The High Five Interview Series consists of 5 questions on themes inspired by current Hub topics, posts, and comments. Interviews are collected with influential individuals making change within the community.
Throughout 2019, Nate Munro has been one of e-NABLE’s busiest community members. He coordinates an international team of 35 people across chapters and continents to form the ‘No-Insurance Optimized Prosthetic’ or NIOP project. Together they have developed a system of modular prosthetic devices based around the Kwawu Arm by Jacquin Buchanan to support a wide range of limb differences.
Over the summer, the e-NABLE community unanimously approved a proposal for the team to develop 12 new devices. The results were impressive, which Nate shared on December 5th during the weekly Strategic Planning Committee (SPC) Meeting. The following day, I sat down with Nate to learn about what inspires his contributions and how his experiences have shaped his efforts.
1 | INTRODUCTIONS
“I realized I was living in a first world country for people with insurance but a developing country for those without insurance and without help.“
Let’s go back to the beginning. You arrived on the e-NABLE scene as an experienced 3-D designer. What did you study and where were you working?
My background is in architecture and engineering, both civil and structural. I have an associate’s degree in mechanical drafting and have worked 28 years as a consultant with a contracting business.
In the early 2000’s I taught for 4 years at the local community college here in Colorado. I was able to contribute to a wonderful network of local businesses and students, finding work for many of the graduates and even hiring and collaborating with a number of them. That was a fun time in my life. When the recession of 2008 came along, I needed to downsize and I worked mainly by myself after that. But it was a great time, I wouldn’t have changed it for anything.
How did you become involved with prosthetics?
I had a bike accident on concrete and my arm was badly broken when I was a contractor with no insurance. I was on my own trying to work my way through the costs but I couldn’t make ends meet. Things unraveled, and 22 months later the bone in my arm had become cancerous. My arm needed to be amputated to save my life. I realized I was living in a first-world country for people with insurance but a developing country for those without insurance and without help.
Ironically, once my arm was amputated I qualified for disability benefits and a Myoelectric arm that cost $16,000 from Medicaid. It is a ridiculous system, and that is a ridiculous amount of money. Half the country is arguing over socialized medicine but we’re already doing it, often through bankruptcies, and the hospitals pass this debt from the patients to the public, who are absorbing the costs. It is a no-win situation when you’re paying this much for devices. If you are a parent of a child with limb difference, that could be $16,000 per limb per year as prosthetics are outgrown. This is a burden on taxpayers and adds to the hardship for these families.
2 | COMMUNITY CROSSROADS
“Stand up and do it –
It’s the basic rule of e-NABLE as a do-acracy”
How were you introduced to the e-NABLE Community and why did the movement speak to you?
After they removed my arm, I still needed intensive chemotherapy to keep aggressive cancer from returning. Investigating free 3D printed prosthetics became my way of coping with the anxiety of the experience. I found the Cyborg Beast model on the Thingiverse website, but it required an operating wrist, whereas I was amputated near the elbow. I realized that I needed an elbow-driven device. It could be done but I would need to do it. Jon Schull had put out the RIT Arm which was good in concept. It used a plastic pipe as the arm, was cost-effective and may be kid-friendly, but I didn’t find it aesthetically pleasing or structurally sound enough to really work for me.
Getting involved has been a staged process. The community is a group effort, and with my design background, it seemed like the only option was to step up to the plate. With disability back pay, I used everything I had after expenses to buy a nice printer. I printed the RIT Arm for the cuff and socket and began rebuilding the forearm. I started getting into it and at first, made some hokey devices I was really proud of. I remember bragging to Jen Owen at the time, saying ‘I’m going to make the arm design that everybody uses in e-NABLE’. It was totally ridiculous, but I had a sense it was going to continue expanding with time.
Is there a volunteer from the maker community who helped guide the path you took?
I found out about the work of Jaq Buchanan, a fellow maker in Colorado who had designed the Kwawu. We were having the same ideas – numbers on the inside of the fingers to code them so you wouldn’t lose parts in the box; he beat me to it! I was working on a rotating thumb and bailed on it when I saw how nice his 3D scanned model looked. Jon Schull hooked me up with Jaq as a design mentor when I first became formally involved with e-NABLE, since he was only an hour and a half North from me. Holy cow, from there it was ‘on like donkey kong’, there was no stopping anybody. It was that whole spirit.
