Body of Work

It’s been two years since the Navy SEAL has walked. Wounded in action, he’s now a patient at Walter Reed National Military Medical Center in Bethesda, Maryland, and a bilateral amputee.

Before being wounded, he routinely fulfilled his military duties regardless of the extreme endurance required. There’s a good chance he never thought about what life would be like as an amputee. Most people don’t unless they lose a limb, or know someone who has. But now, who could blame the Navy SEAL if he feels vulnerable, damaged, even incomplete?

On this day, though, he begins a journey in his new reality. When he reaches his destination, he will have new legs, prostheses that will enable him to once again stand, walk and even run. Artificial limbs will give him back the freedom and independence he had lost.

However, Annie Kaitlyn Caulfield, a resident prosthetist at Walter Reed, knows that this path is never easy. She spends her days working with veterans and active-duty military personnel from all over the world who travel to Walter Reed for health care. As a result, she has witnessed firsthand the trauma patients endure from limb loss and the overwhelming challenges they face.

These challenges are also what inspires the Pitt alumna to do her job well—creating the best possible prosthetic limbs for her patients.

Today, she’s working with the Navy SEAL. Like all of her patients, he can’t simply use one-size-fits-all prostheses. Just as every person has a unique fingerprint, every amputee has a unique set of shapes, sizes and contours. The patient’s prostheses must be crafted for him specifically. If they don’t fit flawlessly, they could be too painful or burdensome to wear, and his dream to walk again would remain just that—a dream.

It’s up to Caulfield’s expertise and ingenuity to help her patient regain a part of what was lost. And so, she gets to work.

The first time Caulfield got her hands dirty making a prosthesis was just two years ago, when she was a graduate student in Pitt’s Department of Rehabilitation Science and Technology. The department, within the School of Health and Rehabilitation Sciences, houses one of only 13 master’s degree programs nationwide that trains prosthetists.

It was a morning of new beginnings for Caulfield and 11 of her classmates, seated on stools in the department’s Bakery Square facility just a couple of miles east of campus. Donning their new, white lab coats embroidered with their names and “Pitt Orthotics & Prosthetics,” they were meeting their first-ever “patients”—or patient-models—for whom they would craft a prosthesis from scratch.

In the chair facing Caulfield was Larry Keys. Years earlier, he had been up on his roof cleaning his gutters when his ladder fell. He had been forced to jump down. “I used to bend,” Keys recalls of his younger days. “Now I break.” His right ankle was crushed and forced up into his tibia. His leg was amputated below the knee after the bone’s healing was disrupted by an infection, leaving him in need of a prosthesis.

After chatting with Keys and inquiring about his health conditions, habits and hobbies, Caulfield turned her attention to the task at hand: She needed to create a plaster mold of his residual limb—the part of the leg remaining after amputation.

“Well, let’s give this a go,” she remembers thinking.

With the guidance of instructor Bob Maguire and previous program director Sara Peterson, Caulfield and her classmates took measurements of their respective patient-models, prepared the plaster bandages and checked and rechecked the measurements they marked with grease pencils. Soon, their crisp coats and navy-blue scrubs were powdered with plaster dust, their pants and shoes splashed with milky runoff from submerging the plaster bandages in water. They wrapped the residual limbs in the wet bandage, holding them in place, waiting to feel the warmth of hardening plaster, and hoping for the best.

That first step, Maguire says of molding, is always the messiest.

Since its start in 2009, the program has been making messes in order to train the next generation of prosthetists and orthotists (P&Os)—the professionals who work with patients to craft individualized artificial limbs and orthopaedic braces to improve patient function and mobility in everyday life. At Pitt, students are trained in both disciplines; often, they later choose to practice either prosthetics or orthotics. Either way, they join the ranks of a field long in the making.

Humans have been wearing prostheses and orthoses for millennia. The history of prosthetics specifically has been bound in the history of warfare, the impetus for most of the innovation in the field.

But in the 21st century, the vast majority of the need for prostheses comes not from physical trauma, as is the case of Caulfield’s Navy SEAL patient, but from the growing number of people suffering from infections that result from advanced diabetes and cardiovascular diseases. In the United States alone, about 9.4 percent of the population have diabetes, whereas 48 percent of adults has a cardiovascular disease. According to one estimate, the number of prosthetists needs to grow 60 percent by 2025 in order to accommodate the patient population in the United States.

Pitt is doing more than simply trying to fulfill that demand. The P&O students, faculty and alumni all agree that learning and working with patient-models to create customized prostheses has helped make Pitt’s program stand out.

The patient-models—who have either experienced the amputation of a limb or were born without a fully developed limb—have already had their needs addressed by Pittsburgh-area P&O clinics. It’s often their practitioners, knowing the Pitt program seeks patient-models, who inform them about the opportunity to help the student prosthetists learn.

And what better way to learn, says Maguire, than to do? “We take the students out of the classroom, put them into the clinical setting. And then with their hands, they feel that limb, they check it for range of motion, they check it for sensitivity—a variety of criteria that each student has to follow to come out with a specific fit.”

Tim Kolich, an upper-limb patient-model who has worked with the program for three years, has witnessed the value of his participation: “The students are learning to be problem-solvers. No two people they see will be the same.” In other words, the prostheses Caulfield would make for Keys or for anyone else would not be suitable for her Navy SEAL patient.

Throughout the two-year master’s program’s prosthetics curriculum, students learn to make a variety of lower- and upper-limb prostheses with the help of a rotating cast of patient-models, starting with below-the-knee amputees like Keys. At this early stage of training, more likely than not, the initial sockets made from these first molds would cause the wearers pain resulting from improper fit.

