The Bionic Warrior
Prosthetic technology is catching up to human willpower
This article originally appeared at Motherboard.
It was Aug. 15, 2012, when Jeremy Maddamma left Afghanistan on a stretcher. Maddamma, a U.S. Air Force pararescueman, was on a mission to rescue Afghan civilians after multiple suicide bombers hit Zaranj, a city on the Iranian border. He remembers the gunshot puncturing his left knee and falling to the ground. He remembers begging for pain meds during the flight back to Camp Bastion, getting them and feeling no difference.
“How much longer?” Jeremy asked a teammate, knowing it was an hour flight.
“Twenty minutes,” he was told.
He remembers waking up after surgery and being told he was going to lose his leg. He remembers calling his wife, Nicole, and telling her the ski season was off.
Jeremy would spend the next two-and-a-half years trying to save his left leg before choosing to amputate it above the knee. He would place his faith in an ability to fuse his will to cutting-edge prosthetic technology ranging from high-grade composite form factors — think Oscar Pistorius — to microprocessor-enabled joint function à la Steve Austin, the Six Million Dollar Man. He would do so with the hope to one day return to duty as one of the first amputee Air Force pararescuemen.
Jeremy was a 24-year-old staff sergeant when we met in 2006 as students in the two-year Air Force combat rescue officer (CRO) and pararescue (PJ) training pipeline. More than 80 percent of our peers had quit or been eliminated by the time we hit the final seven-month course on the same team. Jeremy was a charismatic enlisted leader who grinned when he echoed commands with a muttered, “Kill.”
Together we sucked mud, got smoked, jumped out of C-130 turboprop transport planes and rigged high angle rescue systems. All to earn the maroon berets that would enable us to call ourselves PJs and CROs and grant us the opportunity to save lives in the worst combat situations.
In 2012, Jeremy and I deployed from our home unit, the Alaska Air National Guard’s 212th Rescue Squadron, to Bastion airbase in Helmand Province, Afghanistan. Jeremy had been promoted to technical sergeant, and led PJ teams on rescue missions; on one such mission, he parachuted at midnight into a snowstorm to save the life of a critically injured Alaskan in a remote location called Red Devil. He had Nicole, three kids and a promising career in an exciting line of work.
Within 96 hours of being injured in Afghanistan, Jeremy was in the intensive care unit of the San Antonio Military Medical Center, three surgeries down. An Erector Set-like brace called an “external fixator” was drilled into a dozen bone locations that prevented any movement of his injured leg. Two slits were carved into the flesh beneath the knee to relieve pressure buildup.
The next two months were an endless cycle of pain followed by heavy doses of narcotics followed by brief periods of lucidity. Methadone, Percocet, Oxycontin — when the meds wore off and the pain regained its grip, the cycle began again. Jeremy was in more than he was out of the ICU as doctors worked to piece together what looked like a shattered bone of glass during two more surgeries.
The bullet had entered his left knee and travelled along the lower leg, leaving a wake of bone shard and torn vasculature in its wake. The bullet embedded itself. He had no circulation below the knee for 15 hours after being hit. The only way to save Jeremy’s limb was to piece it back together, hold it in place with the fixator, and hope all the parts and pieces of his leg would heal in a way that undid the damage. Or minimized it. There were no guarantees. This would become the medical mantra Jeremy heard for the next two years.
By October 2012, Nicole had relocated with the kids and the dog to San Antonio to be closer to Jeremy. When he was discharged from the hospital in a wheelchair, they moved into a furnished home on the outskirts of town. Jeremy began outpatient treatment at The Center for the Intrepid, a U.S. military rehabilitation clinic specializing in Iraq and Afghanistan war casualties who endured amputation, burns or functional limb loss. By the time CFI opened its doors in 2007, six years of improvised explosive attacks in two separate wars had ensured plenty of patients.
The first day Jeremy rolled through CFI’s doors, he saw Zach Parker, a retired Army private and triple-amputee, doing a cable crossover exercise with his one remaining limb, an arm. Parker saw Jeremy on his wheelchair, leg elevated and haloed by medieval-looking scaffolding.
“Oh, you’re going to try that,” the guy said. “Just cut it off.”
Variations on this scene replayed for the next 27 months. Sometimes it was in real life, in conversations with amputees; other times it was in Jeremy’s mind, recovering after yet another bone infection that would cost him months of rehabilitation. It replayed in talks with Nicole, calls to his fellow PJs and was borne out in the daily assistance he required to do the things he used to be able to do on his own: Do I keep it or lose it?
The answer came in January of this year. The scaffold was off and Jeremy was chasing range-of-motion in his toes, ankle and knee. But the numbers didn’t lie: 30 degrees was the best his CFI physical therapist, Alicia White, could coax from the knee. In a last-ditch effort to break up the scar tissue impeding his knee movement, the doctors put Jeremy under and performed manual manipulation on the knee. The best it would do was 65 degrees, and a piece of his femur snapped off due to the force required to even get that far.
Jeremy was exhausted by the cycle of uncertainty. He was tired of popping pain meds just so he could take his kids to the park. Tired of losing ground post-surgery only to gain it back and lose it again. It was time to amputate.
Technological advances in the prosthetic industry have enabled amputees to return to the battlefield. But it’s difficult to ascertain beyond generalities how, exactly, war has driven those advances.
