My Very First Medical Mission 8 Years Ago

I'm going to spend this month, also my birthday month, to self indulge in the things I care most about. Since I am not one to enjoy receiving gifts as I am giving, I will share with you a non-refundable gift of a story about one of my dreams and passion.

I most enjoy being able to give things to people, which it should be no surprise as to why I am a doctor after all. This particular trait also explains why I am so fixated on doing/going/planning for medical missions. Watch out! I have a bunch of knowledge to give away! And why not? Well, it goes two ways actually. On the one hand I am giving away my services, time, talent and energy to others, whether it be here in the good 'ol U.S. of A or abroad. On the other, I am gaining so much more, I think. I learn about different people, cultures, beliefs and get a reality check that, in fact, we are all pretty much the same. We are human and deserve the touch of humanity. 

Eight years ago I had the opportunity to travel for my first medial mission trip to El Salvador and provide medical aid to the Salvadorian people. I have traveled internationally before for vacations but never for work. I was just an itty bitty medical student at the time and eager as a beaver to see things and do things. I had even been taking medical Spanish classes exactly for this! Sí! muy emocionado (very excited!)

We flew from Iowa to Texas awaiting a layover. The group of us were hambriento (hungry) and rented a car to get some grub. Once finished, we walked out to find broken glass from our rental car and missing bags. Our car was broken into and one of the gals had her passport taken as well. What a start.

A picture of a picture so the quality is quite poor. But our hearts were rich (and a bit tachycardic) and here we are just landed in El Salvador, 2009.

A picture of a picture so the quality is quite poor. But our hearts were rich (and a bit tachycardic) and here we are just landed in El Salvador, 2009.

We eventually made it to El Salvador in one piece. We ate, got some rest, were given a briefing about the local culture. What I remember from our hacienda was that running water was more like dripping water and it was timed so you took a quick cold shower so that your roomies can wash up too. And maybe the drain didn't really drain. Don't bother putting on makeup or getting your hair fancy. This was not a place for vanity. Drinking the faucet water was also not encouraged. 

We had several successful days seeing many families and giving out bandages, vitamins, performing history and physicals and the like. Everyone was grateful and many traveled distances for the free clinic. A lot of the locals were intrigued by our blue eyed blond hair colleagues, it was the most entertaining thing they saw. I blended in just fine with my brown eyes and brown hair. 

Things were going great. Some things were quite a shock, like the empty buildings with the bullet holes, while other parts were very Americanized like advertisements for pop/sodas, fast foods, and those American things. 

One time I even found a dead spider in a young boy's ear! True story.

One time I even found a dead spider in a young boy's ear! True story.

I believe on the second or third day of clinic our anticipated clinic location was moved for one reason or another. Thinking nothing of it, we did the usual, setting up tables and chairs, saw each and everyone who showed up. I probably mangled the Spanish language, (lo siento) and decided to communicate via the pointing technique. 

A few hours into clinic, we all heard a "pop-pop" then "pop-pop-pop-pop-pop," a total of 21 gunshots went off. Everyone scattered, many pushing down tables to create barricades. Mothers and children were screaming while the staff tried to herd everyone to a safe place and taking cover ourselves. I carried a small hysterically crying child to his mother and then ducked under a table. I had my point and shoot camera in one hand trembling with the other trying to turn it off so that it didn't make any sudden noise. I scanned the room eyeing the open door watching a male figure in black uniform pacing back and forth with the rifle by his side. I had no idea who that was, what side he's on or what just happened. I crouched under the table nearly paralyzed trying to stay quiet. I think I was breathing but I can't be sure. 

I remember thinking, should I take pictures? Should I document the last days of my life? What if they catch me with the evidence? Are they here because they think these American doctors have drugs? What would I say if they asked? 

I don't know how long it was before it was cleared but needless to say we were all frazzled. We finally learned that there was dead man (maybe in his twenties) in front shot at point blank in the head and a small child at the nearby school struck by a stray bullet. It was a gang-related fight of retaliation. My heart was heavy that day. This is what the people of El Salvador live through everyday. Violence runs the city. El Salvador is still considered to be the Murder Capital of the world and has a murder rate 22 times that of America. But they also need medical care. 

At the end of the day, we had a meeting and debated whether or not to continue the mission. Half of the group was very vocal about staying while the other half said we should leave. And all of a sudden tears were streaming down my face. I was pissed. I was pissed that we were even debating and downplaying the trauma. I was pissed that we couldn't do more. I was pissed for being pissed. These emotions were unexpected and that's when I realized I was truly naive about what was to be expected on these trips. 

