Joining Forces

Returning military service members have varying wounds including amputations, blast injuries and psychological scars. Through a collaboration between California State University (CSU), Dominguez Hills Orthotics and Prosthetics Program and the Naval Medical Center San Diego (NMCSD) Division of Comprehensive Combat & Complex Casualty Care (C5) Program, O&P students are getting a rare chance to work with injured service members returning from Operation Enduring Freedom and Operation Iraqi Freedom.

According to Scott Hornbeak CPO, program coordinator, CSU Dominguez Hills O&P Program, the collaboration was under discussion with Peter Harsch CPO, the head of the prosthetics division C5 at NMCSD for almost two years before the first students walked through the doors at NMCSD. Recognizing the rare opportunity to work with returning military amputees, the U.S. Navy invited the students in to share their knowledge as well as iMpart their own.

Excited about giving the students this extraordinary opportunity, both men talked to O&P Business News about what this partnership can do for the future of O&P, comprehensive care and the learning process.


Brian Zalewski, C5 prosthetist shows Luis Mora, student in the CSU Dominguez Hills O&P Program how to apply a fiberglass wrap
All images reprinted with permission of the U.S. Navy.

Each Thursday since early September, NMCSD has welcomed a new team of O&P students to learn about amputee patient care. The program has been designed to allow each of the 16 current students in the CSU Dominguez Hills O&P program to visit the medical center at least once before the semester ends in December. Hornbeak is confident that many students will have the opportunity to visit NMCSD twice before the year ends. For now, they visit in teams of two making each visit different adding further value to each student’s personal learning experience.

Harsch explained that the students have access to the newest technologies and techniques and they promote both clinical and technical freedom so almost nothing is off-limits in terms of participation in care, but that does not mean protocol is ignored.

“Every patient is asked if they are comfortable with having a student shadow us,” Harsch explained adding that the majority of the patients have granted this request.

Also, students are expected to follow standard medical operating procedures such as patient privacy and HIPAA compliance.


To begin their acclimation to the new surroundings, students are first given a tour of C5 and an important briefing on some of the challenges they might face working with such a specific population.

Returning military service members present more challenges due to the nature of their wounds and the psychological ramifications of combat. Post-traumatic stress syndrome (PTSD) and issues with traumatic brain injury are just two of the special considerations the students received education about prior to their visit.

Military amputees returning from Afghanistan “have really high pain levels because of other injuries – ankles that are crushed, burns and tissue injuries. The students are starting to see that for some of these [soldiers] that are injured in the war that have amputations, that’s just one of the problems,” Hornbeak said. “There are so many other medical and psychological conditions that are going on. Some are visibly depressed. Some are in severe pain and are taking some kind of painkillers and it really affects you to see these young people with such severe injuries. Yes we are looking at the prosthetic rehabilitation but you can’t help but think about all the psychological rehabilitation that is required.”

To deal with the psychological ramifications, students have been instructed to be cautious and consider what they say and do.

Some of the students who have already visited NMCSD have had a chance to reflect on their experiences. Evan Markell, a current student in the CSU Dominguez Hills O&P program has previous military experience as a hospital corpsman and served in NMCSD, coincidentally where his rotation took place.

“I had some expectation as to the sensitivity of seeing patients that were coming back from Iraq and Afghanistan with traumatic injuries,” Markell told O&P Business News. “It’s a very sensitive issue and I made sure when I spoke to any patient, any wounded warrior there, to really gauge how much further I should go into how the injury occurred or what I should and shouldn’t say and took it on a per patient basis.”

Another student, Elisa de Jong, CO, came to the collaboration with no previous military experience and was anxious about her visit given the briefing they received beforehand.

“I was happily surprised that it wasn’t as intense as I thought it would be because we were expecting a lot,” de Jong told O&P Business News. “We were told to watch what we ask and it completely makes sense but when we got there… the [patients] that we saw were so open. It’s really neat to hear them talk and see how they’re coping with it.”

