Civilian Casualties from Iraq: Caring for the Forgotten Wounded
By Judith Philipps Otto
Content provided by The O&P EDGE

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 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

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

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
"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."
American Contractors in Iraq and Afghanstan
Contingency and WarZone Operations

Contractor Loses Leg to Preventable Infection
Joe Williams completes his first day in
therapy following his amputation with
therapist Sandy Fletchall, OTR/L, CHT,
Joe Williams and
Tien Tran, CP, FAAOP,
on his first day of
fitting and
prosthetic training
Joe Williams concentrates on
strengthening his trunk and lower
extremities prior to receiving his