Diary of a Mission: Project Hope Belize-Part Two

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This July the summer prosthetic mission trip to Belize, Central America, marked the ten-year anniversary of Sonrie Inc. and Project Hope Belize providing prostheses in Belize. The following is the second half of a diary of the mission trip by Rob Kistenberg, recounting the ten-day experience. The first half of the diary appeared in the October, 2006, issue of  The O&P EDGE.

Day 6: Tuesday, July 18, 2006 1:00 PM

I didn't have a chance to journal this morning as we had patients scheduled and a cast to modify. We are breaking for lunch now, although we have a 1:00 PM appointment. Time in Belize is a little looser than in the US. We often make appointments for the morning or the afternoon because if we make an appointment for a specific time, buses, flooding, power outages, and government turmoil occasionally take precedence over punctuality. Belizeans are understanding of this phenomenon. Schedule-driven practitioners from the States usually take a few days to adapt. It makes for some patient backup, but they don't seem to mind. They enjoy the company of others and the waiting area is always filled with laughter, family, a few kids, and conversation.

Barry on a plaster test socket
Barry on a plaster test socket

So far this morning we delivered Farrid's leg and did Barry's plaster diagnostic socket fitting. Farrid presented a bit swollen as he had not properly donned his shrinker and had been sitting in the car with his leg bent for the hour and a half ride from Belize City to Orange Walk. We began by reapplying the shrinker, wrapping with an ace bandage and propping his leg up for 30 minutes.

The edema reduction worked, and we were able to don the leg with a one-ply sock. It was an endoskeletal prosthesis with a Pelite liner, Plastazote® distal end pad, and supracondylar suspension. He walked around with a walker for about 45 minutes on and off as he learned how to properly don the leg and take it off. His daughter was with him so she helped to cue him. She also brought us lunch, which is why I have the time to write now instead of going out to the restaurant. Lunch was from the Hong Kong, of course.

Barry's socket fit fairly well, so we are going to proceed with the next step of socket fabrication and try to figure a method to do a static/dynamic alignment. The plan is to go with an endo system for the static alignment and then transfer to an exoskeletal ankle block harvested from one of the legs we have and use that. He will come back tomorrow for a static socket fitting.

Yesterday, Don knocked out two more socket laminations and then proceeded to put a "beauty coat" on Juan Carlos' leg. I walked into the modification room where Don was cutting the socket off the cast and shaking his head. The second lamination didn't work either. We had to refabricate it, which means a significant loss of time and materials, but it was what we had to do. By the end of the day, however, he had it re-laminated as well as two additional sockets for good measure. Pfau is a machine.

The first delivered leg of the mission was to Deodato, the architect, yesterday. When he had the amputation, he was not able to work and he needs the leg to get back to work. It was an endoskeletal transtibial prosthesis with a gel liner and cuff strap suspension. He had been wearing the liner as instructed since Friday and his leg had reduced some. The socket fit well with a three-ply and he was very happy. He came with three of his friends who, together with Deodato, constitute the Belizean national domino championship team three years running. He had been depressed since his amputation, but once he was up and walking with the leg, it was smiles all around.

Francis returned for a socket fitting. His leg is so long that we aren't able to utilize standard endoskeletal components. In order to get the height correct and be certain the socket fit, it was necessary to have him come back in. He was able to don the socket and liner, and we obtained the needed alignment information.

Prosthetics in Belize is very different than in the US. We have a limited number of days to make the limbs without the benefit of thermoplastic diagnostic sockets, and the patients often come from a long way at great personal expense, along with many of their extended family members, but may only be able to afford coming for two appointments. We take the impressions, modify the models conservatively, and hope that the socket fits—or at least fits well enough that it can be modified or padded—to make a deliverable device. In most cases, we are able to deliver the legs. The worst-case scenario, which has rarely happened, is that someone has to wait until the next mission.

Adrian working on Juan Carlos' socket.
Adrian working on Juan Carlos' socket.

In the afternoon we finished fabrication and assembly of the legs for today and modified the remaining casts. I also went through our boxes of knees to sort them by really good knees, usable knees, and knees that may be used for parts. This is the first time I went through our entire stock, and it is reassuring to know that we have a good supply of components, thanks to the generosity of so many practitioners and patients too numerous to list.

