The doctor was telling the teenage war veteran from Uganda that he could alternate between two attachments to his new prosthetic arm: a hook or a hand.
The hook "doesn't look as beautiful," said Alberto Esquenazi, the physician who leads MossRehab's Regional Amputee Center and who also wears a prosthetic arm. "But you can do more with a hook."
Ronald Okello, 18, wasn't buying it. But he certainly wasn't arguing either. There were just too many new possibilities to explore.
"Will I be able to write, to wash - what about [cleaning] my uniform?" Okello said. "I want to ride a bike."
The teenager should be able to wash himself better and clean his school uniform, Esquenazi answered, but not write so well. And the bike depended on whether Okello could ride one before he lost his arm.
It's been a long ordeal for Okello, who said he was abducted into a rebel Ugandan militia at age 9 and forced to fight for four years until he lost his arm. He recalled watching a fellow soldier hack his father to death.
Now, with the help of a Philadelphia philanthropist and aid groups, Okello is set to return today to Uganda in east Africa with a new, $10,000 prosthetic right arm and memories of a bustling America unlike any place he imagined.
Helping Okello, though, isn't as simple as it might appear. His arm is expected to last about five years if it isn't damaged or worn out sooner. And there's no guarantee he will get a replacement. The euphoria he feels now could turn to anguish later if he can't get more care.
But that seemed far from his mind as he was being fitted with his prosthesis at MossRehab in Elkins Park. Okello has discovered his new arm helps him balance better when playing soccer. And he's already imagining what he will say to his friends at school about laundry: " 'No more begging you guys to wash, because I can do it myself.' "
Okello, an ethnic Acholi, was born in the midst of a bitter, 21-year civil war. The conflict dates from 1986 when current President Yoweri Museveni's army ousted the first Acholi president, Tito Okello (no relation).
Acholis launched rebel movements, including the Lord's Resistance Army, led by the mercurial Joseph Kony, famed in part for vowing to rule by the Ten Commandments.
When Acholis rejected Kony as a leader, he turned on them, filling his ranks by abducting children as young as 9. Personal accounts and independent reports document how boys were forced to be soldiers and made to kill. Girls became soldiers too; they also were given to commanders and serially raped.
Rebels and the government have largely stopped fighting since another attempt at peace began in 2006.
But both sides have done great harm. During the war, an estimated 66,000 children were kidnapped, and 200,000 from the Acholi and Lango groups have died. While statistics are sparse on the number of amputees, help is rare. Twenty children received some kind of prosthesis in 2007 at a clinic in the region around Gulu, a large town in northern Uganda, said the Association of Volunteers in International Service.
Okello was 9 years old in 2000 when his mother sent him on a four-hour trek to the market to buy soap. Rebels emerged from bushes on a dirt road and captured him.
At first, Okello cooked and fetched firewood; later he was given an AK-47.
He is tight-lipped about how many times he killed someone, but he said he was in firefights often. "Sometimes we fought the whole day, from morning to morning," he said.
In 2001, he saw his older brother, Ochen, another abductee, in a fellow rebel unit, but Okello does not know where he is now.
The next year, during an attack on his home village, rebel leaders ordered Okello to slay a man they did not realize was his father. Okello said he refused, but had to watch another boy hack his father to death with a machete.
The following day in yet another battle, Okello said, he shot the rebel who killed his father. No one saw him do it, he said.
After four years, Okello took a bullet in his right arm during a skirmish with government soldiers.
"I did not even know they shot me," he said.
He realized it after a few minutes, and rolled under a tree, bleeding heavily, until the rebels fled and army soldiers found him. They took him to a nearby hospital in the town of Kitgum, where his arm was amputated. Like many kidnapped children who are freed from the rebels, he announced his name on the radio. His mother heard him and came to the hospital to get him.
In 2006, Stephen Shames, a freelance photographer in Brooklyn, met Okello when the foundation bearing his name held an art workshop for children in Uganda. Okello, who lags behind at school, is the first person the Shames Foundation has brought here for treatment.
