and tell jokes and stories while they wait their turn.

Some 70 amputees have come through here since BAMC opened its dedicated amputee center in early 2005. Surgical scars still are fresh and skin grafts raw as they roll in wheelchairs for their first fittings. Months later, they leave walking. Or running. Or climbing.

"He has done amazing stuff here," said Army retiree Chad Johnson, 23, one of the first amputees to go through rehabilitation at the BAMC center. "People that were told they would never be able to walk on a prosthesis, he gets them walking."

But this recovery never is a simple, straight road. Hand and arm amputations are tough — the technology to replace fingers and wrists hasn't advanced at the same pace as that for artificial feet and knees. Patients with leg amputations often struggle with unexplained pain that vexes doctors and therapists.

"I have one guy that I am working with now; I am just having a tough, tough time getting him comfortable," Fergason said. "I want to spend a lot of time with these cases. It is just very difficult for me to deal with when I feel it is the prosthesis that is limiting their ability to move forward."

Gift of a profession
Fergason drove ambulances when he was in college and really wanted to become a physical therapist, feeling drawn to a profession that would allow him to help people regain mobility and independence. One sub-par grade kept him out of an undergraduate program, though, so he took an internship in prosthetics while at Fresno State University and later enrolled in a post-graduate training program in that specialty.

Prosthetics is dirty work — he went home each day coated in plaster and foam dust, and thought seriously about switching careers.

"But then I fell in love with it. I began to realize I had this ability to use tools and create things that could really help people," Fergason said. "The biggest motivator for me as a clinician is the drastic effect you can have on someone's life in a relatively short amount of time. Someone can come to me in a wheelchair and they leave me walking."

Fergason came to BAMC from the University of Washington Medical Center in Seattle, considered the birthplace of modern prosthetics and a hub of research and development. During his eight years there, he directed one of the country's few undergraduate degree programs in prosthetics and built a solid reputation as an excellent technician and compassionate clinician.

When the military started talking about opening an amputee center at BAMC, Fergason heard about it and called about the job.

"They will tell you I was recruited, but the truth is I called them here," he said. "I asked, 'What are you doing there and can I be a part of it?'"

Col. James Ficke, BAMC's chief of orthopedics, said Fergason had the passion and the vision that the military needed for this new program.

"John said, 'I like to build things, and I mean more than just legs,'" Ficke said. "What he was looking for was a chance to serve. I think he was called to this."

The military has pledged to give its amputees full access to the newest technology available, empowering therapists to do their utmost for every patient.

Fergason's move to San Antonio also brought his wife, Karen, back to her hometown.

Their three children, ages 4, 6 and 8, join their dad for lunch at the hospital occasionally and come into his lab to meet the troops, learning about war and sacrifice with child-like openness and simplicity.

"They do understand that war is a difficult thing, soldiers protect our country and some of them get hurt doing it, and dad helps them get well again," Fergason said. "They see a soldier with an artificial leg and they'll ask, 'Dad, did you make that one?'"

Fergason's parenting skills are obvious in the way he treats patients.

One humid summer morning, the mission to rehabilitate wounded warriors had him and seven other therapists in their jogging shorts outside the AT&T Center, where eight amputees in various stages of recovery were about to test their progress in a 3-mile run to raise money for charity.

Fergason looked into the quiet face of a 22-year-old Marine named Bacillio Santellana.

Santellana, with an artificial leg, was stretching his hamstring muscles before running.

"Are you OK? Are you nervous?" Fergason asked.

Three months earlier, the Judson High School graduate had lost a long and painful battle to keep his right foot after it had been mangled by an Iraqi insurgent's homemade bomb in October 2004.

Now, under Fergason's watchful eye, he tried running.

Fergason, a runner himself, broke into an easy jog beside the Marine for about 20 yards, then turned and backpedaled as Santellana ran toward him.

"Let me turn you out just a touch," Fergason said, priming the palm-sized hex socket wrench he carried in his pocket. He squatted and twisted the tip into a socket, crunching until he got the precise tension on the carbon fiber arc that flexed like a spring between Santellana's knee and the ground.

Then the race started and Santellana was the first with a prosthetic leg to finish, crossing the line with a smile and hugging his happy wife.

Back on his feet
In the quiet of the carpeted physical therapy wing, Jacobs' legs turn rhythmically on the pedals of a low-impact stationary bicycle, where amputees build endurance without putting pressure on their still-healing limbs.

This is where the real work takes place, Fergason tells visitors.

Patients will spend months here with physical therapists, taking daily sessions of four to six hours as they learn to balance, walk and run all over again.

They have to tolerate pain and build calluses where tender skin meets the hard plastic socket. All without inflicting new injuries that could lead to infections and further amputations.

Jacobs doesn't get emotional discussing his injury.

"I know exactly why it happened to me," he said, shaking his head and smiling. "I guess my curiosity got the best of me."

It happened last February when he got out of his patrol vehicle to check on a suspected roadside bomb. He got a little too close. It exploded.

"I literally walked right up on it. It was a small ambush," Jacobs said. "I remember a white flash, and the next thing I remember was (the medics) loading me into the Humvee" ambulance.

The blast peppered the front of his leg with shrapnel and burned away muscle and skin. After stops at a field hospital in Iraq and at Landstuhl Regional Medical Center in Germany, Jacobs was transferred to BAMC, where surgeons amputated his lower right leg in March.

Surgeons tried to preserve as much of his leg as they could, which required using skin grafts across the bottom half of his shin.

But grafts don't have the sensation or elasticity of real skin and are easily injured. That's a constant concern for the therapists who have to make sure the hard socket doesn't lead to an infection in the bone. That could force further amputations.

Rehab has been full of starts and stops for Jacobs. Several times he has had to stop using the artificial leg for a few days to give injured skin a chance to heal. Doctors have warned him about the prospects of more surgery, but also hope Fergason's skills can figure out ways to avoid it.

"They say if we can't get John's magic to do wonders on the leg, the worst case scenario is more surgery," Jacobs said. "We are going to do everything with the prosthetic that can be done."

He and Shannon have rented an apartment in San Antonio and expect to be here six months or more while he learns to use his leg and rebuild the stamina he will need to fulfill his goal of returning to military duty.

The Marine Corps does have a program that allows Marines with war-related injuries to qualify for non-combat duty that accommodates their disabilities.

Getting back to full duty will be harder. Doctors will have to determine that Jacobs is medically sound enough to be deployed to a hostile war zone anywhere in the world, said Lt. Col. John Shaffer, deputy director of the Marine for Life program.

Shaffer knows of two Marines with amputations who have returned to duty in Iraq and a few others who've taken limited duty jobs. Many injured Iraq veterans, though, decide to leave the military by the time their rehab is complete, he said.

Jacobs has been through three socket fittings already and makes regular trips to the prosthetics lab, where Fergason sets an upbeat tone that helps his patients cope, Jacobs said.

"He keeps everybody in a good mindset," Jacobs said. "That keeps a positive mental attitude going, just knowing about the advances they have and the knowledge that the staff holds."

Of Jacobs and all the others, Fergason said, "They never cease to amaze me."
ctumiel@express-news.net

Ellie