We are on track for delivery of eight legs (three transfemoral and five transtibial), if all fits well and we can navigate through the challenges of Juan Carlos and Barry. I am hoping we can make it ten legs as it seems appropriate for our ten-year anniversary trip. Juan Carlos' appointment was an hour ago, and he has not made it in yet. We also have two more patients that were scheduled for this week who we have not heard from.

Tuesday, July 18, 2006 9:15 PM

This was the first day that we did not get any rain all day, which made it a very hot and sticky experience. A little note about the rain in Belize: when it starts, go out in it. The rain offers immediate relief from the heat and being damp from the rain feels better than being damp from sweat. The showers come and go quickly so if you think you will go out "in a few minutes," you'll be too late.

Juan Carlos is all smiles on his new leg, his second one in 22 years.
Juan Carlos is all smiles on his new leg, his second one in 22 years.

Juan Carlos arrived and we proceeded with fitting. The socket fit well and we installed a Silesian belt. He said it was comfortable and he was able to walk on it well. He has a much abducted gait so we worked on that for a while. We also reviewed the leg, its components, and suspension. After a few hours of sitting, walking, and standing, he was happy, and departed. He plans to go home tomorrow morning. I let him know we would be here until Sunday if he had any immediate problems. I encouraged him to try the leg as much as comfortable and to come back if he even thought there was something going on.

Francis returned for delivery of his leg as well. It fit with a one-ply sock and the supracondylar suspension held nicely. He was able to stand and walk almost instantly. After a while he noted a pulling sensation on his distal end. We evaluated for distal contact and installed a distal end pad which helped but did not alleviate the problem. Upon further examination of his residual limb, we noted that the adhered skin just proximal to his distal end was the source of the discomfort. He was encouraged to massage the leg and go easy on the prosthesis while he is just starting with it.

We broke for dinner at 7:30 PM at the Hong Kong.

Day 7: Wednesday, July 19, 2006

Breakfast was at Marvia's. I was in the mood for pancakes, and it was on their menu. Unfortunately, one was not cooked and it spread batter upon the rest of them. I went with the eggs, beans, and cheese.

When we arrived at the clinic, Brijido was already there (with only four family members this time) as was Juan Carlos. This was a bit of a surprise. He wore the leg for seven hours yesterday and had an irritated area. The proximal edge of the medial brim was rubbing on his sound side thigh, which is not surprising. After a small adjustment, he put the leg on and noted immediate relief. He tried it for a while and then left satisfied with his new leg. It was also inspiring for Brijido to see Juan Carlos walk.

On to Brijido. After explaining to him what was about to happen, we fit his socket which, thankfully, fit well with a three-ply sock. We installed his Silesian belt and he was able to walk in a walker, then with two crutches, and finally with one crutch quite well. Of course he and his family were ecstatic. He walked 10-15 minute blocks of time and then rested. We reviewed the necessary information, and he practiced donning and doffing the leg. He did it all very well and also departed happy. Manville arrived when Brijido was leaving, continuing the experience of one transfemoral amputee showing the other how to walk.

Adrian's wife Claudia made a lunch for us this day of poached fish, rice, potatoes, and vegetables. It was the best meal we had in Belize yet.

Brijido testing the fit of his new socket.
Brijido testing the fit of his new socket.

Bellies full, we proceed with static alignment on Barry. It went surprisingly well. The suspension sleeve held the socket on; he is strong enough to stand and hop and was able to give us enough information to proceed with fabrication. This will be an exoskeletal leg, so we will have no room for adjustments.

Next was Manville's fitting and delivery. Before we even began, his first question was "how long do you think it will take for me to walk without a crutch?" When my answer of "perhaps three or four months or you may always use a crutch or a cane" was met with shock, I knew we had to work on his expectations before working on the socket.

He admitted that in his mind he was still 40 years old and getting his prosthesis was going to be getting his life back again. He planned to ride a bike, mow the yard, hit a baseball, and most importantly, get back to work welding. I tried to gently remind him that he was 66 and had diabetes. I suggested that perhaps he could do welding work at a bench, but he quickly described the work that he would be doing involved climbing under and on top of large trucks. It seemed that no amount of words would convince Manville that the power of his positive thinking, while remarkable, could not overcome the reality of his current physical condition, so it was on to the fitting.

