foreign [Music] good evening I'm Dr Jeffrey Speer current president of the El Paso County Medical Society for 2022. we at the El Paso County Medical Society are very proud of this program we are certainly grateful for the collaboration of both star studies Studios and kcos for making this program a reality we're also incredibly grateful to miss Catherine Berg who has been such a terrific partner for the last 25 years being this program's host we hope you continue to join us each and every month for this fantastic program and please enjoy the presentation tonight thank you very much [Music] on the El Paso physician we're going to be talking about pediatric surgeons and conditions that happen here in the Borderland pediatric surgeons diagnose treat and manage children's surgical needs which are very different from adult surgical needs and we have specific issues and conditions that happen specifically here on the Borderland that don't happen in other areas around the country we're going to be talking about that this evening the program is underwritten by El Paso children's hospital and always a huge thank you to the El Paso County Medical Society who's been bringing this program to you for over 25 years thank you [Music] thanks again for joining us we are here this evening discussing pediatric surgeons and conditions specifically here in the Borderland and uh Dr Diamond we were talking prior to the show this is Dr Sean Diamond who is a plastic hand in micro surgeon and we were talking a couple of uh goodness months back about brachial plexus but there's a lot of other things that you do which are absolutely fascinating and being part of just being a pediatric surgeon in general you're looking at a lot of Bones and ligaments and growth plates that aren't finished yet so your specialty is just spot on with what you're doing and I'd like for you I know we joked earlier I said you know one of my questions is going to be what do you do all day every day and you showed me photographs and videos of what you do um which we're going to put into the show later on as well but if you were able to verbalize that and explain that to our audience how would you describe what you do all day every day yeah it's tough right I mean plastic hand micro surgeon that's a mouthful right and there's a ton of variety and as you really um explain nicely the hands are a really complex organ as you know there's skin tendons nerves arteries bones veins ligaments growth you name them all that was like very impressive and so plastic surgery why am I doing this I mean what in the world it's really the surgery of these really complex tissues that have to all work in Orchestra as one and what we didn't mention is it all has to work to move and to function and to reach out and touch the world and be able to play a piano or do sports or get people back to their life and that's the fascinating and really fun part about hand surgery and I'm lucky that I work with kids because they just heal and recover like gangbusters they just kids are amazing in that way meaning they can get really hurt and you can fix their hands and they do fantastic because they don't even need therapy they just start moving and doing things and on the other side kids born without Parts meaning born without a hand or born without fingers also do extremely well meaning I know NFL football players champion Surfers I mean really can go on and do anything they want to do so it's fun working in a specialty where there's like no losing yeah I love that no losing and very little I said I don't know if we're allowed to say no but very little but I like what you talked about earlier we were talking about when you said elf outgrowth issues so this is children that are born with maybe and you know their hand is not necessarily all there maybe they've got a couple of tips of the fingers and their arms stop short when you're talking about outgrowths you were talking about first how a child doesn't know that they don't have the extra hand it's just that's how they operate and you said often you don't talk about Prosthetics with the family with the parents until years after their birth three four five six years if even then because you said also some times the child will just know how to do better without a prosthetic than what they're prosthetic I'd love for you to take that for a little bit and explain that to us because sometimes you we look around the world and we're thinking well we can make you a hand we can make you a foot we can make you a knee and a leg but maybe sometimes you don't want to and talk about why no that's right well we can't quite make a hand yet it's pretty complicated yes we can transplant hands and there has been a pediatric patient who's undergone bilateral meaning both hands transplanted at the University of Pennsylvania at chop and children's that is a one-off meaning it's so rare and it's because he was born with hands and lost the hands to infection so he already knew how to use a hand okay now imagine being born without a part like you're born without a unicorn horn what if you just grow up and you're five years old and someone just sticks a unicorn horn on your forehead what do I do with this thing you're not gonna know how to use it it's like who knows so that's the issue right if you're born without a major part is maybe in the future we can transplant or put on and