A young El Salvadorian girl carrying cashew fruit. Hustling can start at any age. 

A young El Salvadorian girl carrying cashew fruit. Hustling can start at any age. 

Instead of a weeklong international medical mission trip, it was cut short to just a few days. Everyone on our team was safe, but some took home traveler's remorse like myself. I felt awful for the things I took for granted, like my safety, running water and material things. While there were others who were more experienced in dealing with traveler's remorse. You just kind of just push it down, ride the wave and learn to appreciate all that you have. Counselors were offered but I kindly declined it. I felt I needed to deal with these feelings and sort it out myself.

There were so many beautiful parts of El Salvador, the coffee, the dedicated families, their food, the beautiful children and things they made. And the broken parts that is beyond any one person or small group to fix. 

La Clinica in San Salvador, El Salvador

La Clinica in San Salvador, El Salvador

So you're probably asking, would you recommend medical missions after all that?

I don't think it's for the faint of heart. You have to really know what you're getting into, what the goals are, what your resources are, what the backup plan is and a safety get-out plan. You may be going to just explore new land, offer your services, collecting some memorable pictures and calling it a day. There's really nothing wrong with that. Many people have gone and never dealt with anything traumatic. Some others may have had a way worse experience. 

Essentially, it's your own judgement call but I know this is something I will continue to build on. My deepest passion is to share my knowledge on wound care, amputation prevention and correcting foot and ankle deformities so people can just live without pain or a cumbersome wound or a deformity limiting their ability to make income. I have since been to San Miguel, Mexico with a few more trips planned and brewing for the next few years so stay tuned! Ultimately, the big goal is to spread awareness of what services podiatrists have to offer since we are still such a small profession and create sustainable clinics all over the world where it's needed. Naive? Probably. Committed? Yes. 

Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.
— Mark Twain
Adiós!

Adiós!

 

 

Diabetic Foot Care: Preventing Amputations

I've learned from reading all of your comments how concerning it is to be diabetic and see all these amputations. I want to assure you that amputations do not happen overnight. And it doesn't just happen because of diabetes alone. Often times there are early clues and many situations are easily corrected. Here's an example:

A callus builds up pressure causing the skin to break down. Shaving this down regularly and wearing appropriate diabetic shoes can prevent this callus from becoming an ulcer. Open wounds or ulcers are beginnings infections and amputations. Let's prevent that!

A callus builds up pressure causing the skin to break down. Shaving this down regularly and wearing appropriate diabetic shoes can prevent this callus from becoming an ulcer. Open wounds or ulcers are beginnings infections and amputations. Let's prevent that!

A long time diabetic patient presented for her first diabetic foot check. She states walking a lot at home, cooking and doing housework often wearing no shoes. She's developed a callus but doesn't see the podiatrist until "it really hurts." Unfortunately, she has the late stages of diabetes that affects the nerves in the feet, so she has some numbness as well. She is older too so cannot bend over to see the bottom of the feet and has blurred vision so cannot see clearly. 

Can you see how all of the combined issues in this case make this particular patient more vulnerable to foot infections? How so, you ask?

1. Having diabetes "for a long time." As soon as you are diagnosed with diabetes, you should see a podiatrist right away. Foot specialists can tell you what your particular risks are and make recommendations. It could be as simple as caring for dry cracked feet, foot fungus or more serious like having a prior amputation. 

2. Only waiting to see a doctor until it really hurts. The problem with this philosophy of waiting until it gets really bad is this, it's probably really bad. Prevention is key. I repeat, PREVENTION IS KEY. I have patients deathly afraid of doctors so when they finally get to me, well I only have bad news for them. The good news is podiatrists, myself included, are very diligent about preventing any level of amputation. We are on your side. Do not be afraid. And if you are afraid of one podiatrist, there are other, many thousands of others.

3. Numbness in the feet. This is the number one reason why many patients delay care. They simply do not feel a problem because they have neuropathy. Without the gift of pain, one does not know they are walking on a thumb tack or other sharp object and overtime this gets ignored, infected and you can imagine the domino effect. 

4. Not being able to see. Our older patients simply cannot see due to diabetic retinopathy (eye damage). So it will be difficult for them to report any problems if they cannot feel or see their feet.  

I hope to prevent as many amputations as I can but I can't help if I don't know who you are. Keep sending me your questions! Thanks for reading.

