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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.

Joe Williams and Tien Tran, CP, FAAOP, on his first day of fitting and prosthetic training.

"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."

Together with her husband, Hector Torres, Sandra Fletchall, FAOTA, OTR/L, CHT, MPA, owns and operates Capabilities for Living LLC, a clinic specializing in catastrophic injuries, which is located in Lakeland, Tennessee, near Memphis.

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 her team 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.