just like a prosthetic maybe you can but it's a learned behavior meaning they have to learn how to use the prosthetic they have to learn how to keep it on et cetera et cetera and like I said before kids do amazing on their own they just learn how to use their body and adapt in a different way than um people born with five fingers right and on that note and again we'll we'll show some graphics throughout the program as well but talk about fingers because we'll see these that are fused together at Birth and what is it that you are able to do when you said earlier a hand is complex so we're talking about and we joked earlier and actually I'm going to have you have some fun with tubing sure okay talk about what you told me about surgeries are all about tubing yeah I mean we don't have that I mean we have a ton of body parts and then that at the same time we don't have that many meaning right we have lots of tubes right ear tubes we have intestines which are tubes the gallbladder essentially is a blind ending tube and appendix is a tube with a blind end um what else did we say we're talking about when I'm thinking about the hands we're talking about arteries we're talking about veins we're talking about the all the the nervous system that goes in there's all the tubing that belongs and you've got the fingers that aren't tubes but they look like tubes all right cool so now let's break down all of medical pathology into this very easy keep it simple method of saying tubes can be blocked right which is like a blood clot right tubes can pop which is like a ruptured appendicitis and tubes can tear which is like a aorta problem in a young person with Marfan syndrome sort of thing aortic dissection what else do we say tubes can do tubes can be infected they can be infected like you said yeah and you're talking about ears intestines all that we'd already gone through but yeah absolutely that's all it is and so I'm thinking reconnection so if you're looking at veins reconnecting one vein to a new vein again in hands if you are doing hand uh not Replacements but yeah hand Replacements I guess when you're looking at a donation of a hand through yeah a circumstance there are nerves in the hand that need to be connected to the nerves that are already in the wrist that connect to the arm that connect to the brain etc etc so those tubings are what fascinate me and how can you connect a tube situation from another person to now a tube to the person who's going to be using it you know where I'm going well let's make it easy let's just say it's the same person okay because it's again really rare that we're talking about transplant although plastic surgeons they did win the Nobel Prize for inventing transplantation so we not only do all the aesthetic stuff but we do have some brains too but yeah anyhow tube connection so let's say a young person Cuts their wrist with glass and cuts the nerves and the arteries to the hand at their level of the wrist the way I typically will reconnect those is with either really powerful Loops which are those doctor glasses that have those long things coming off them that magnify your operating field or with an operating room microscope but I sort of see the world in microsurgery which is to look at one of those blood vessels and you can see all the different parts of it the advantage on the outside the media on the inside and then the aluminum in the inside and it's just amazing what you can see with light Optics and magnification and instrumentation meaning our instruments need to be able to work on those very fine parts and we can reconnect blood vessels suture by suture usually those stitches are like the tenth of a human hair geez and I'm going to stop you there because I don't understand that I don't I have a hard time comprehending how I know you got micro micro glasses on I get that but just the instruments that you would require to grab onto something that small no and what is what is what is assisting you with that so so talking about hands yeah operating is to do with the hands meaning I don't use a robot or a stick it's very tactile so I have a surgical instrument in my hand that looks like a needle driver but it's very fine and it reaches out and it grasps that very fine suture needle and it's laser wedged onto that thing that's less than a human hair okay and underneath the microscope I'm physically looking at myself throwing each suture so it's a very tactile human thing it's very cool so if you're looking at and I don't even want to even try to get into sizes so if we're looking at Pediatrics and a lot of the the videos that I saw are of toddler age I would say you know um so we're like one or two years of age and so when you're looking at the nerve endings in a hand how many might one have going from the wrist into the hand um and let's just first talk about these transplants and then let's talk about these fingers that you just did so let's talk about the transplants first because I know that's big and grandiose and get that out of the way and then we can talk about being able to move two or three fingers that you showed me earlier today sure so we have three major nerves from the risk going into the hand the median nerve the radial sensory nerve and the ulnar nerve each of those in a little kid are probably on the order of about five to seven millimeters in adults probably seven to ten