Nazir Hussain

University of Illinois at Chicago
Bioengineering


//forty two //reminisce //the big G

//forty two 

It has been forty two days since we first began this internship. The time flew by quickly and the perspective I had of the program transformed throughout the 6 weeks I spent shadowing clinicians and patients. To be completely honest I wasn’t entirely thrilled with the idea of my first and only undergraduate internship would come from the university I attend. However, looking at the intensity and true immersion the program has provided, I am more than exhilarated from my experience and the opportunities afforded  to me. The understanding of how the University of Illinois Hospital functions not only as a hub for medical teaching, environment of healing, and as a profitable business puts quite a bit about the healthcare system into perspective. 

//reminisce

I waited over a week to actually post this post so that I could revisit some of the thoughts I initially had about the internship. Also, I wanted to be able to describe the feeling of coming back to school after an internship. This semester I am taking 18 credit hours. The mere concept of that initially would make my stomach turn over in the past. However, after seeing the discipline and drive of physicians under pressure, I’m both inspired and motivated to take the task at hand on. Knowing that I want to pursue an M.D. in the future, it is more than possible for me to complete my degree with excellence. 

//the big G

God. There are countless religions, conflicts, and controversy surrounding the topic/idea of an absolute power. For some, God is the final solution, to others a pure fallacy. However there are places when the views of one should not be forced upon another. The hospital is one of those places. 

One thing I have not talked about was the fact that the a few days prior to the beginning of the internship, one of the most active and prolific friends I have suffered an incredibly debilitating injury. She is destined for greatness. Weeks after meeting with Chelsea Clinton, and months prior to what was supposed to be her presentation to the United Nations in New York, she had sever neck pain and was completely unable to move her left arm. The doctor she went to see ignored her symptoms, which pointed to a neurological issue, instead stating that “It could be a pinched nerve or something” and leaving without actually treating the patient. Within days she suffered an aneurysm near her medulla due to an undetected AVM (arteriovenous malformation) which could have been prevented by some level of competency by the doctor who saw her (please note this doctor was not from University of Illinois Hospital).

She could have died. Most people die. She is not most people. 

As her body was shutting down, and while fighting through excruciating pain, she managed to call 911 and was taken to the hospital where she was stabilized and then cared for. Throughout the 6 week internship she was at University of Illinois Hospital, making visiting her more than convenient. I was there to see her unable to move or speak, when her sensory and motor function was severely impaired. I was there to see her cry due to nurses’ lapses of empathy. I was there to see her wiggle her toes again, when the doctors told her she could make a full recovery. I was there to see God become an issue. 

Poop. It’s usually inconvenient, it’s usually smelly, and it usually causes pain if you can’t release it. Part of losing all of your motor function is the inability to open your sphincter. The buildup of bowels due to constipation was causing her intense pain. During a brief stay at RIC, she found that digitally impacting her bowels provided immediate relief. Now, this a gross procedure. A nurse would have to stick their finger up the patients rectum, and essentially poke around until the poop comes out. For those of you who have made it this far in the post, this is where things come together. 

My friend’s nurse at UIH for the day was a woman named Carol. She is known for her Catholic beliefs. After suffering in pain due to days of constipation, my friend asked the nurse to digitally impact her. An abridged version of the conversation is below.

Patient: Hey I’ve been constipated for days. Can you do this procedure they did at RIC?

Nurse: Are you Catholic?

PT: Uh, sure.

NR: You should pray to this saint. She was a guardian for those in pain. 

PT: Are you giving me spiritual advice as opposed to medical care?

NR: It’s almost 3 pm, you should really pray. Do you know why we pray at 3 pm? Jesus died at 3 pm.

PT: If you won’t do the procedure will you find someone who will?

NR (quoted because I will not forget the sheer gall of this statement in a hospital): “You should embrace your suffering. The pain you feel is saving countless souls”

This is not a joke. This nurse said this. There are moments where God can be someone’s hope and salvation, and there are times when God has given you a procedure to help alleviate the pain of a patient. 

//grey area

I’m biracial. A product of my Indian father and my African American mother, I’ve been exposed to both cultures at different stages of my life. A significant part of my childhood was spent surrounded with Indian food and culture, influencing my upbringing and understanding of race. this changed when I moved to the suburbs in my early teens and, for various reasons, I was able to more easily identify with the black part of my heritage. Being able to understand the differences between the two cultures while existing in the grey areas between them has allowed me to shift between the two depending on the circumstances I am in. For the most part the choices I have made and the perception of my race in the eyes of others has had no truly major difference in my life. Until Wednesday. 