 

 

What I wish for everyone I meet in the Emergency Department

Whoopsie doodle, looks like I missed the entire month of April to blog! Needless to say I am happily busy in my practice in sunny Northern California. So busy that I am seeing a preventable trend in the Emergency Department (ED) on patients I am called in for and hope to be able to help some of you or your loved ones suffering from diabetes related foot problems. 

IF YOU HAVE DIABETES...please establish care with your local podiatrist. We can point out early signs of problems such as pressure points, blisters, calluses and ulcerations and provide recommendations to preventing infection and ultimately loss of limb. We can provide prescriptions for diabetic shoes and custom inserts and offer recommendations based on your foot type and activity level.

The most recent set of patients I have seen in the ED have had a sore for more than one week that was left ignored or self treated and, sadly, resulted in an amputation of part of the foot. This is often necessary to save the leg but also could have been prevented early on. 

I'M A DIABETIC, WHY SHOULD I SEE A DOCTOR WHEN I HAVE NO FOOT PROBLEMS? Excellent question! Not all diabetic patients will have foot-related problems but for some who develop neuropathy (loss of sensation) in the feet, you may not have the pain signals alerting you that you stepped on something or have a callus that is creating a sore underneath. Leaving this ignored is how infections brew and spread. Better to prevent than to wait for something bad to happen. 

Email me with your questions and I'll share the answers to benefit our readers. 

 

Heel Pain 101

Image from https://www.foothealthfacts.org/conditions/heel-pain-(plantar-fasciitis)

Image from https://www.foothealthfacts.org/conditions/heel-pain-(plantar-fasciitis)

Plantar fasciitis, used to be called heel spurs but is a misnomer, affects many people. It is caused by an inflammation of the fibrous band on the bottom of your foot that may be from having flat feet or very high arches.

The good news is pain can be managed conservatively in the majority of people. The bad news? Nothing good will come easy and it take consistent practice to prevent the pain from getting worse. Here are some freebies for you if you suffer from heel pain:

1. Pain first thing in the morning when you step down? Before getting out of bed, stretch your arch by extending your knee and dorsiflexing the foot. You can also use a towel to help with this stretch. Warm up for a few minutes every day. 

2. Pain still there through the day? Take a break and repeat the stretches. Use tennis or gold ball to massage the plantar fascia. 

3. Pain at the end of the day too? You may need to take a closer look at your shoes and invest in durable, supportive shoes that provide support to the arch. If the shoes fold in half, that's no good. If they are completely flat like the current trendy shoes, that won't work either. Walking barefeet will make it worse as well. What you can do is take a frozen water bottle and massage the arch out again. The ice will be very nice. 

Rest, Ice, Night Splints, Better Shoes & Orthotics are usually very successful in relieving pain. Surgery is a last resort. 

I'd like to send a special shout out to Rist Roller for providing me a  sample mini foam roller. I use foam rollers in general for my back so it made sense to have one for foot pain. This type of product is perfect for massaging out the plantar fascia in heel pain syndrome. Check them out. *I do not get any sponsorships whatsoever if you decide to purchase. They just seem cool.*

Wishing you all freedom from foot pain!

Reflecting on the last year in internet-land

I started this website as a place to collect and share my thoughts about patients I encounter (of course, with their permission, de-identified to protect their privacy & HIPPA laws), including some challenging cases that I failed at and some that I am most proud of. Whatever the situation, I vow to never abandon people who trust me to help them, however long the ride may be. These limbs are attached to beautiful people who have revealed their most vulnerable state to me and truly count on me to care for them. I find deep satisfaction in building these relationships and hope to continue in doing so. 

Along the way, I have engaged with dynamic people offering their pearls and sharing their personal struggles with me, whether they are patients or other health care providers. I want to thank you, the reader, for dropping by and opening up to me. I hope we will continue this curious journey we call life together and learn about all the different ways there are to heal people like you and me. In turn, I will share my struggles too. 

My husband & I working together in the operating room on a mutual patient. This counts as date night, doesn't it? :)

My husband & I working together in the operating room on a mutual patient. This counts as date night, doesn't it? :)

This website's 1 year anniversary is dedicated to my hubby who has seen me struggle to figure out my identity and purpose in a profession dominated by men. In training, I've been mentally beaten down by superiors, figuratively thrown under the bus by colleagues, punished by having necessary training experiences taken away from me, mandated to having one-on-one intimidation meetings, essentially outcasted for one reason or another...of course this list can go on and on but I won't dwell on it because that has passed. While inside though, I felt my morale was withering away and that I couldn't get through it another day, let alone another year. I started telling myself it is not worth it. I can't do this anymore. I can't do medicine. I can't help people.