millimeters so they're sizable things they look like big thick linguines and on the inside of those are smaller and smaller and smaller and tiny little fascicles it's sort of like if you cut an electrical cord and see each of the little wires inside that's what a nerve kind of looks like Okay um and then as far as repair we suture and nerve ending wise they all go out into the fingers meaning you can map each one of those nerves and we're very cognizant of all them as we're operating on hands so so when you map a nerve what does that mean that means we know its usual course and for nerves that are injured sometimes we'll use a nerve stimulator in the operating room and even though the patient is asleep you can actually use a small stimulator and watch the function of the nerve and gather a sense as to if the nerve is functional or not based on how well it stimulates the muscles Downstream a bit so let's say the nerve going into the bicep if I use a nerve stimulator on a healthy person on an operating room table their hand will usually slap me in the face interesting and if so you know this immediately while you're in surgery check that out real time okay 100 real time okay so when we are looking at um three fingers now or two fingers that are that are severed together for the lack of a better word are you looking at in these surgeries that you've done are you also splitting the bones apart are the bones already split apart you're just doing uh soft tissue or all of the above depending on what the situation is it's all of the above depending and that's a great question because everything comes basically in Rainbow flavors you know there's no one syndactyly which is the condition you're talking about which is connected fingers or webbed fingers they're sort of called the most common one is a connection between the middle and ring finger statistically oftentimes they involve the entire length of the digit so we call it complete okay incomplete meanings it's not the whole length of the digits simple means it's just skin only usually it's like skin fat they share a nerve in an artery which can be separated and then complex means they have connections of the bones then we have to separate parts of bones or even extra digits inside of that connection that's the other one I want to ask you about before we're done okay sorry about the very last one is um those hands that are complicated and what we mean by that is that they're associated with other syndromes so there's other hand differences that are related to for example craniofacial syndromes where okay that kids look at least in their face different than others and you can gather a sense that they may have something like an Apert type syndrome okay which is something to do with a different appearance and also with clefted hands or with attached fingers so if you don't mind explain what Apert syndrome and or an aper syndrome might be for someone like me but doesn't know yeah no this would be great to have our oral maxillofacial team and and cranial team here because it is a syndrome that involves the frontal bones and the craniofacial skeleton and it evolves differently than others sutures are prematurely fused about the same time that fingers are prematurely fused interesting all goes together and these are kids that require a team of both craniofacial surgeons and hand surgeons at the same time so usually and I know we talked a little bit about this prior to the show but we were talking about sonograms we were talking about MRIs done fetally or uh while mom is still pregnant are these things that you can see prior to giving birth and and then I guess the next question is when when is the best time to do these surgeries and and I know again everything's different and every every case is different but in general is there you want the baby to thrive for a while first to yep okay so those are two great questions firstly um women getting a prenatal Anatomy scan meaning those 3D scans with ultrasound are very um they're very high resolution so you can see a lot of different hand issues and so I take and have seen patients who are mothers at the time and they'll usually get those scans in the third trimester early third trimester and I'll see them during their pregnancy just to talk about what to expect um as far as surgical timing for patients that need surgery because again a lot of my patients don't meaning we really have a discussion with the family and talk about what our goals are Etc and like we already said plenty of kids do fantastic keeping things as they were born but for certain things for both function and Aesthetics and future to avoid teasing in school Etc we do decide on surgery and for the most part I'm doing hand surgeries at about one year of age okay and there's reasons for that right yeah so anesthesia's safe and their hand is big and their hand is Big at what you I get it you've got a newborn six months a year is pretty large at that point okay when you say their hand is big if you were to wait until two years or three years would there be functionality differences because you talked in the beginning of the program how a child learns how to adapt with what they have yeah does that factor into the idea that you kind of don't want to do it more than one or two or three years it does so I would say one year is kind of the Common Ground that I look for but between one