I took a PFT or pulmonary function test. In the simplest terms you blow into a pipe in different breathing patterns and intensities. Various metrics including volume and flow rate are then processed to provide information regarding the state of the patient’s overall pulmonary function. The test requires that each section is reproduced three times with relatively similar results. The technicians who perform the test are incredibly expressive and coach patients so that they can provide the proper waveform to the best of their abilities. The only profession even slightly similar to the expressiveness of these technicians would be a futbol commentator. After about half an hour the test was complete and my results were read to me. The first thing the technician mentioned was that I had about 70% of the lung capacity as compared to the predicted capacity based on my height and weight. I explained that I used to be a heavy smoker a few years ago and the technician stated that this wouldn’t explain such a large discrepancy at such a young age. He also noted a flattening of the bottom of my Flow vs Volume waveform, which signified restriction while inhaling. This could be a cause for my snoring if related to redundant tissue near my esophagus. 

Another patient entered the room maybe 10 minutes after I had completed my test and we were prepared to observe the procedure. The technician asked the patient if she identified as Hispanic and she replied that she is Latina. I asked if race was a factor in the testing to which he replied that the only race with more than marginal changes in predicted values was African Americans. There is an overall 15% difference in some predicted values which alters the subsequent calculations quite a bit. This is dude to African physiology, comprised of smaller torsos and longer legs. I noticed the technician had set my race to Asian, which he based off of my last name, and asked if he could reprocess the results as Black. There was still restriction present, easily explained by the smoking, but the results improved dramatically. For the first time being lost in the grey area between races wouldn’t suffice. 

//for the love of

We talk about empathy a lot in this rotation. Considering the amount of time spent in the MICU we have to be careful with every action we make. Curiosity isn’t exactly welcome by families with admitted loved ones. Nevertheless we are there to learn and that can be accomplished with a bit of tact. Taking interest in the discontent of a patient’s family leads to conversations about the patient’s perceptions about hospital procedures. This opens a dialogue that can help enhance transparency in certain areas so that patients are more aware of why certain actions are taking as long as they are. Discussing difficulty completing a test or discomfort while a minor procedure was taking place allowed for insight as to shortcomings regarding the devices and procedures used by doctors. Essentially, we had to listen to the patient’s complaints. However, it’s interesting how I feel that we get more out of a patient within the brief conversations that take place as opposed to the results I assume they receive in the rarely completed surveys offered online. The difference being that now the person that is hearing your plight is also coming to you as opposed to waiting for you to go and fill out a form on your own time. 

While exploring the odds and ends of the supply room, filled with various equipment used for everything ranging from testing procedures to IV equipment to basic hygiene. While certain items held interesting purposes, like the green dots sterilizers that allow doctors to sterilize the connector ports of IVs quickly and effectively, there was one item that stood out from the rest.

A teddy bear. 

Surrounded by hygiene products like toothbrushes, deodorant, and combs, there was a basket filled with fluffy brown bears. Although it is easy to assume why they were there, I asked the nurse and received an answer slightly outside of my original thoughts. As opposed to being used to comfort as children, the teddy bear served multiple purposes. Some patients who may have been in the hospital as a child may find it comforting and reminiscent to the past the overcame and hold onto the bear. For others it serves as a new texture as opposed to the crisp sterility of hospital sheets. The most unique application involved a small overlooked feature of the bear, its flat back. Patients with may find hugging the bear with its back facing their chest may help alleviate various pains the patient may feel. Overall, this adorable stuffed animal shows how easily it is to integrate the empathy into the melancholy of the MICU. Simple actions followed by simpler objects can help create comfort during an incredibly difficult time. 

//breathe

My rotation with Orthopaedics has finished and now I am beginning my rotation with the Pulmonary Critical Care division. Walking in to the hospital to meet and greet a new set of doctors, nurses, and medical assistants reminded me of walking in 3 weeks ago to meet Dr. Chmell and the Ortho Team. This time I met with Dr. Dudek and later the two teams he directs. 

