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True Grit

True Grit

By Shawn Diamond, MD

I discovered “true grit” in of all places a five-year-old from the Chihuahua desert.

I started practice this year in Paso del Norte, a region comprising sister-cities of El Paso, Texas and Ciudad Juarez, Mexico. When driving East on I-10 toward downtown El Paso, the Rio Grande reflects a border wall, and beyond are calles lined by vibrant colorful homes. Juarez and El Paso stare at each other from an arm’s throw. And in years without a pandemic, with friendlier politics, commerce bustles over the Bridge of the Americas and the distance between us lessens.

Before arriving to El Paso, Justin Mitchell, a fellow ASSH member, told me about a young girl who suffered an open forearm fracture, developed osteonecrosis of the radius, and was offered an amputation in Juarez. Through affiliations with a local charity, FEMAP, imaging, including an MRI and clinical photos, voyaged across the border. These showed a substantial limb deformity, little motion through the wrist and digits. In another circumstance, one could mistake the photos for a Bayne Klug III dysplasia with severe derangement. Behind this twisted wrist, a five-year old girl, eyes big and bright stood ready to accept a major limb amputation. Certainly Dr. Mitchell, our third partner, Gilberto Gonzalez, and I felt compelled to offer an alternative.

After arrangements with the border, El Paso Children’s Hospital, we had an opportunity to intervene. I met “D” prior to surgery. She sat quietly, perfectly behaved, a professional patient, one who had numerous interactions with physicians. I did my usual, dopplered the calf, found some nice septal perforators, drew out a generous skin-paddle, marked the access incisions to the forearm, a Bilobed flap for the wrist if needed, Z-plastys…and explained to mom that the “worst part is the heat, the lack of sleep, and the starving post op.” It’s a ritual before free flaps rehearsed over and over. Well, D understood it all. It made no difference to her. She would do what was asked of her. She was without fear, without complaint, perfectly intrigued, engaged and at the same time, sage.

After five hours of operating, blood seamlessly flowed from a 1.5 mm radial artery to peroneal artery. And a fibula bone flap interposed a 6 cm gap. D had a new wrist and forearm. She suffered through my tortuous warm blanket, warm room, hourly flap checks that often enrages adults. Her only medicine: Aspirin and Tylenol. She had a massive surgery and zero narcotics. She did not wince nor whine. She walked in her CAM boot. Her mom need not scold her. When asked, she closed her fingers into a fist for the first time in two years, rotated into supination, and could grab her stuffed animals. It was then, that she looked up, her eyes softened, and relaxed. She let out an awesome big smile. Grit.

Note: The appropriate consent was obtained for use of these images

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