and two the hand doubles in size again and just makes my job so much easier because I'm dealing with big parts that are easier to work with how you call them big Parts yeah your old goodness yeah so um about age three and there's a whole you know there's a very clear algorithm of how a normal developing child goes on to use their hands meaning you can see they grab and reach and then they start Crossing midline and then they can rake which means physically pull an object into their palms from outside and then eventually about age three four they start working what their thumb is okay my thumb is the most important part of the hand it's about 50 of hand function you said that's about H3 and that's probably I think would be earlier than that I guess not okay it's about age three when it becomes critical interesting and there may be sort of non-reversible things happening so that if a child doesn't have a thumb by about age three four and you need to for example make a thumb for them it probably ought to happen sometime very early so that they can have that brain plasticity because again it's that old thing of that muscle memory not born with a thumb yeah kind of not born with a unicorn horn and if you wait too long they may not learn how to use it perfectly but in other words there's young children born without a thumb at all and we will use their index finger for a thumb so that's the perfect transition uh you were showing some video and some footage earlier so I want to go first to when there are extra digits I want to say that there was a foot with maybe seven toes six seven toes sure so when we're looking at yes Aesthetics but also growing up too that shoes aren't going to fit because they're that many extra digits so there are reasons to have these type of surgeries so how would you then go into is it is it simply amputation and then adapting it from there and nothing simple that was a wrong word to use that was a wrong word to use but um describe how you would a toe with seven digits yep how or excuse me a foot with seven digits how how do you deal with that surgery no I mean nothing is simple I think that's the perfect way to put and again all of these feet have all kinds of parts and what we're looking at is creating a balanced foot or a balanced hand that we know is going to grow row uniformly and the long story short is that even with an extra let's make it simpler and say thumb just because I deal with extra thumbs pretty often that extra thumb is often borrowing ligaments or tendons from the one we're going to keep so when we remove it we also keep the usable Parts okay and that's a huge principle of hand surgery because in hands there's so many parts and we call it spare part surgery and so we're borrowing those parts that are usable workable perfect and they're going to help the thumb that we're going to keep so we rebalance the ligaments we rebalance the tendons and we use part of the skin to reshape the skin and make it look right make it look perfect work perfect grow outwards straight as an arrow and that's what we're doing and I like when you were talking about the reshaping and the balancing of of the foot and I know we had a program uh not too long ago but we were looking at the fibia bone and I know this is not feet but the fibio bone in the leg is used as the spare part bone it is and so I I've learned all kinds of things about spare parts and as you've learned microsurgery already exactly and so we were talking a little bit about microsurgery and this is where my joke about all the tubing comes in yeah because when you're looking at reconnecting everything to me that's fascinating so now taking it to creating a thumb because that is an opposable figure I mean that's what separates us from so many other animals that's right um when there is no thumb and you were trying to create a not make a hand but for the lack of a better word create a hand as much as you can that isn't there and digits I know you could talk five hours on this one but I'm curious how does one do that no and is there I say that with the fibia because if there's not tissue or bones there in the hand say it was an outgrowth type of the situation where do you get that tissue and bone from so the operation is called policization and it's kind of the penultimate hand surgery operation it's a beautiful elegant surgery that's been getting refined and refined and refined over again will never get it as perfect as we can and we've been working on it for some 90 to 100 years at this point and that operation is using an index finger and turning it into a thumb and it sounds okay simple com you know conceptually you're just like yeah it's a finger it's a finger just trade out yeah not a problem it's complex in the way that you have to reseat the index finger in a thumb position meaning if you look at your own hands the thumb is in a very different place than the other four fingers and so you don't rotate that index finger all the way around and how the joint works you have to keep the joints and remake what's called a carpo metacarpal joint which is this saddle joint all the way at the bottom of your hand right forward in order to rotate it you need to ligate meaning clip one of the arteries to the index finger but be careful to preserve the other because that's the only way it's going to have blood flow you rebalance the tendons and make