Necessity is the mother of invention, it is true, but its father is creativity, and knowledge is the midwife."
If anyone is going to figure out how to fit a square peg into a round hole, it's the O&P technician. Self-described common-sense engineers, fabricators have to consider human anatomy as much as the thermodynamics of polyurethane resin. Consumed by standards of precision and aesthetics, those attracted to fabrication strive for optimal performance in the devices they create. Constantly on the lookout for a better plastic or laminate material while streamlining and improving processes to enhance fit and function, these lateral thinkers reach for solutions that often land outside the box.
Consider a hefty battery pack taped to a work order with the directions, "Attach this to the leg somewhere out of the way." The fabrication design team must come up with a creative solution that positions the pack so that it's cosmetically pleasing, accessible, and doesn't impede the patient's gait. In a field famous for having few reference guides that inform "How Things Are Done," creativity has become essential to the technician's survival.
Learning from Failure
In the mid-1980s Tony Wickman, RTPO, owner of Freedom Fabrication, Havana, Florida, engineered a swimming leg that was a spectacular failure from a design standpoint. Wickman's memory of the device is a fond one; his pride in its production mingles with a deep respect for the process, in which he learned just as much from the design's flaws as from its perfections. Wickman built every part of the leg, from concocting the epoxies to manufacturing the hydrodynamic carbon-fiber keel and articulating ankle. As much a flop as it was revolutionary, he says the job "opened my eyes that virtually everything we do is questionable." In his view, the technician needs to evaluate all of the designs currently in use because they "can be improved on, [in addition to] all the materials we use. We have the opportunity to do a lot of improvement [for] expected outcomes. We can [always] do a better job."
The technician's job is not for the purely creative, Wickman notes, because the skilled artisan has to be able to follow a blueprint. There is a specific design objective, "and [the fabricator] has to realize it," he says, "as opposed to an artist who comes in with a block of clay and no oversight." Still, he explains that there is a lot of room for self-expression because once specific procedural parameters have been met, the fabricator must then "breathe life into that design...."
Creative Problem Solving, Precision, and Artistry
Fabrication "isn't cookie-cutter work," explains Brad Mattear, CFo, general manager for O&P1, Waterloo, Iowa. As a result of the O&P profession's emphasis on customization, technicians have to be able to think on their feet. With each job, fabricators must "inflect some of their own creativity [into a job]," he says. While there is a series of steps, such as lamination and trim work, there is still a "huge gray area" where individuality and ingenuity impact outcomes. If a customer requests a certain material for the inner liner of a socket, for example, one of Mattear's technicians might explain that the company has had some problems with that particular material breaking down with high-activity-level patients and make recommendations accordingly. "You have to have foresight," Mattear says. If, on the other hand, a customer of his wanted a VCR attached to an AFO, he says, "We'll find a way to attach that VCR to that AFO," adding, "we'll find the newest VCR that may only weigh a pound. [That's where the] critical thinking [comes in]."
Craig MacKenzie, CP, RTP(c), president of Evolution Industries, Orlando, Florida, describes how his company's technicians use ingenuity to solve design riddles. "Otto Bock has the [Harmony®] e-pulse," he says, an electronic vacuum pump, but "they don't have any recommendations about where you should put it, so it's up to the technician to find the best place that's going to be least invasive." He adds that a radical alignment can pose design challenges such as "a large flexion angle [where] you have to push the plate posterially quite a bit in order to maintain your weight line." Aesthetics in such an instance can be tricky, "and that's when the creativity, or real problem solving, comes in."
MacKenzie says that if a customer wants a foam finish, he'll likely assign the work order to the technician who is most skilled in that particular finish, but the company aspires to make each technician's best skill the standard for all employees. The angles and the height on a job have to be perfect, he says. "The artistry comes...secondary. If you don't get the socket to fit," he explains, "it doesn't matter how beautiful it is.... You have to have that precision first and foremost."
From a quality-assurance standpoint, two fabricators can produce check sockets that are technically correct but differ slightly in appearance, a potential snag for a central-fabrication facility. As a result, central fabs will develop protocols that control for this variability so that sockets carry the stamp of the facility to a greater degree than the individual's imprint. "We train all of our technicians in the same lamination technique, the same pulling plastic technique, the same edge buffing, trim work, everything," MacKenzie says. His aim? Consistency, he says, because central fab customers are looking for it. "After consistency...of course, they want to know that it's consistently good," Mattear adds.