The most harmful words to myself: "I can't."

And then one day I thought to myself I wouldn't accept this to be. I was determined to complete my training and then continue on with another year of fellowship training. I changed the conversation in my head from "I can't" to "I will." I will make this work. I didn't want to give up on patients I could help and I didn't want to give up on myself. 

The most rewarding experience is when patients are traveling distances just to see me and they thank me for saving them from the crippling effect of an amputation. There are days that the only salvation are words of kindness and I am thankful I am able to make it out the trenches to hear them now. 

As I reflect on this past year and the challenges I face, one thing stands out. There is power in kindness to others and most importantly, to yourself. Despite your battles, the one inside your head is the one you must learn to overcome.

"Whether you think you can or think you can't, you are right." Henry Ford   

Charcot? Osteomyelitis? Both? A Case Review

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

I inherited this patient from a colleague from what I thought would be a simple case. It started out as a middle aged poorly controlled diabetic with a foot infection. After surgical debridement, we were not sure if the bone was also infected so took a bone sample. The results were also inconclusive so together with the infectious disease specialist, we agreed that we should treat it as if it was osteomyelitis (bone infection) since this patient had recurring foot infections in the past. After 7-8 weeks of IV antibiotics, the patient developed bony destruction at the midfoot. 

What to do next?

Cases like this keeps me up at night for days at a time. I worry about the patient's deteriorating health, possible loss of job, and mental decline. The patient is at a risk for a below knee amputation since the antibiotics did not help all that much and surgical resection of the midfoot would leave it very unstable. If the midfoot continues to collapse, a plantar ulceration could result and then more surgery. 

Could this have been prevented? Bone infection is difficult and there has been no easy answer to "curing" chronic bone infection. Antibiotics can quiet it down but the infection will linger and acute flare ups can always recur. There's no definite duration for therapy, it is based on the idea that bone takes at least 4 weeks to remodel so 4-6 weeks of antibiotics became the gold standard of treatment along with monitoring of bloodwork. This patient received longer duration of therapy and was still not cured of the bone infection. The risk of longer treatment is kidney damage, cost, and other adverse effects of the drug. 

The plan for this patient is another round of IV antibiotics but realistically, another surgery is likely, whether it be a radical midfoot wedge resection or a below knee amputation. This will be dependent on the patient and what they want to endure. 

Email me your thoughts and what you have had success with. Let's discuss. 

 

Nonhealing Diabetic Toe Ulcer

I received this patient as a second opinion for a nonhealing diabetic foot ulcer located at the bottom of the great toe and the patient had been treated for at least 4 months. Off-loading and local wound care was not sufficient and the wound would never completely heal. I had to consult a good friend who I trusted to have seen more of these then I had. There are many approaches to this problem and I wanted something very simple and we both agreed that an in-office flexor tenotomy was the way to go. This took no more than 5 minutes to perform, from sterile prepping to wound closure. After one week of the procedure, the wound healed. Although not pretty, both the patient and I are happy with the results. 

Things I learned from this case & hope residents (and aspiring medical students) take away from my posts:

- If the wound does not change or improve after a month of the same treatment, you must try a different approach. Don't be afraid to try something new. Of course, weigh the risk vs benefit to what you choose to do.

- Consult as many people as you need to, read as much as you can, and use all of your resources. Don't give up too soon!

- Be clear and honest with the patient. I often find myself saying "I am not sure if what I do will work perfectly, but we need to try something different because the current treatment is not working. I want you to get better and I'm sure you do too." If I sense the patient does not trust me (yes, it happens), I am more than happy to recommend other providers. I need the autonomy to do what is necessary but I also need the patient's cooperation and set the appropriate expectations. 

Naturally, when patients heal and they don't need me anymore, a piece of me is sad that I may never see them again. But  oftentimes, that is a good thing. 

Skin Grafts, So Many! But One Reigns Supreme

My favorite thing about my job is surgery. This is not to say that I want to cut people all the time. In fact, many people are not surgical candidates and the mere mention of the word surgery will turn off a lot of my patients. Why? Well, I presume it is the work of the media who sensationalize the trauma of surgery rather than the benefits of it. But that is a realm I will not be diving into today. Or ever. 

What I do hope to accomplish is to educate people who indeed need surgery of the risk versus benefit. At the end of the day, the patient has full control on how they want to live and how they want doctors to help, for better or for worse.