the flexor tendon of the index finger into a new flexor tendon of a thumb and vice versa and then you rebounce a lot of the different muscles and I could go on and on and on because again it's been this deal that's been getting refined for decades but long story short you end up with a four finger hand if you meet someone in your life with a forefinger hand who had this operation I would be hard-pressed that you would notice walking down the street or even shaking their hand that they have a forefinger hand so we call it a Simpson's hand but I'm telling you if done very nicely which often they are you would never know that someone's missing a finger and go through if you don't mind because how big of a deal this is is that when you have four fingers but without a thumb and now that there is a what can they not have done in the past if they can now with that thumb and I imagine you talk to families about this all the time with the surgery we can a b c and d yeah I mean you would have to meet and speak with people who are missing their thumb after having it for a long time and those are people who've lost their thumb owed to cancers or traumas most often table saws or the injury I would see or even gunshot injuries or firework blast injuries it's a huge barrier because you don't have something to oppose or pinch and you lose all your pinch strength and you learn you lose this digit that can circumduct and what that means is the thumb can make this huge Arc all the way around the hand to touch the small finger notice I don't call it a pinky hand surgeons don't use the term peaking oh not the pinky okay but the thumb is there and can touch every other digit you know it's very challenging take your index and touch your small finger versus your thumb and touch your small finger feel the power that pinch power you can get between your small finger and thumb and I'm just thinking about this muscle if you have to create this muscle from scratch because you're right that is so that's another great question we don't create that muscle we borrow other tendons in the wrist and the forearm to recreate that muscle so think about that let's feed it forward to that person who's waited way too long to fix their carpal tunnel and that nerve compression at the carpal tunnel has really atrophied the muscles at the thumb so much so that they'll never recover but they're really important and so we actually borrow their palmaris tendon or one of their flexor tendons or even a tendon from around the back of the hand so the palmaris tenor is a palm tendon basically is that what you're saying okay and we rotate whatever we're going to borrow to insert on that spot on the thumb so we reroute a tendon and we give it a new task that's more important and we basically are robbing Peter to pay Paul but oftentimes Peter has has some other stuff going on meaning we don't Rob too much that it's gonna negatively affect in other things so that's why hand surgery is really neat I mean you can do a lot of crazy cool stuff and just connecting the tendons fine but I'm still thinking brain to tell the hand what to do and when you're talking about tendons again it's these nerves that your brain is saying okay now move your thumb yeah how does that new connection for the brain talking to the new digits now work yeah that's a perfect question I mean that's magic to me that to me almost seems unexplainable so that's sort of the magic also of hand therapy I can't do anything about what I do without some good hand therapists which I'm fortunate that children's in El Paso has them and there's great hand therapists around town in El Paso which is that you're right it's a work in progress meaning recovery from a lot of these surgeries it's the surgery and then it's sort of a recovery and a relearning but amazingly people do real good with this stuff and it's the physical therapy oh yeah okay and when you say oh yeah so is this uh and maybe there's somebody tuning in that that might have this or curious someone who's been through that physical therapy right after surgery occurs that week that day and then how long it depends depends really on the problem I'm working on and sometimes I have patients meet the therapist before the surgery they get a good working relationship that's really really important that they know that there's a positive relationship even they just know they can get to the office and then some surgeries I'll do and they'll immediately get therapy that that day or the next day it really just depends on what the operation is but I say oh yeah because it's like Make It or Break It some therapists can make me look like a rock star genius surgeon and sometimes if a patient does not do their therapy I look terrible and I get an unhappy patient so picking choosing wisely very important having a positive relationship with your surgeon and with your therapist and your whole team is sort of critical to having a good outcome you know and that's actually one of my questions prior to coming here and it depends a lot on how do you as the surgeon and I know and I respect that there's an entire team involved here there are different Specialties there are nurses but talking to the parents in the family who handles that I know you handle some of it because they have to look at you and Trust you're the person cutting into my child you're how does that process work so