The socket was donned with a five-ply sock. The belt was not installed yet because we needed to assess the socket fit. He had some difficulty standing and finding his balance. Once initial socket comfort was confirmed, a TES belt was installed. After some brief balance and gait training, he was off to the races. After four to five passes in the room with the rolling walker, he refused to acknowledge his fatigue and wanted to continue on even though he was starting to sweat. We encouraged him to sit down and take a break while we worked on the leg. We were able to go through one more round of fittings before he was too tired to continue, although he wanted to. His courage and will were boundless, his body, alas, was broken.

We delivered the leg but he understandably chose not to wear it for the long ride home. We covered the necessary education for him and his family. We provided him with bus fare to return on Saturday if he needed to. The bus stop was a block down from the clinic. Manville and his family went out to wait for the bus.

We went down to the hardware store to pick up a few needed supplies. An hour and three buses later, the Manville crew was still waiting to be picked up. All the buses which had passed were already full.

Homer's residual limb.
Homer's residual limb.

The last patient of the day, Homer, was one that we were expecting on Sunday but he could not make the trip until today. He lost his leg secondary to an accidental gunshot wound while he was serving as a shooting instructor for the Belize Defense Forces in 1991. He received his first leg in San Antonio, Texas, in 1992 and his second and current leg in Merida, Mexico, in 1998. The socket is effectively destroyed and has been reinforced by duct tape, wire, string, and anything else he could find to keep it together. The brim is split in three places.

He is currently working driving a taxi but wants to get back to the military work for which he was trained. He hopes that when he gets a new leg, he will be able to go back and show them what he still can do.

He was cast and evaluated. His limb is very strong and much scarred with the signature adductor roll found in transfemoral amputations that are pushed into sockets that are too small for them. His impression was filled so I could modify it first thing in the morning and make the diagnostic socket. He will return tomorrow to see how it fits.

We also have the other missing patient scheduled to come in tomorrow as well. That will make ten if all get delivered. Ten years, ten legs on a nine-day mission. Perhaps we should stay for an extra day.

Dinner was back at Mr. Lee's as it was 9:00 PM when we left the clinic and nothing else was open.

Day 8: Thursday, July 20, 5:30 PM

Barry's new leg.
Barry's new leg.

Today breakfast was at Juanita's: eggs, beans, rice, and homemade flour tortillas with fresh lime juice. We arrived at the clinic just before 8:00 AM. It was on to socket modification and fabrication for Homer while Don finished out Barry's leg. It is a bit heavy, but so is Barry. I completed Homer's test socket as Barry arrived.

The delivery again went well. He was able to walk on it with the walker and the suspension sleeve stayed up. The foot was bonded to the ankle block and the foot bolt was loctited. The alignment was acceptable but a bit dorsiflexed. This was done with intention, as I hope it will prolong the life of the foot keel and foot bolt. He was very happy to have a leg again. We were all a bit surprised with how well he did.

We went back to the Come-n-Dine for lunch which was really good. Fifteen US dollars bought us all rice and beans, fish or chicken, a salad, and a beverage. This has become our favorite spot. Homer was not yet at the clinic when we came back at 1:00 PM so Adrian drove us to the flooded areas of Orange Walk Town. The river has crested over its banks and now fills the yards of many of the houses close by. With the river come the snakes and crocodiles. It was an amazing site to behold. We also saw a crocodile by what used to be the bank of the river. Then, back to the clinic where Homer had just arrived.

Homer's diagnostic socket fitting showed where I had not left enough room in the anterior brim to include his anterior roll. He was able to stand on the socket once pulled in and offer some guidance on modification of the proximal medial brim. After completing the brim modifications, he stood again and was comfortable. He was able to hold the leg on and only a small gap was on the distal end by one of the window cutouts.

Then the distal socket attachment separated from the distal socket. But that was okay, as we had gotten the information from the socket we needed. [Note to self: Add a lot of plaster on the distal end of all future diagnostic plaster sockets.]

I completed the necessary modifications to the positive model and gave it to Don to work his magic. We have only one of the familiar US suction valves but a bag full of imported valves. Unfortunately, we don't have any of the dummies that go with them. We have taken the gamble that we can fabricate an effective dummy for the lamination and make it seal rather than go with the one green dot valve from the US with the rationale that we will have no shortage of spare parts if something goes awry.

We will have Homer come back on Saturday around 10:00 AM, leaving tomorrow open for us to have an adventure day. We always try to have an adventure day each mission, but at times the need to make limbs for people becomes more pressing. We have not yet decided what we will do, but the plan is to head to the south of the country to the mountains. I have never been south of the capital, Belmopan.