Shames, who worked at The Inquirer from 1986 to 1991, was impressed with Okello and enrolled him with a Ugandan nonprofit partner, Concern for the Future, which helps orphans and war victims. Okello now attends a good boarding school in the Ugandan capital of Kampala; his school and living fees are sponsored by Philadelphia philanthropist Lynne Honickman, who met Okello a week ago for the first time.
Esquenazi, MossRehab and a local firm, Allied Orthotics & Prosthesis L.L.C., donated their services. A fund started by a MossRehab patient paid other costs. The total medical expenses were about $18,000, according to MossRehab's parent, the Albert Einstein Healthcare Network.
Angelo Russello, a certified prosthetist with Allied, was at MossRehab nearly three weeks ago to measure Okello's partial right arm.
Okello's amputation was done slightly below the elbow, leaving him with barely an inch of his lower arm.
"This is actually unusual for what we see," Russello said, gently cupping Okello's stump in his hands. "A piece of the bone is still left in his arm," he said. "This pressure, that hurts a little bit?"
Okello winced. "Yeah, just there," he answered with the stutter he has had since birth.
It's unusual for a young person in the United States to need an arm, said Howard Brand, Allied's owner. The children at Moss generally lose lower limbs due to disease. When an upper limb is gone, it's mainly because of a blood vessel problem or a trauma, such as an accident.
Moss delivered 320 prostheses last year. Only eight were for patients under the age of 18. That's because children often don't survive a trauma that claims a limb.
Esquenazi, who uses a prosthetic arm with a hook, was the next to examine Okello. The doctor had once dreamed of being a surgeon, but a chemical accident claimed part of his arm. Now he is noted for his work in physical medicine and rehabilitation.
The doctor told Okello he would get two "terminal devices" - a metal hook and a mechanical hand covered with a urethane glove - to attach to the wrist of his prosthetic arm. With training, Okello should be able to switch back and forth.
Esquenazi gave Okello a high-quality, but basic, arm that might be easier to repair in Uganda if it breaks.
What happens when Okello needs another one in about five years is unclear.
"If he needs a new prosthesis, we'll do the best we can," Shames said. "But I can't make an absolute guarantee."
Sustainability is just one of the challenges of taking someone, especially a child from an impoverished country, for treatment here.
As with clothes or shoes, children outgrow their prostheses. Will there be someone near home to repair or replace it?
Questions such as these mean many relief workers prefer to build a system delivering care rather than treating one person, said Wendy Batson, U.S. director for the nonprofit Handicap International.
While she is happy for an individual child to get care in the United States, Batson said victims should be treated in or near their home countries to maximize resources.
"It's not from being cold-hearted. It's because of hard practicalities," Batson said. "You end up breaking hearts" if a child gets used to the benefits of a prosthesis and has that taken away.
Okello was not pondering moral questions as he spoke almost two weeks ago to students at Lower Merion's Welsh Valley Middle School about life in northern Uganda.
Stammering slightly and moving from foot to foot, he told them about being abducted, and about one man he was compelled to kill.
It was in the evening, he said. The rebels found an old man and wanted Okello and others to kill him.
"I wouldn't" was his initial reaction. "But rebels said they would kill me if I didn't - so I did," he said.
The auditorium was silent as he spoke. One young man who seemed to be sleeping earlier was wide awake at that point.
Okello later talked about his future. Although he is in Uganda's equivalent of ninth grade, his motto is "No excuses" and he dreams of becoming a lawyer and maybe writing a book. He envisions doing all this with his new right arm with a hand at the end, not a hook.
"The hook is good for the old people, but not for the boys. Girls would turn away," he said with a smile.
On the Web
More about Ronald Okello's experiences as a child of war, and the foundations that have stepped in: http://go.philly.com/health
How you can help
Donations to assist Ugandan children may be made via the Web site at left, or by mail addressed to:
Stephen Shames Foundation
328 Flatbush Ave. #198
Brooklyn, N.Y. 11238EndText