Back to my favorite thing that I enjoy doing to help patients with nonhealing wounds, particularly diabetics, are skin grafts. Imagine the last time you scraped your knee from falling. These usually heal very well because the injury is small and superficial. It may take a week or so to completely epithelialize (become skin). What if the scrape became infected, became larger or deeper, and is not likely to heal in a few weeks? What options do we have?

I've mentioned in a prior post the differences of the skin-substitutes (allografts) versus a split-thickness skin graft (STSG which is a thin layer of skin from your own body, usually thigh or calf). Some products are designed to stimulate your own cells to regenerate a nice tissue layer to fill in the defect. Others claim to be "as good as skin." I have yet to find this to be true so I tend to go straight to the STSG (best option!) when the wound bed is well prepared to accept it. Plus, it's more cost effective with less than 1% donor site complications. See picture below. 

Top: lateral ankle wound with a well prepared wound bed demonstrating red granular tissue with minimal space defect. Middle: STSG applied to the wound bed, approximately 2 weeks post-op. Bottom: STSG fully healed, image taken at 2 months.

Top: lateral ankle wound with a well prepared wound bed demonstrating red granular tissue with minimal space defect. Middle: STSG applied to the wound bed, approximately 2 weeks post-op. Bottom: STSG fully healed, image taken at 2 months.

When Patients Say "Just Cut it Off"

As the year is coming to an end, our practice finds an increase in surgery demand with folks wanting to maximize their insurance benefits. That also mean getting peculiar requests such as amputations. 

Why would anyone make such a request? Without having to go into too much science, you already know that your feet is needed for day to day activity and it has to support your entire body all the time. I was a weird kid and wanted to experience what it was like to have only one functional leg. So I'd hop around on one leg for a few hours at a time and it didn't take long before I was exhausted. Granted I didn't have crutches or a wheelchair, only my imagination. And I thought, man this would totally suck if it really happened.

But you know it does happen. Children born with a missing limb or needing an amputation are incredibly resilient. They adapt very well, putting most of us adults to shame. Adults who have non-traumatic amputations have a harder time adapting. Walking with one leg increases our energy expenditure (makes our heart work harder) because we're doubling the remaining leg's workload to support our entire body. 

There are legitimate reasons to get an amputation. Trauma, degloving injury, pain out of proportion that has exhausted conservative measures (CRPS, PVD), infection, etc. Often time there is no question about the necessity of an amputation. 

I had a patient who got a small infection in their foot from stepping on a piece of glass and it went ignored for some time. She is diabetic, her daily fasting blood glucose is frequently over 250, and needless to say she has neuropathy, that is no feeling to her feet from the damage of high sugar levels. After having the infection drained, she has an open wound that will take a long time to heal due to a compromised immune system, also a complication of diabetes. She then told me, "just cut off what you need to so I can move on."

A heel ulcer from neuropathy

A heel ulcer from neuropathy

In the patient's mind - cut off the problem, I need to go back to work. 

In my mind - whatever I cut it'll take longer to heal and I will be seeing her for a very long time.

I think at times what I want and what the patient wants are not always parallel. I want the patient to take her poorly controlled diabetes seriously. She is at a very high risk of an amputation among other things like blindness, kidney failure, and heart problems. What she wants is to go back to work right away. The reality is, whichever road we take, amputation or continuing wound care, it will be a long one. Her body is not equipped to heal as fast as a non-diabetic so "just cutting it off" is not the solution to her problem. 

Things I tell patient to think about when they undergo an elective (non-urgent) below knee amputation.

- Prothesis? Can you afford it? Will your insurance pay for it? If not, can you manage living in a wheelchair for the rest of your life?

- Problems to the other leg - new sores will develop and within 5 years, you will have wound problems and possibly another amputation and possibly you may not live that long

- Stump pain - the stump may still break down and you may still need more surgeries. That's a common complication for diabetics.

There is no easy fix for a diabetic wound but with close monitoring from multiple specialists including you primary medical doctor, nutritionist, endocrinologist, vascular, cardiovascular doctor, and your podiatrist, this can be managed. You don't have to "just cut it off."

Weird Toenails

Every now and then, more often then I'd like to admit, I run across a patient with something so peculiar that I just have to snap a picture of it. Check out the pattern of growth to this toenail. What do you think it is?

It's so intriguing, like if it wasn't on a body part it might be a cool mixed media art to put up in the living room to act as a conversational piece. Or not.