A unique experience

Brian Zalewski, C5 prosthetist shows Luis Mora, student in the CSU Dominguez Hills O&P Program how to apply a fiberglass wrap
Brian Zalewski, C5 prosthetist shows Luis Mora, student in the CSU Dominguez Hills O&P Program how to apply a fiberglass wrap.

The treatment of war time amputees is a rare event and the students are really excited and enthusiastic about going to take part in their prosthetic care, Hornbeak said.

With only 70 miles separating the CSU Dominguez Hills campus and NMSCD, it was an opportunity the two entities could not pass up.

“There’s not been anything like this since Vietnam in terms of amputation care and sometimes it takes a war to advance technology prosthetics,” Hornbeak said. “At the three Department of Defense hospitals they are embracing a lot of high technology and that’s going to pull through for the benefit of all veterans.”

Harsch, a graduate of the CSU Dominguez Hills O&P program is happy to give back to his alma mater and thankful that the Navy offered this unique experience to students.

“I know that if I was a student I would be very grateful,” he said. “I wish I would have had this opportunity when I was in school to come and see something like this. My profession outside of the Navy and being a mentor to these students will hopefully bridge some of the challenges that prosthetists have with sharing education and experiences and being able to give back.”

Comprehensive care

NMCSD C5 offers the additional educational experience of working in a comprehensive care setting, one that many practitioners unaffiliated with the military see as a great way to manage care in the best interests of the patients overall health. Giving these students the chance to work in such a setting might encourage increased comprehensive care in the future.

“Students are getting a better understanding of what comprehensive care means,” Harsch said explaining that NMCSD C5 houses such specialties as occupational therapy, psychology, physical therapy, an orthopedics team and case workers. “When you put all of that into place, you’re going to get great results. When you can all focus on one goal for one patient the outcome is going to be a life-changing one.”

Harsch is confident that these students will take this kind of comprehensive care out into the mainstream field of O&P.

“These students will be able to go out and be able to understand that if we worked in this team environment or if we collaborated with other medical specialties like physical therapy and occupational therapy, that their patients will have a higher probability of getting great outcomes and being able to…get integrated into life again – back to work, back into athletics or sports or whatever their goals,” Harsch told O&P Business News.

Hornbeak, a proponent of the idea of a rehabilitation team agrees that this kind of comprehensive care is an ideal.

“It is a nice situation over there at the Navy hospital because the physical therapist is right next to the occupational therapist, [who] is right next to the prosthetic practitioners. It’s seamless,” Hornbeak said. “They have clinics with the doctors on Thursday and the patients don’t have to go to some far flung clinic to get additional services.”

Future care

Harsch (center) shows students Mora and Rachel Hartsell how to create a stiffer heel
Harsch (center) shows students Mora and Rachel Hartsell how to create a stiffer heel.

The Navy’s initial purpose for pursuing a partnership was to allow students a chance to become aware of the kinds of injuries that veterans will be walking into their O&P offices in the future; to give the students a chance to see how that care begins in an effort to continue in that care with more knowledge.

“It was an opportunity to have a class of students that will be familiar with not only the prosthetic fitting issues but understanding what each one of these individuals has gone through – going from a combat zone, understanding what they’ve been doing here for 12 to 18 months and that they are not here for just a basic fitting,” Harsch said about the impact this partnership will have on future care. “It’ll give them a true understanding of each of these [returning service people] when they come into their offices all over the country. It’s a way that the Navy is able to continue the education and continue the care for these individuals once they leave here.”

By expanding an invitation to work with and shadow practitioners at NMCSD, the students are becoming familiar with the challenges associated with blast injuries so that they can use that knowledge for long-term care planning of war veterans that will flood offices around the country in years to come.

“The patients are very appreciative because they realize this is the younger, newer generation of prosthetists that will be around the next 40 to 50 years of their career,” Harsch said. “The patients themselves have all opened doors allowing the students to see what they are going through and to understand because they realize there will be a day that they’ll walk into an office years down the road and they might recognize one of the students. The feedback has been very positive from the service members and I think [they] recognize that the Navy has given these students an opportunity to come here and learn and educate and train and it’s really for them. It’s not for us. It’s truly for the long-term care of these service members and I think they are appreciative of that.”