of of talking to the family just to where they start to feel comfortable because it's a big deal I mean this is something you do all day every day this is their child and they only have you know four fingers without a thumb you're gonna fix it how are you going to do that and talk me into it yeah so um this is really really important kids who are born with differences whether it be attached fingers extra fingers a missing hand they um the parents are immediately mourning the death of their normal baby right so when I have new patient consults and these are often done in my office rarely in the NICU because oftentimes I'll tell the nicus like can you please send them into my office it's just a much better environment it's quiet it's calm there's no beeping things you're a real person you found a person at the bedsides and we're all a person and oftentimes I will have a very honest conversation about my role I build a relationship with those parents like I mentioned I don't operate often times before a year of age and so I'll see those families time and time again throughout that period to watch how their baby's growing that they're thriving that they're doing awesome that they're learning to use their hand in a different way than others but they're doing fantastic and so my relationships very personal with the parents and I get to know them very well and then I get to see them grow and grow and grow and you know I've been in El Paso a couple two and a half years and my hope is I'll get to see a lot of these kids when they're 17 18 19 and they get to bring home their wives eventually or their husbands and so it's very personal to me that said I am in a team and this is a team sport and so when they enter the hospital they're in a new environment with lots of people and I'm there with them and they're in pre-op but I get to ensure them that the teams that we have here are just awesome I mean they are kid focused we do do this every day but we do not take anything for granted meaning we may do this every day it is our job but we know that this is special and it's special things that we're doing and taking care of and we don't ever you know right it's not just like hey whatever yeah uh question choose I know we've been talking about very young ones and you were talking about a one-year-old's hand is huge and I respect that um just in your time practicing and doing surgeries what has been the oldest person that you have operated on I love case studies I love just stories that is unique and maybe this person and we didn't get to him until he's eight years old for whatever reason oh we didn't get to him until he was 15 years old for whatever reason what is a case study that sticks out in your head um that's that's unique a little bit different that we may not have talked about yet this evening oh man and I'm sure there's so many there's a lot I'm um I mean the most one of the more striking ones is a young girl I'm taking care of in Juarez as part of the FEMA group that children's links up with it's a girl with a really challenging problem she had a bad infection in her forearm it's something that we don't see that often because she lost a huge section of bone oh my the radius bone is the bone on the thumb side of the forearm right so we have two forearm Bones the ulna is on the the small finger side again okay and the radius is on the thumb side she's missing a big length of radius bone and so we did that surgery that you now have learned from Dr brockov Right Moving the fibula bone which can be used to make a mandible but it also can be used to make a radius so we we've made our new radius bone and her forearm was corrected in length and now we'll have to go back and do some revisions but I'm just excited because it's it's going to be a project but we're going to get her so much better and it's so exciting so out of curiosity when she lost part of that bone was it through an accident was it through and again there's no names or no nothing there's no identifying this person but so uh just curious of how how did the affection start occur so those infections occur from breaking the bone and it's common things that we see in El Paso amongst the pediatric orthopedic surgeons or the pediatric surgeons which is break the bone but the bone has a little poke hole through the skin and the bacteria enter and so on and so forth the bone gets an infection the fracture doesn't heal and then ends up losing a section of that bone my goodness so you were talking about the work that you do in Juarez and I'd like for you to expand on that just a little bit because I I loved I'm very familiar with mop and all the work that they've done now for decades and decades how did you get involved with that and what are some of the what are some of the issues that you are facing over there and do they do they come to Children's to get their surgery that operation for example was done in children's where we moved the leg bone to the arm bone and transplanted it okay there is a relationship between femap and children's and I am just so lucky that there are kind of giants whose shoulders I could stand on which which is Jack Heidemann and the Heidemann family and they allowed me the opportunity to work with them and then with Fabian Calderon their therapist who's right outstanding and so we will typically I will accompany actually the oral maxillofacial group