Kirk Simendinger, a former CFI prosthetist who currently works for a civilian prosthetics company, believes the advances were inevitable either way. But he said they were accelerated by the military’s commitment to its Iraq and Afghanistan amputees, including cooperative investment into research and development between CFI and the prosthetics industry.
Most compelling, however, was that the industry can “realize ideas so much faster” because of the constantly advancing state of technology in general, Simendinger told me. He said it was easier to point to singular advancements after World War II and Vietnam, whereas now, he couldn’t state that any particular innovation was a direct product of Iraq and Afghanistan.
John Fergason, currently chief prosthetist at CFI, sounded a similar note on advancements in prosthetic technology. “It was moving that way,” he said, but the state-of-the-art was accelerated by the needs of “young, fit, [military amputee] athletes.” This, in turn, helped deconstruct societal norms surrounding amputees and prosthetics. Before long, Fergason said, civilian amputees were thinking that if a military amputee could reclaim his or her active lifestyle, they could as well.
The reality is that the relationship between prosthetic technology and amputees is symbiotic. The industry has responded to the needs of demonstrated human will. Once largely designed for “aging and/or diabetic patients,” according to White, prosthetics now reflect the needs of most young, healthy and active men and women who want to run, cycle, ski and in cases like Jeremy’s, return to service.
I asked White what’s more important in returning amputees to duty: technology or human will?
“Human will, absolutely,” she said. She told me a story about a disarticulated hip amputee, a guy at CFI with nothing in his hip socket, who wanted to run. White remembers thinking no way and at the time, it was impossible. Eight years later, the technology is there and the guy is now running ultra-marathons.
“Show the human will,” she said, “and the technology will eventually catch up.”
Jeremy woke up from the amputation 15 pounds lighter in body. He looked down at where his leg used to be.
“Holy shit,” he thought. “It’s gone.”
It was weird, still is, to wake under bed sheets without that familiar shape where his left leg used to be. But Jeremy had no remorse and no regrets. One last cycle of pain meds (he’d planned on going without narcotics for the amputation, but the nerve pain proved too much) and he was off to the races.
Eight weeks after his amputation, Jeremy completed the 14.1-mile short course of the Bataan Memorial Death March, an annual event in New Mexico commemorating the survivors of WWII’s infamous Bataan death march. It took him eight grueling hours. But he finished.
White said she’d never seen a CFI amputee try to do something so hard so soon after amputation. But it was Jeremy, after all, a guy whose “over-the top” motivation was the same during limb salvage as it was post-amputation. He kept a list of amputation pro’s and con’s before going under the knife. So it wasn’t unexpected.
To some extent, the road ahead was known: adapt to life as an amputee. In terms of CFI that meant three to four hours each day spent re-learning to walk, cycle, run and lift weights on a prosthetic limb. But there was also the mental grind of building new routines and the extra time required to do even little things, like showing up at the pool, taking off his limb to shower, replacing it for the walk to the pool, then taking it off again to swim.
Beyond living as an amputee, Jeremy’s professional future was anybody’s guess. He wanted to return to duty as a PJ. The gut-wrenching Bataan hike had been a challenge to himself to see if he still possessed the dogged, never-quit mentality that got him through PJ training. But to prove to his medical evaluation board that he was worth keeping, he’d need more than that. He’d need the technology.
Technical Sergeant August O’Niell is a PJ who also underwent an above-the-knee amputee, a month before Jeremy. O’Niell was the first amputee PJ to meet a medical evaluation board. Three Air Force medical professionals looked at his physical fitness scores, letters of recommendation and questioned whether all of this business of returning to duty was realistic.
After all, this was the first time a PJ amputee had shown up looking to not only stay in the service, but go back to jumping out of airplanes. O’Niell was “sweating it until [his] prosthetist took the stand and knocked it out of the park.”
A week after meeting the board, O’Niell got the news: he was retained in the service.
When I asked him about prosthetic technology, he offered a surprising take: “It’s all about the socket.” The socket is the molded sleeve atop the residual limb that the prosthetic attaches to. “The limb makes it easy,” he said, “but the socket makes it work.”
White, the CFI physical therapist, agreed. The limb could have all the technology in the world, but if it can’t attach to the body for a long period of time it won’t work for people like August O’Niell and Jeremy Maddamma, who seek to prove that they can operate for days in the field with no limitations. Once held in place through uncomfortable mechanical means, sockets are now custom-molded to the residual limb, then vacuum-sealed by the amputee to distribute movement forces and ensure a comfortable fit.
Then there are the limbs themselves. By the time Jeremy left CFI and returned to Alaska, he had six prosthetics that ranged from carbon composite blades for running, to his favorite, the Ottobock X-3. Its artificial knee is controlled by a microprocessor and linked to lower limb sensors that ensure the limb moves as naturally as possible. White estimates the value of Jeremy’s quiver of appendages upwards of a couple hundred thousand dollars. Jeremy believes these are the legs that will allow him to do all the things he needs to do in order to be a PJ.
Jeremy is back in Alaska now, and feeling a little better about the road ahead knowing that O’Niell’s medical evaluation board went well. There are precedents in the other armed services, to include other special operations personnel like the U.S. Army Ranger who went back to Afghanistan with a prosthetic leg, pulled a wounded soldier to safety during a firefight and received a Bronze Star with Valor.
But if Jeremy is also retained, both he and O’Niell will still need to prove they can do the job, and become the first amputee PJs in the history of the Air Force.
“No matter what happens in life, you stay in the fight,” Jeremy said, looking ahead. “Quitting is not an option.”