Hands-on experience

“These are blossoming practitioners and frankly they are very open to new experiences,” Hornbeak said. “They’ve done enough volunteer work or technical work that they’re really not too shocked at what they’re seeing.”

This hands-on experience is adding a new dimension to the school, Hornbeak added. In addition to the weekly visits to NMCSD, the students share these experiences in the classroom setting to broaden everyone’s knowledge and shed some light on the differences between the in-class education and that received in the field.

“I saw a casting which was very similar to what we learned in school,” de Jong said adding that the difference is that it went beyond the basics of a textbook case or model patient. They teach you the basics in school which is good . . . and a lot more detailed and then when I saw [someone at NMCSD) take a cast it took him less than ten minutes just to wrap him up. It was great because with school we get patient models who we go through a whole project with – a casting, making a check socket, making a definitive socket and walking them. It’s nice to see in a different setting what we’re learning in school.”

This kind of exposure produces the “aha” moments for students who finally see the end result of so much study.

“The students are being exposed in school to some of the same technology although they see more of it at NMCSD,” Hornbeak told O&P Business News. “For instance, just about all transfemoral amputees get a microprocessor knee. All lower extremity amputees get some kind of a high profile, dynamic response carbon fiber foot. Just about every amputee that has an upper extremity amputation gets at least the option of receiving an externally powered arm, such as a myoelectric. Now they are fitting i-LIMBS and some of the other modern technology. Our students are getting exposed to that here but it’s just a brief lecture about the i-LIMB – down there they are actually seeing them.”

Treating the individual

Harsch (center) shows Mora and Hartsell how to remove a side-spring
Harsch (center) shows Mora and Hartsell how to remove a side-spring.

One lesson that both Markell and de Jong expressed as invaluable was the idea of treating the individual.

“You need to look at each patient not as being a transtibial or whatever level amputation they’ve had,” Markell said. “You have to look at them and take their whole package and really be sensitive to everything about the patient, especially with these wounded warriors. A lot of them do have PTSD so really as a whole you need to take the patient and treat them individually and encompass everything that they have going on in their lives.”

de Jong echoed her classmate’s sentiment adding that while the she recognizes the value of her in-class education, this once-in-a-lifetime experience has allowed her to realize how much hands-on clinical practice aids in educating about those things that can not be simulated.

“Even though you learn the basics, you can’t always go by the book,” she said. “You learn by the book but … every patient’s going to be different and in order to treat them effectively you may have to think outside the box.”

The unique setting offered by NMCSD also allows for a patient feedback that is not always experienced in a traditional clinical setting. The patients form an unmatchable camaraderie and talk about what components work for them and vice versa offering advice to one another.

“Each patient that you’re treating really knows a lot about what you’re doing,” Markell said adding that he welcomed feedback to help him improve his skills for later clinical practice. “That’s something I was really amazed by. These [patients] knew about alignment and they knew about feet and what they wanted to try and what they didn’t want to try. Patient feedback is definitely something that you have to take into consideration so [it is important to] listen to the patient in general.”

Win-win situation

“The young amputee soldiers and marines relate to other young people so they love our students,” Hornbeak said.

But the students are not the only ones taking something valuable away from the collaboration. This experience also allows the patients a chance to see what a career in O&P would be like – from the educational perspective and well as the clinical perspective. CSU Dominguez Hills invited some of the patients to the university for career orientation in mid-September

“We showed them some technology here at the school in case two or three of the soldiers might want to pursue O&P as a career,” Hornbeak said. “It’s another career option.”

As long as the program is successful, Harsch and Hornbeak plan to continue with the next class of students in February 2009, an idea that current students think would be wise to make.

“It’s really made me appreciate the field in general and just to be able to work with these patients and to see them so motivated to get on with their lives and to be active and use the devices that they were given was pretty inspiring,” Markell said. “I think it’s something that everyone in the field should experience.”— by Jennifer Hoydicz

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