To be fair, the whole idea of a modular arm system was already floating around before I came in. As I understand Jon Schull had this idea from the beginning. When I joined, Jaq already had a Loomio proposal for a modular system in the works. I was pushing Jaq to do it but he is a busy guy too: super talented and super busy. I remember telling Jaq “we have to do this, the future is in a modular system”. The goal was to have the complete set of options so that regardless of where the arm stopped, we would have pieces for everyone and everything in between. I just saw the genius there immediately.
Was there a recipient volunteer from the adaptive community who also helped spark your contributions?
The Shelbow came from a friendship I made during my chemotherapy. In the hospital, I met a trauma technician who had come to take my vitals. She mentioned that her sister Shelby had a ‘little arm’. With Shelby’s anatomy ending above her elbow, I was introduced to another group of people that couldn’t use the available e-NABLE devices. She had looked at e-NABLE devices, liked the idea of the community but wasn’t impressed when the available stuff wouldn’t work for her.
She had an $80,000 myoelectric device that sat in her closet because it was too heavy and she hated it. And that’s what started the crusade! I was on this quest to make an e-NABLE arm for Shelby. It took me almost 2 years to get her a final design that worked. It took time, but I needed to stand up and do it – It’s the basic rule of e-NABLE as a do-acracy.
3 | UNMET NEEDS & EMPOWERMENT
“A protest in so many ways but also a solution.”
How did e-NABLE’s unmet needs grow into a unified system?
When I became involved with e-NABLE I was amazed to find amputees around the world suffering through the same story I had experienced. I wanted to make a change in the world, and I felt I could have a direct impact on the e-NABLE community. It’s funny to think that it was easier to create a whole line of prosthetics than to work within the broken healthcare system dominated by the insurance industry. This obstacle became the inspiration for developing a disruptive technology to throw into the market. I called it the ‘No-Insurance-Optimized-Prosthetic’, or NIOP project; a protest in so many ways but also a solution.
My contributions were all powered by the understanding that out there, there are a lot of people thinking “Dang, they’ve got everything out there but what will help me”. I’ve been a problem solver by trade. Being a consultant, people only reach out when there is absolute chaos, never when you can do something about preventing the chaos. They wait until it’s a firestorm and people are calling out ‘Come save us!’. I did that for 20 years before I did prosthetics.
I saw e-NABLE was missing an elbow and upper arm. The connections evolved just from the needs that came up. We started with Shelby needing an elbow, we took the forearm up to halfway and we transitioned it into the joint. We needed a brace to secure the driveline but designed a device that could still hang on its own. If you’ve seen the photos of Mohammad wearing the XO-Shoulder in Aleppo, Syria, that’s where they started by using a sling at first. It was better than nothing, but he needed a shoulder. That’s what started that last round. Each design was shaped by the needs of a specific individual, yet when all the pieces come together they make the design system.
To summarize, the Kwawu Hand is for you if you’re what they call ‘transradial’, meaning your arm ends below the elbow. The Kwawu Thermoform is for a longer residual arm, the Kwawu Socket with the Radial Conductor is needed if your arm is shorter or the amputation is near the elbow, like mine. The Shelbow takes you past the elbow, and you can choose the Helix Cuff for a longer bicep. The XO-Shoulder is for a shorter residual arm to wrap around the other shoulder and support the weight. For those with a near-shoulder amputation, I recommend the Humeral Conductor which helps the arm to be more responsive by increasing the leverage.
Can you share personal experiences about empowerment through a device?
One of the most important personal roles for me is being a musician. When I lost my arm, I thought I had lost music and the ability to play guitar forever. All the prosthetics that were shown to me were big clunky things like my myoelectric arm. It has no wrist, it can open and close like a grabber but has no functionality to be able to strum, let alone express notes in a way to articulate yourself through music. You lose all responsiveness with an arm like this.
One of the things that really got me started with e-NABLE design work was creating a simple little guitar pick adapter. Out of everything, It is my favorite prosthetic, my first really effective design. It allows me to strum. It doesn’t look like a normal hand but I don’t care, because when I shut my eyes it’s the only time when I feel like I still have my hand. I just forget about it because it’s so tuned to how my brain works and my elbow just works like a wrist. That was my first successful e-NABLE project. I had made another arm design earlier that was big and complicated that had moving parts that needed tolerances fixed. The music adapter was one piece and it worked awesome from day one.
A great way I’ve found to inspire people to get into e-NABLE and help the community is through music. The people who want to play music don’t have many options with prosthetics. I got to help a little kid in Australia who wanted to play the ukulele with his class. We got him one of these adapter devices, and now he’s playing with all his buddies. In fact, they were all helping him measure his arm and everything. It’s really cool, because while this kid is learning to play music, all of his classmates were learning to not freak out about somebody that only has one arm.