“And we want our patient-models to come back,” Maguire jokes.

It’s not until the students further hone their skills and do their second molds and check sockets that the patient-models give the student creations a go.

At every stage of the process, Caulfield and all the students must keep in mind that prosthetists have to help patients get maximum usage out of their prostheses. Therefore, every movement to control a prosthesis must be well-defined and purposeful; nothing can be accidental.

“This is almost an art,” Kolich says. “They’re craftsmen.”

Oftentimes, the job requires prosthetists to experiment with various fixes and work with failures until they find solutions—such as creating a new cast, adding padding, heating and reshaping the socket or adjusting the trim lines.

According to Alexis Emad, a 2020 graduate of the program, tinkering is part of the field’s appeal. “I love having to think, ‘Okay, what looks off and why?’” she says.

Sometimes very little needs to be fixed, and patient-models declare that they could “walk right on out of here” wearing the student creations (even though it’s not allowed).

But as Peterson, a faculty member and previous program director, tells her students, “This is the place to make mistakes—and, most importantly, learn the corrections—before entering the job force.” Even the smallest detail can make the biggest difference in a patient’s life.

After learning to recognize those details, Caulfield and the other future prosthetists are on their way to seeing patients take their creations—arms and legs, fingers and toes—out into the world.

Ask a prosthetist to describe their work, and the response often sounds like a creator’s dream, linking fields as disparate as woodworking, computer coding and car manufacturing to plumbing, surfboard-making and 3D printing. One look at the Pitt P&O lab reflects this reality: Materials range from plaster, fiberglass, plastic, foam, plumber’s putty, metal hardware and resin; tools and heavy-duty machinery abound.

Paths to the field are just as varied. Many P&Os, like Peterson, discovered the field after working in or studying physical therapy or athletic training. Maguire, a former steel mill worker, turned to prosthetics after creating a playing-card holder for a triple amputee in a nursing home run by his family. Pitt P&O students have ranged from artists to engineers.

Caulfield, who grew up in a military family in Hattiesburg, Mississippi, traces her interest in prosthetics to her 10th-grade anatomy and physiology teacher and high school’s football coach, Lonny Schraeder, who as a college student lost both of his legs below the knees after being hit by a drunk driver. “He’s one of the most incredible people I’ve ever met,” she says. “He would take his legs off and show me how they worked. I didn’t even know prosthetics was a profession until then.” Her interest was sparked.

After high school, she attended the University of Mississippi, where she studied exercise science. Once she began shadowing P&Os, she quickly decided that with its unique combination of skills, such as patient care, engineering, biology and art, prosthetics was the path she wanted to take.

When it came time to pick a graduate school, “I was trying to hold out for Pittsburgh,” she says. The combination of patient-model work, lab work and internship/externship opportunities at the heart of Pitt’s program stood out to her. 

One particular externship caught Caulfield’s attention: With its consistently high caliber of P&O students, Pitt has an agreement with Walter Reed. Every year, during the second-year students’ final semester, two to three Pitt students are selected to complete their externships at the world’s largest joint military hospital, home to some of the world’s most advanced prosthetic technology. 

Caulfield eventually earned the Walter Reed externship. After completing it and graduating, she successfully sought her P&O residency with a company Walter Reed contracts for P&O services.

“I get to work with active-duty military who are still going on deployments,” as well as with military dependents, she says. With the need to quickly serve patients who travel long distances for care and who often need multiple products, Caulfield and her colleagues “need to work at an extremely fast and demanding pace.” 

One of her military patients is the Navy SEAL, who, like many new amputees, may never have considered what it would be like to use prostheses.

“There’s a lot of misconceptions” regarding the prosthetics field, Caulfield says. “Most people don’t think, ‘Hey, there’s someone who’s behind that. Someone makes those legs,’ unless it’s something they’ve been through.”

Forming trusting relationships with patients is incredibly important, Caulfield says, particularly because prosthetists depend on their patients’ input throughout the prosthetic-making process. “You really have to be able to read the patient,” she says. A natural conversationalist with a relaxed demeanor, she tries to get to know patients as individuals before doing any physical prosthetic work. Of course, they need to know her, too; with her thick Southern accent as a frequent conversation starter, they soon learn about her quick wit and love for sports and Cajun food. 

That’s not to say she doesn’t take her work seriously. If anything, she hopes her warmth and openness show her patients that she is invested in helping them reach their goals—the part of the process she cherishes the most. “Just looking at someone who’s wearing a product that you built for them, and it’s allowing them to walk, is a very surreal and humbling feeling,” Caulfield says.

Maguire echoes this sentiment. “Seeing someone walk after they’ve been unable to for a period of time and they’re darn near tears is very rewarding.” Although Maguire no longer works with patients, he experiences the same reward through his students. “You see a student who’s experiencing that very same thing, where they’ve made a prosthesis with their own hands, and they’re walking a patient in the parallel bars, and you see that smile that they have ... you just know that they got it; they’re on the road.”

It’s the same kind of smile Caulfield has learned to strive for in her patients, like the Navy SEAL. After hours of working in the clinic and the lab, she gives him his very first prosthetic legs. With Caulfield’s help, he puts his new limbs on, stands in front of the mirror and looks at the man staring back at him, incredulous.

They both smile. Soon, the legs will carry him as he playfully chases his 2-year-old child around for the first time. But not the last.

Cover image: Annie Kaitlyn Caulfield stands in front of what she and her colleagues call “the graveyard,” where parts of patients’ old prostheses are kept.

This article appears in the Summer 2020 edition of Pitt Magazine.