The last patient who was going to come in today could not make it because her village is flooded and none of the buses could get to it. She will have to be rescheduled for November.

Day 9: Friday, July 21, 8:30 PM

After a relaxing breakfast at the open air food court (love those fish empanadas!), it was off to the "mountains." We headed south out of town on the Belize City-Corozal highway in a light rain. The rain added a slight concern to the flooding. There was one point where the river was only a foot below the highway. Many houses were flooded. It has been rising since we arrived as the rain from the higher elevation southern part of Belize flows through Orange Walk on its way to the ocean. If the water reaches the highway, it will all be shut down. So much for flying home tomorrow, Don.

Almost to the main airport in Ladyville, we turned right on the Western Highway. The first place we came to is Hattieville, complete with the country's prison. The high barbed wire double fence and watchtowers certainly portrayed a prison. The gift shop seemed a bit out of place. From there we could see the green mountains in the distance. We passed the Belize Zoo but opted not to go. Our destination was the ocean and Dangriega. Once we hit the outskirts of Belmopan, the capital, we turned onto the 56-mile Hummingbird Highway.

This was truly the most beautiful stretch we hit. The terrain consists of limestone hills amidst broadleaf jungle forest with breathtaking views opening around each bend. Farming is done on the hillside, so tall rows of corn are meticulously spaced, creating lines that further emphasize the ebb and flow of the hills. Harvesting must truly be a trial. Rivers run throughout the region, so waterfalls appear off to each side on occasion.

We stopped at the Blue Hole National Park which was for the most part unoccupied except for a few park workers and the children selling bags of plantain chips for two bits. (Fresh and tasty!) We decided to hike in (roll in, in Adrian's case) to see what it was all about. The path was loose gravel, the only thing harder to skateboard on than sand, so it made the trip a true workout for Adrian. Because of all the rain, the Blue Hole was a muddy brown and even it was flooded up over the bottom dozen or so steps. So much for a refreshing swim. We didn't stay long as the mosquitoes in the jungle were thick and swarming with the scent of imported warm blood.

Back on the road we passed through the scenic Stann Creek Valley. Here is a picturesque valley that is loaded with citrus fields as far as one can see. We reached Dangriega and the coast by lunchtime. We found a very good Indian restaurant, dined heartily, and encouraged the owner to open one in Orange Walk.

The ride home was uneventful, peaceful, and smooth. It could be said that we spent the day driving four hours south to have lunch at the coast and then came back. After a long week of full-throttle prosthetics, this leisure trip was just what we needed.

Day 10: Saturday, July 22, 2006 9:30 PM

Don Pfau caught an early taxi to the airport with our long-time taxi friend Fox, as he had to depart today. I don't leave until tomorrow.

Delivery day for Homer. No matter how many limbs I make, I will never lose the knot in my gut that emerges at the moment of first socket fittings. First socket fittings are an excited nervousness—the accumulation of measurement and palpation and casting and modifications and intuition and experience and fabrication and prayers. It doesn't matter where in the world you practice. So much is riding on the outcome.

Manville with his new leg.
Manville with his new leg.

For new wearers, it will be the first time they have ever put what remains of their amputated limb in the plastic receptacle that is intended to bear their weight, transfer forces to components below, transmit forces from the lower components to their remnant limb, and be endurable through all the activities in which they desire to engage. Donning a socket for the first time after an amputation truly is the first taste of their new reality. As prosthetists, we are beholden to assure that this first taste had best not be a bitter one.

For experienced wearers, it is a time of optimism for a measure of improvement over previous designs or a longing for a duplication of the socket that "fit just right" but simply wore out. I've heard it said that the hardest socket a prosthetist will ever have to fit on an individual with an amputation is not their first socket, but their second one. I believe it.

For the prosthetist, the ability to make and fit a prosthetic socket is defining. It is when the rubber (and plastic, foams, carbon fiber, etc.) hits the road. You may be the most affable limb maker in the country but if you can't produce a well-fitting socket, you won't be around long. And the individuals with amputations who have entrusted you with their prosthetic care will move on to seek a prosthetist who can make their sockets "fit."

When we arrived at the clinic at 8:30 AM, we found not one but two individuals with transfemoral amputations waiting for us. Homer was too excited to stay at home. Manville had returned with his eldest son. He had been using the leg and had some suggestions to make it "right."