How have prosthetics changed your experience of limb difference in daily life?
I gotta tell you, when you’re missing a hand or a leg, a trip to the grocery store is the most obnoxious thing in the world. People stare at you or treat you weird, there is this social aspect. That’s why prosthetics help so much. I’m sure people don’t mean to do it and they’re nice enough when you go talk to them but they just get completely weirded out by different things. It’s really good to have them exposed while they’re kids so they don’t see it as different. It’s so powerful.
There is an interesting thing that happens by standing out in society. When you’re trying to sneak in, it doesn’t work at all. You feel bad in the end, everyone else feels weird about you being there. But if you embrace it and lean into it, if everyone is looking at it, something changes. Someone suddenly says “Holy cow, that is cool man! That is crazy, what is going on there”. They come up to you and interact about it instead of pressing on the other side of the hallway when they walk past you. It’s weird like that. Little kids don’t have that problem, they run right up and say “Oh my gosh you’re a cyborg!” That’s what gives me hope. the younger generations aren’t as bad, adults tend to lose that innocent curiosity.
I think about it like a spider web going out in the world. We are making devices that help people feel better about themselves, which helps the public treat them differently. It’s kind of a grassroots thing where you start at the bottom and work up. You can evolve this concept to the next level as kids with prosthetics grow up. That’s where it’s really going to come together. We bridge the gap when people can accept each other regardless of differences. I think, generally speaking, American society is becoming more accepting, people find themselves in other parts of society that aren’t representative of themselves. The ones that don’t like it still have to do it. It’s happening, whether they want it to or not. We can all try to help a bit.
4 | NIOP TEAM & INSPIRATION
“You are only limited by your imagination
and vision.”
Who has been involved in making the NIOP vision become reality?
There are a lot of people involved. This Spring there were maybe 25 people, lots of ancillary people on the outer rim for consultation and then the inner circle of designers. The lead designer Will McCaffrey has been a complete game-changer for the team, responsible for adapting the Gripper, MotoGripper, and most recently Shea’s Bow Holder (for violin) to use the Quick-Connect (Q-C) Wrist. Leland Green is a pretty active member. Alexandra Lamp is a really awesome German industrial designer, Donna Zimmerman has worked with a bunch of different designs; she was actively consulting and designing with us. Each person is working on different projects.
Another great member who hardly gets enough credit is Lorenzo my helper, a retired master machinist who is 80 years old but has eyesight better than mine. He is so skilled and has all this experience packed in his brain – he just knows things. Show him a design and he goes “Oh you just change this here and it works” and I realize he’s right, that it’s what I should have done! He and I together are a wicked combination because we can prototype almost anything, with all these little plastic mechanisms.
Lorenzo Lopez 
Adam Klaum 
Madison Bondoc 
Leland Green 
Shawn Mathiesan 
Jacquin Buchanan 
Will McCaffrey 
Nate Munro 
Ken Bice
Where do you find inspiration for the system?
NIOP designs take a lot of inspiration from children’s toys. A ‘Big Wheel’ is a great example; a tricycle toy with metal fasteners and springs on the inside, but the majority of the housing and body is plastic. They’re economic but tough, designed for little kids to beat the snot out of them. NIOP is the same idea. You have to take into account the different ways you align the printing, like grains of wood, along with the support material. In general, it’s a lot like working with wood.
Legos are really incredible. You take a kit with a million weird little pieces and kids put them all together into something really specific that serves a purpose. It’s almost the exact same concept as 3D printed prosthetics.
The power of making stuff with a 3D printer is so impressive! When you can create something in a digital model out of nothing, you can make anything that fits on that print bed. You are only limited by your imagination and vision. If you see something that needs to be done, you can just go and make it happen.
5 | THE HORIZON
“The Community Take Over”
What is next for NIOP devices?
The Q-C Wrist is a game-changer. You’ll be able to pop hands and adapters on and off and add features. This opens the door for all types of bionic development too. Then we’ll have all kinds of hybrids. It’s not just having a hand, this system becomes a toolkit – a different adapter for different tasks to swap back and forth. The most important things within a design system are common connection points. These give other developers a place to build off from. The community can copy and paste from one design to another, creating hybrid designs at an exponential rate.