It’s crazy how just 4 weeks ago I was picking up my hospital badge, excited to start the internship I had been waiting all summer for. After picking it up there was a second card behind the badge explaining the various codes that may be called over the intercom system. The most confusing for me was the Number 1 Emergency. I’m rather cynical so the next thing that I wondered was what constituted a Number 2 Emergency and the priority given to each one. For the next 3 weeks I wouldn’t ask for clarification as I had plenty to learn from in the Ortho Department; however within the first few days of being with PCC, I would experience a Number 1 Emergency first hand. 

Dr. Dudek clarified that Number 1 Emergencies happen every other day within the Medical Intensive Care Unit (MICU), and are called when a team of doctors is needed to treat a patient in arrest. This may include respiratory arrest or cardiac arrest, in either case it requires a full team of doctors because as Dr. Dudek said, “The patient is actively dying”. I wasn’t prepared for this concept, seeing lots of blood in a surgery or the smell of bone dust didn’t bother me because often the patient would walk out of the facility. To think that someone I was going to pass in the halls often could eventually simply be gone left a very empty feeling within me. 

Day 2 began with a tour of the MICU during the PCC Rounds. These took about 2 hours to complete and required anywhere from 9 – 16 doctors to occupy 150 square foot area in the hallway. A report was given on each patient’s current status and the doctor went in to see the patient and get a response if he could. This hit home hard as during the first week of the internship a close friend of mine was in the NSICU, across the hall. There was a very stark realization in the fact that this is where people fight what could be their last fight. This is where every breathe counts and all you have left is your life. The world outside seemed to  no longer matter when I realized that this is where my friend had been admitted for a few weeks, fortunately she is presumed to make a full recovery in due time. 

Lunch was a moments reprieve from the morbidness that is the MICU. Laughing with the other interns as rap battles commenced, hair advice was traded, and stories were told took my mind away from what I would inevitably have to return to. The final fleeting minutes of the break were approaching when on the intercom an announcement was made, “Number 1 Emergency in Room 6xx. Number 1 Emergency in Room 6xx.” My partner and I sprung up, we knew we had to go to truly immerse ourselves, but it wasn;t the most desirable pool of knowledge.

Walking into the room the air changed. There were 17 doctors scattered around the room, it seemed like madness. There was no way they could be any near as coordinated as the OR staff. The patients pO2 dropped quickly, at times flat lining to zero as the heart pumped at 150 bpm. Then his blood pressure skyrocketed. In the back of the room, amidst the rushing doctors and the chaos and tension there was a woman. She must have been the mans family member, rocking back and forth with tears streaming down her face. I found myself tense as well, hoping I would not have to see her watch a loved one die. 

This is real. 

This is all very real. 

People live and die daily in the rotation I am in, changing the lives of those around them instantly.

This is the world I have to improve, to make safer, to make easier. 

That is my responsibility as an engineer. 

//sophisticated savagery

Surgery is often either gentle or completely medieval in the eyes of the media. Shows like House thrive off of the lack of synergy between the two, however the realism lies more with the human element of the proceedings. Surgery is difficult, which is no profound statement, however it is interesting to see how the surgeons react to stress. On TV you see the beads of sweat resting on the forehead of a frantic doctor, worried about the next complication. In the OR you find that doctors will step away from a patient, frustrated and at times impatient before calming down and returning to the procedure. The control over human emotion is incredible, even when a surgery is difficult or not going to plan the near nullification of frustration is only a moments notice away. 

During a particular case in the last week of our rotation we were able to view a revision surgery. In the most basic sense it means that the prior surgery had a flaw major enough to require another corrective surgery. The patient was a large man whose hip replacement slipped and caused a hole in his femur. Initially I believed that the hole in the patient’s femur needed to be plugged prior to the insertion of the next hip replacement. The attending physician informed me that the reason for the slip and subsequent hole was because the hip that was inserted into the femur was too small. 

Overall the surgery seemed similar to the total hip arthroscopy we had witnessed earlier that day. The removed hip rested next to a bowl filled with bloodied tools resting in saline in the previous procedure. This time there was an artificial hip as opposed to the ball of the organic hip, tissue from the bone still clinging to the rougher edges of the artificial hip. Looking at the blood stained surgeons you could almost assume the procedure was medieval.  This was until you noticed what was happening with the blood. It was being suctioned and then filtered into a large basin, to then be placed into bags and circulated back into the patient. This prevented the need for withdrawals from the blood bank for a patient. 