Establishing Benchmark Standards
Mattear says that as the industry trends toward increasing specialization, "new school" practitioners are increasingly tailoring their practices around central-fabrication services. He describes "old-school" practitioners as those who have been in the field for 20-plus years, typically beginning as technicians and then working their way to the "front of the house." Generally speaking, the new breed of clinicians are not as well-versed in fabrication procedures, he says, and with advances continuing on the clinical and (less rapidly) on the technical sides, that gap is only going to continue to widen.
Outsourcing benefits an O&P clinic's business model, he says, because the practitioner's time is freed up to see more patients. "The kids today aren't going to wake up at 4:30 in the morning to get into the lab at 5:30...and start fabricating a half a dozen jobs before they start seeing patients at 8:00," Mattear asserts, "so they use...central fabrication...and that's great...for my business; it's great for their business."
The increasing interdependence between clinicians and central fabrication facilities underscores the necessity for effective and comprehensive communication between the two. "I've gotten work orders on...bar napkins," Mattear says. "I had one work order on the back of a beer coaster. That's somebody's leg," he says, contrasting this style of communication with the "everything and anything" he receives from other practitioners, who provide "measurements, measurements, measurements.... More rather than less."
Mattear says he'd like for these old-school clinicians who are well-versed in fabrication procedures to share their industry trade secrets. "Because of the lack of published research in the field, the profession's archives—its protocols derived from decades of laboratory trial and error—mainly survive inside the heads of the industry's aging thought leaders," he says. Their information continues to be relevant, in part, because technology and materials management haven't kept pace with the brisk advances occurring on the clinical side. So the information possessed by "these guys who know the A to the Z, and the Z back to the A," is dying out, which puts the profession at risk of losing it forever.
The dilemma emphasizes the industry's lack of benchmark standards. MacKenzie says that the absence of a centralized knowledge base has created one of the field's biggest challenges: the training of its technicians. Fabricators at Evolution Industries "have good base skills, and then [we] train them in our way. [But] imagine how many 'our ways' there are," he says. There's a duplication of effort from an industry standpoint, and the inefficiency can only be overcome with greater knowledge sharing. One result would be to liberate time for needed research and development, allowing the field to gain momentum, thereby keeping better pace with advancements currently being made on the clinical end.
"We're putting so much [money, time, and effort] into the clinical side, we're forgetting about the technical side...," Mattear says. "If we can't create the device correctly, then [patient care] is out the window."
Though flawed, the trial-and-error system has been effective. "Why do we do things a certain way?" Wickman asks. "Because they work. Very few people tend to do [an] elemental analysis to make sure their socket wall can withstand [a level of] stress. We just know that...we did it this one way and it broke, and when we did it this other way, it didn't break. So from now on, we're going to do it that way."
Technicians at Evolution Industries fabricate sockets according to their in-house lamination chart parameters. The chart details how many layers of carbon fiber and fiberglass, among other materials, are required for the safety of a patient at a given weight and activity level. "But nobody's ever studied it to say that...maybe that's too much [carbon fiber], maybe we're making it too heavy and we need to cut back...or do something a little different to give [the patient] less weight, but [have the socket still] be strong," MacKenzie says. He notes that the industry won't be seeing a lot of scientific studies on the structural integrity of sockets because manufacturers make their money in components, not sockets. The manufacturers can fall back on international standards for prosthetic components that have been tested at certain activity levels, and if something breaks, the company can gauge when a patient has most likely done something extraordinary at the time of failure. "But you don't see laminated sockets...being subjected to those kinds of tests," he notes.
The lack of a current procedural manual puts a hole in the industry, Mattear says. "I challenge you to find a handbook that's been published in the last 25 years [on fabrication techniques]," he says. The gauntlet is being taken up by the Orthotic & Prosthetic Technological Association (OPTA), whose members, along with other industry professionals, aim to pen a "limited-edition, spiral-bound" textbook that will serve as a base. "We're not…saying this is the only way to do it," Mattear says, but the authors' intention is to provide a historical record that can be updated every two to three years that can serve, for fabricators, as similar texts do for practitioners, providing benchmarks for procedures…."
Ongoing worries about reimbursements, which are affecting the O&P industry as a whole, are putting additional stress on the technician's position as a member of the O&P continuum of care. Depending on how legislation shakes out, Wickman says that while he doesn't necessarily fear it, there's certainly the potential for major change, and his business model would undoubtedly be affected. "If people are self-pay, they are not going to drop $50,000 on a leg," he says.
"Like anything else, usually the winner in this game is technology," Wickman says. "If people can't afford cars, people invent cheaper cars. They don't stop driving. We figure out a way." Finding the solution may well be left up to the fabricators.