I’ve had lots of adapter ideas. Just a piece of a rope with a few knots and a loop, with a piece of plastic to cinch up on would be great for shoveling heavy loads. You could put it over tools, pull a wheelbarrow, winch on a car, or lift weights. Another adapter for push-ups, I’ve been missing them. It would have a big round top that just snaps on the end that becomes a pad that you push off of. An adapter for a steering wheel with a little knob that makes it easier to grab with a device hand.
I get lots of ideas about Lego adaptations as well. I used to love Legos, if you couldn’t already tell, but they are really useful for this. Lego post connectors are round pieces that snap into a hole, part of the Technic series. You can drill holes in anything and stick these in them. If you have holes like that set in the hand…’click!’ There goes a brush into the hand! A pencil? Put a little hole in your finger and you make a pencil adapter that fits right in. You could make those connectors per finger or on the palm. It opens these CAD customizations to regular folks, we all become makers.
There are so many people doing hands, it’s like a romanticism. I understand it, a hand has more “personality” than an elbow or a shoulder, but that’s why I went up the arm, because no one was going in that direction. I’ve considered going back to the wrist but with a new mechanical perspective.
The majority of the devices out right now start out open and you push them closed, called ‘voluntary closing’. The effort involves pushing it closed, but then you’re straining to hold the hand shut tight. This can really hurt if you’re an amputee. Those muscles spasm right around the ends of the bone, it’s just not comfortable. What’s more preferable for me as a user is a ‘voluntary open’ device. It holds itself closed all the time, and you add pressure in one little moment to open it before it holds itself closed again. That way you can get up and walk around holding something and you don’t have to worry about it. This is better for a bionic system using electrical power as well. It saves a lot of battery power.
What is the plan to bring the world up to speed with NIOP?
The first step is to make sure everyone can bring NIOP devices into their favorite design software. We’re looking to use Fusion 360 to export files into all the major design platforms (Solidworks, Blender, Tinkercad, etc.). I’m also interested in developing tools for non-designers to custom fit without needing traditional CAD design skills.
OpenSCAD is an open-source sizing program that scales parts by length and width. Imagine if the files loaded up with design options. You pick the wrist connection you want or the kind of cuff you want in a dropdown menu. You could decide whether you want a prosthetic finger or space for the natural finger to come through. Once you’re done you just click to render, take the STL and go print it. It would be an amazing time-saver for customizing devices and allow people without CAD skills to customize them too…
The usability ratings are almost done, so we should have all of the NIOP devices registered and on the Hub within the next couple weeks – something like 22 different devices and counting. Documentation is needed to help people see the trees from the forest. Jon Schull, Bob Rieger, Shawn Mathiesen, and Jeremy Simon are helping with graphics and videos.
We have a project proposal set up with Bob and Shawn. She will be doing the OpenSCAD work, looking at every little part and how it goes together. Her husband Earl helps with bionics. That will be a really good team to get started. Once they are on board, we will know what is required for badging and instructions. If we can visually connect the dots between the different compatible devices we can shorten the learning curve that goes with the system.
I’m looking to go with a visual ‘Legos style’ instruction manual for each of the modules. You put them together in many combinations. Kids who are six years old figure out Legos on their own, and visually they are nearly a universal language, perfect for our international community. One of the coolest things with the Lego manuals is that if they have something like axles in a step, they’ll have a true size illustration up in the corner of the instructions so you can lay your part down right on top of it to make sure you get exactly the right part.
I’m going to do the same thing with screws and fasteners. You’ll be able to buy the hardware kit from 3D Universe, get the bag of stuff and lay parts down on the instructions. So we’re working on simplification, but you don’t have to wait! It might seem new and strange at first but Ahmad in Syria put these things together without instructions. The parts are intuitive. The hope is that it all comes together with community involvement.
What is next for you and the community?
My disability doesn’t cover my rent, so I need to be finding other work or funding soon. I won’t have as much time doing e-NABLE projects with another job so it would be really nice to secure long-term funding so I can continue with designing prosthetics as my career. The community can also continue to develop the catalog and remix things as needs arise.
With NIOP resources and design files at their disposal, the community can hopefully fill in any holes I have missed. I want to release this project and help the community take over. I’m looking forward to the many advancements created with the NIOP system in the future.
AFTERWARD
Several weeks after our conversation and after an extended discussion, the proposal to create a series of videos to help global volunteers adopt the new system was approved. When the NIOP devices on the Hub are rated and released Spring 2020, we will update the missing links in this article. Follow along on Loomio and the Hub to be involved with the NIOP workshops and roll-out!