The procedure was going according to plan until suddenly the attending backed away from the table. There was a very still moment within the OR and then he spoke, “The femur cracked”. His frustration was more than apparent, but in the blink of an eye he was back, calm and ready to proceed. His calmness was much needed as the 3 hour procedure immediately doubled in length with that simple crack. 

//jump

It’s not common to meet someone holding a current national record. It’s less common that this person used to have cancer. It’s even less common that this national record holding, former cancer patient, is an amputee who uses his foot as a knee. Sam Grewe is an incredible young man, whom I was able to meet this week during a stop by Scheck and Siress. 

The focus of this visit was to become more familiar with the procedures the CTOs use to optimize a prosthesis for a patient. On the way to the office/machine shop, we passed up a father and his son sitting outside of the room. At first glance I noticed that the son has a prosthetic leg, but I pushed forward into the machine shop to find out that the young man outside was an athlete. I had heard of how many athletes Scheck and Siress work with, and the stories of amputees running quite quickly in the hallway. The limb he was going to receive that day was for athletic use and nor for daily use. With carbon fiber supports and an Ottobock blade, Sam would use this blade to compete in the high jump. The fitting procedure was quite lengthy, with CTOs referencing the extended hours needed to find the most comfortable fit, carefully cutting and removing small sections until 2 am. There were certain oddities about this prosthetic compared to other, primarily a section of carbon fiber near the knee joint. It appeared out of shape to fit a tibia and far too low to fit the femur. The CTO explained that the patient had undergone a procedure called a rotationplasty, where a section of a limb is removed and the remainder is rotated as needed then reconnected. After a few hours of laborious fine tuning, we took the prosthetic out to Sam where he put it on and laced it up. 

Then, he ran.

His first run was his high jump form which differed significantly in lateral acceleration when compared to his more lateral form. He could easily outrun me, but his talent wasn’t amplified by the prosthetic, he was just that good. A few laps later, he gave his opinion on the fit and adjustments were made to prevent any irritation or uncomfortable friction. Without a doubt the impact of orthopedics is more than evident, not only can an amputee walk, but run, and even jump higher than any other man of his caliber.

//horizon

The Illinois Bone and Joint Institute on North Michigan Avenue is a perfect example of the potential of a private practice. As an LLC, they enjoy the rights and privileges of the IBJI while retaining some level of independent function, thus operating similarly to that of a private practice. The clinic is nowhere near as hectic. The view is incredible, erected in close proximity to Millennium Park, with a full view of Soldier Field, the Field Museum, Shedd Aquarium, and Adler Planetarium. It’s more than evident that the attending physicians are leaders in their field. It is no surprise that one of these physicians is Dr. Gonzalez, the orthopedics department head.  However it should be noted that with great power comes great responsibility.

Ensuring the patient is on the path to recovery is a doctor’s top priority whether in the clinic or the operating room. However it is important to note that this requires a patient to be present. One of our patients was an elderly woman with diabetes who presented with pain in her right knee. She was brought in by a caretaker who mentioned that she was new to the position and the previous caregiver neglected the patient. She was skinny, frail really, her face was sunk in a sorrowful gaze. Her right knee was very swollen, which the doctors assumed to be fluid. In an effort to reduce the swelling they asked her to change into a pair of paper shorts so they could drain the site. While we waited for her to be changed we viewed an x-ray of her right knee that showed damage caused by rheumatoid arthritis.

When we reentered the room my partner and I were visibly taken back. The patient’s legs were covered in what looked to be picked at scars or burns. As it turns out, it was caused by mismanaged diabetes developing ulcers on her legs. Not only did a significant amount of pain and scarring result from the neglect on behalf of her former caregiver, but future pain as the surgery could not commence with so many open wounds and her blood sugar levels.

 

It’s easy to get lost in the horizon from the 14th floor of 150 North Michigan, but when you turn around the real world presents you with complex cases that you, as a clinician, are responsible for solving. Dr. Gonzalez stayed within the confines of his specialty, mentioning that the patient should see a wound specialist and lower her blood sugar levels before her next scheduled appointment. That is all he could have and should have done. Responsibility isn’t about being the one person who saves the day but being humble enough to let the best man do the job.