So while Adrian was breaking the plaster out of Homer's socket and trimming it down, I proceeded to see what we could do for Manville. His only request was to shorten the leg ½-in. In the limited amount of time we had to perform static and dynamic alignment on Manville, we were able to level his pelvis. He however had too much difficulty getting the prosthesis to swing through at full length even though he had put almost six hours of wearing time into it yesterday. After the prosthesis was lowered, he was much more able to steadily swing the leg through and get it properly positioned. He practiced with it for almost an hour with rest breaks and coaching from Homer. Manville left very happy.

Of all the patients we made legs for this mission, his was the only one that had given us cause for concern. He was so exhausted from such a short amount of walking and wearing that we wondered if he might not have been safer in the wheelchair. But this morning, he was well rested, strong, and confident. Any concerns we had about his ability to use and benefit from this leg were gone.

Homer's socket.
Homer's socket.

On to Homer's leg. The first potentially catastrophic obstacle was the valve. After the plaster was removed from the socket, we epoxied the valve in place. We as a rule have not been fitting suction sockets in Belize due to the need for residual limb volume consistency and the fact that we are only in town for a week at a time. In Homer's case, he is a past successful suction wearer and hated wearing belts. So, suction suspension is indicated.

Fortunately, the valve passed the water test (fill the socket up with water and see if it leaks) and we were good to go forward with fitting. He put on the socket and it held suction and he thought it felt great (hooray!). After walking on it for a while, however, it became a little bit tight on the brim (uh-oh). The socket was fabricated using a thick layer of Dacron® felt on the brim in order to allow for grinding adjustments, so grinding adjustments we did. Over the period of two hours, we were able to get the brim contoured to Homer's satisfaction. Everything was torqued and loctited down and Homer took the leg with a spare foot home with him.

Homer with his new leg.
Homer with his new leg.

He actually wore his old leg home and carried the new one in a bag because he said that the old one was too heavy to carry.

So, another mission has ended and it was only 3:00 PM. Adrian and I tidied up a bit and gathered whatever I needed to take back with me. We decided to go out for a drive and survey the flooding.

Because Orange Walk Town was built by the New River, it reaps the rewards and pays the price for being so close.

Over the radio this morning there were pleas from the owners of these houses to come and get them and to offer refuge.

This (photo below right) is a standard cinder-block style house for this area; however, there are many still built from thatch. This one only has about an inch of safety before the water starts filling the house.

Many houses near the river are built on stilts in order to provide shade during the hot summer days and elevation during the occasional floods.

Adrian said that the town has not been this badly flooded in almost ten years since Hurricane Mitch in 1998. What is most concerning about this flooding is that it is not hurricane-related. This has strictly been from the continuous rains that have been going on for the past months. The ground throughout the country is already so saturated that many areas are flooding, just in time for hurricane season.

Day 11: Sunday, July 23, on the plane home

Another mission done. It is always bittersweet leaving Belize. The work was hard and fulfilling. Many now have limbs where last week they did not. We had the opportunity to offer the special gifts we have been given so that others may have the ability and independence to do as they want. Or at least not be limited by their circumstance.

It is always a joy to be back with my family and in the comforts of our home, yet there is always a murky transition period going from the clinic and life in Belize to the States, to the air conditioning, to the billboard-strewn landscapes, to working "at the office."

The pace of life is much more tempered in Belize. While we work feverishly, it is not stressful. Perhaps it is the absence of insurance companies, paperwork, and financial transactions associated with the provision of care.

Mostly, it is the act of giving and receiving that feeds my soul and brings me back to Belize year after year. We make limbs and give them to people who need them. For this we receive their heartfelt gratitude. For this we receive the opportunity to help others for no greater reason than: we can; and furthermore, we should.

Robert "Rob" Kistenberg, MPH, CP, FAAOP, is the prosthetics coordinator at the Georgia Tech Master of Science Program in Prosthetics and Orthotics. He is also a clinical coordinator for LIVINGSKIN by Aesthetic Concerns Prosthetics. In addition to teaching and clinical work, he does mission prosthetics in Belize and is serving as chair for the US Member Society of ISPO. Last year he completed his masters degree in Public Health with a focus on program evaluation and international health.

Sonrie & Project Hope Belize conducts missions to Belize two to three times per year and is always interested in volunteers. For more information, visit the website at: www.sonrieministries.org or contact Rob Kistenberg directly at: robcp@oandp.com

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