//in the shell

Prosthetics and orthotics are why I decided to major in Bioengineering. The idea that you could replace and potentially augment a human limb eludes to a future defined by the limits of technology as opposed to physiology is mind blowing. However, until recently, I didn’t have an opportunity to work with prosthetics first hand. A recent research paper I wrote for a class at UIC, BioE 430, focused on the potential of myoelectric prostheses. These prostheses function in response to the electrical signals normally sent to muscles to cause motor function. The main benefit of these prostheses when compared to body powered prostheses is that myoelectric prostheses can fully replicate the intuitive function of a natural hand. 

While in the clinic I had expressed an interest in the process for custom fitting a hip brace, as a patient from last week was scheduled to come in for the fitting process. According to our schedule I would not be present for the fitting process and as such I wanted to receive as much information about the procedure prior to. I was pointed to a Technical Representative from Scheck and Siress, a prosthetics and orthotics distribution company, who brought me to their facility at the hospital. The facility looked like a bike shop that sold prosthetics; the devices were strewn across work benches and parts hung from the walls and off of shelves. I was first introduced to the orthotic devices, namely the hip brace that would be used on the patient. The size range ran from infants to overweight adults with a vast set of parts reliant on the three main size measurements: the circumference of the waist, of the pelvis, and of the thigh. A single fitting for the thigh was connected to a waist band that surrounded the pelvic area in a similar fashion as the plate we saw attached to a femur last week. Limiting parameters such as maximum leg flexion and abduction were set by the orthotist who would be installing the brace. An important point was made differentiating the terms custom fit compared to custom made. Custom fit implies a device that is adjusted to fit the user, like a seat belt it can accommodate a large user population with a single design. Contrarily, custom made implies that a device is made specifically for the patient and is manufactured specifically for their body, like a tailored suit.

After the crash course in orthotics I was shown the golden egg of the facility, a $60,000 Ottobock myoelectric prosthetic hand named the Michelangelo. I had done a fair amount of research on this specific product and knew its capabilities but was ignorant as to where it fell short. The concept of a motor signal causing motion in the hand was straight forward and seemed almost foolproof. In addition,  I asked the prosthetist if he found the Michelangelo to be more intuitive that other current market prostheses, especially considering its usage of pattern recognition to ‘learn’ the patient’s intended action and associate it with complex signals. To my surprise he disagreed pointing out a flaw within the concept of myoelectric prostheses. The electrical signal processed had the potential to misfire if it read a false positive or if the patient accidentally trigger the wrong mechanism, causing some patients to desire the simpler, body-powered, hook prosthesis.  While the pattern recognition software offers the capability to prevent these misfires, modern myoelectric prostheses are still a developing technology. As such, it can be expected that in the foreseeable future problems such as misfiring will be addressed and eventually eliminated as signal processing and pattern recognition software improves. 

Note: Image used taken from Ottobock.com

//simple gifts //hustle and slow

//simple gifts

Conversation is the forefront of innovation. Simple ideas can be passed from one individual to another until they reach someone who can capitalize upon them. My partner, Sam Dreyer, is the President of BMES at UIC. One of his main personal goals within the program is to find a problem that could be addressed with a simple device design project for members of his chapter. Throughout this week doctors have been able to readily answer our questions but recently they have given us little gems of information that elude to a device design. 

The first was during a carpal tunnel release. The procedure is completed with all of the surgeons seated in draped seats around the operating table, which is attached to the bed the patient is resting on. This particular table has a single leg which rests on the ground for support. Immediately we could see the work around doctors used on the table, the foot of the operating table had been wrapped in Coban. Coban is a self adhesive wrap that exhibits grip similar to a rubber end in this case it was used to replace a worn end. The primary question I had was why a simple piece like this needed a makeshift replacement as opposed to simply purchasing the required replacement piece. Considering the size of the hospital, it’s surprising that there isn’t a machine shop nearby to fabricate simple replacement pieces like this. Even more surprising is that since the U of I Hospital is in such close proximity to the UIC campus, it doesn’t have accessibility to the many machine shops on campus. It is my personal opinion that many of the makeshift parts could be replaced if a relationship between the hospital and a campus machine shop was formed. 

When talking with another doctor during a later procedure he noted that the approximate cost of one minute of time in the OR was $80. This fact became more relevant when discussing the lengthy extension of a procedure due to the suturing and cast molding. The cast molding procedure requires that a scrubbed surgeon must physically hold the cast and limb in place in accordance to the angles for optimal recovery. This is arbitrary and done subjective to the surgeon, not to say they aren’t capable of doing that but human error does occur. For some surgical procedures, plaster casts are used as opposed to fiberglass. This is because plaster is much easier to mold, however, it take 20 minutes to hold. The approximate value of a device that could hold a plaster cast after it has been molded with similar or improved accuracy is at minimum $1600 per surgery. It also allows for a swifter surgery and potentially a faster turnover of OR. This problem statement could be resolved in a number of ways an will definitely be investigated further.

The last notable improvement we noticed is procedurally based. The turnover of a hospital room can run up to an hour and a half on average. This leads to less surgeries taking place which the room is being cleaned and then prepped for the next surgery. While options to address this problem have been introduced in modern hospitals, there are currently no well known options to retrofit an older hospital to these newer procedure. This will be looked into further over the next week. 

//hustle and slow
coming soon

//one //blue //the other m(ixup)

//one

Post 1. Week 1. Day 1. Today was exactly what I expected out of a first day, until the last 2 hours. I expected this internship to leave me feeling like the residents following House, wide eyed and enamored following a doctor around halls and corners. The day started simply, an orientation with bagels and cream cheese. The room was quiet, whether it was shyness or sleepiness causing it depends on the intern. We talked about the purpose of the program, read the syllabus, and outlined our hopes and fears for the next 6 weeks. To be completely honest, my partner and I didn’t really have any fears. There wasn’t anything to fear, we were meeting new people and learning from them; essentially it was school. Side note, my partner’s name is Sam and we are in the Orthopedics rotation We met Susan King after the meeting. She showed us around the areas we would be working in for most of this 3-week rotation, the OR and the clinic. We then waited to meet with Dr. Mejia. A few hours pass and we get news that Dr. Mejia is still in the OR operating on a patient. Arrangements were made quickly and we were taken to the clinic We were then left in the hands of Dr. Chmell, who carries a very happy air about him. He was older but very upbeat and energetic, often asking residents, “Do you got anybody? Do you got anybody?” If a resident had a patient he would immediately introduce us and have us follow them into a procedure. Within 30 minutes I watched a patient have fluid removed from their knee, and another have collagen* added to their knees. For the next hour and a half we followed Dr. Chmell and the residents around the clinic, into, and out of office spaces.

//blue

Day 1 was basically the kiddie pool compared to the deep end that was Day 2. Waking up at 4:30 am to arrive at the hospital by 5:45 am to observe a 6:30 am total knee replacement surgery. Completely worth it. The day started quickly and moved quickly. With two total knee replacements completed before noon, the synergy and capabilities of the teams we were assigned to was more than present. I was introduced to some of the doctors who would be working with us during the procedure. Everyone was warm and friendly, especially for it being 6:30. I was shown equipment used in the OR, including an electric suture.

Prior to the patient arriving I was told the one thing I needed to remember: stay away from the blue. The “blue” referred to the blue cloths wrapped around sterile tools. Actually, everything that was to be treated as sterile was blue, from the surgeons gowns to the draping. Touch the blue and it’s over. The surgery has to be aborted, 

The first patient presented with rheumatoid arthritis in the left knee, with the femur and tibia eroding and causing pain. After sedating and sterilizing the patient, the procedure began. Lasting about 2 hours from prepping to suturing, the procedure itself seemed both advanced and archaic using both crude tools such as mallets and saws to cutting edge technology including a flexible drill bit. 

The third and final procedure lasted the longest. The patient was shot in the leg during the 4th of July weekend, with a bullet lodged well into the right femur. A steel plate was inserted tangent to the femur and drilled in using screws of various size. I don’t know if it was the fact that this surgery was much longer than the others or if it was the fact that it was the last surgery today, but my feet were killing me by the time I left. But, like I said it was completely worth it. There were some interesting circumstances about the last patient that make it stand out. The one thing I will not forger is when I heard one of the surgeons say “I can’t find the hole” while placing a catheter. Full team of doctors, not a single scrubbed doctor could figure this out. Some time later a urologist scrubbed in, I had to see what we was going to do. Big mistake of the day, weirdest looking genitalia I have ever seen. 

//the other m(ixup) 
coming soon

 

 

 

 

 


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