I was doing a lot of the cleft and craniofacial surgeries Dr Yates and team and we'll go once a month and I'll see patients with hand and nerve issues and we're to the point where we can safely operate at the hospital in FEMA meaning provide the same quality of care and and feel comfortable and confident in that it's fantastic and I know femap is trying to expand as is children so I think it's kind of a symbiotic relationship between the two and between our sister cities growing and thriving together I love hearing that there's so much going back and forth too I'm a rotarian why does that matter because we've been working on the cleft palate program for ever and ever I feel like and there's a lot of shared doctors back and forth and and I love that relationship I also really like uh with the map I got to tour their facility geez probably 2018 at this point when they were just rebuilding out some new stuff and I was fascinated by it all and I just again love the relationship between our doctors and the Juarez doctors and they're one of the same in so many ways um I want to talk a little bit about because this still fascinates me I know that we did a show a while back sure on break break your plexus and I'm still fascinated with how you're able to go in so let's talk about number one let's talk about what it is that might be helpful for those that that weren't tuned in on that but what is brachial plexus and how does it usually occur so brachial plexus that name comes from kind of a group of nerves that go from the spine into the arm okay and those are the nerves responsible for moving the shoulder and the elbow and the wrist and the hand so if you imagine you injure those nerves you can the outcome is kind of a paralyzed arm or partially paralyzed arm brachial plexus birth injury is a problem that arises up or around the time of birth to those nerves resulting in a baby that's not moving the arm or not moving different parts of the arm okay in a nutshell in a nutshell so when this happens at Birth what is happening and I remember you talking about I'm just visualizing the birth canal and visualizing the placement of the baby you know normal placement head comes out shoulders come out together but sometimes shoulders get shoulders stuck which is called shoulder dystocia that's the biggest risk factor towards the development of plexus injury and what I try and tell families and I just try and tell obese is that this like birth is a life-saving maneuver for a long time births were didn't result in a live baby be your live mother so medicine has come a tremendous way and there's still issues and this is one of them where birth injuries can occur and it usually occurs from his shoulder that's stuck in the birth canal or it can come around because baby is very very large or other things were done to save baby's life or brain at the time of birth and I have no I am not an OB I'm not you know these are things that can come up though right so when you now are called uh baby is now born and mother's okay thank goodness but now baby is in a situation where oh sorry I keep doing that to the table um where the shoulders misplaced you've got nerves you've got you've got displacement yeah where do you come in what do you do yeah we're gonna do a hand exam after this okay yes yes we are exactly right here so um so my role is part of this brachial plexus combined specialty clinic and I helped develop it along with David Jimenez at the Children's Hospital and we're a monthly clinic and again it's a situation where oftentimes I'll run up to the NICU or I'll go to the newborn nursery and just have a kind of cursory look and and short talk with Mom or Dad but really get them into the clinic because everything happens there meaning we have really excellent OTS that are trained and therapists who can look and see exactly what's going on with baby in their arm Dr Jimenez and I meet together we have a time set aside just to do this thing and a special clinic for it and the long story short is the diagnosis is clinical there's not a big MRI or a big scan that we do to ensure we don't do needles which is all those things that people are getting with their carpal tunnel syndrome so I want to ensure you we're not poking babies with needles everywhere yeah so it's a pretty Pleasant exam with the exception for the older kids we kind of torture them we stick out candy and toys and bracelets and things and swing it in front of their face and that's the only way for them to show us what they can and can't do interesting and they get really upset if their arm's not working as well as they want it to work but but how else can you tell that that's such an excellent point that's how we do it and when you're looking at then surgically fixing again you talked about nerve endings and just when you are fixing a joint when you're fixing something that is displaced can there be permanent nerve damage if if the trauma was too big was it or is that something that you can always go in and somehow fix the nerves so again Rob Peter from Paul what'd you say earlier that's right and I do that every day all day okay so yeah um we're fortunate that the majority of these recover on their own meaning 80 of these nerve injuries recover over time without the need for me so I kind of disappear and what happens is a lot of therapy and monitoring to make sure that they're recovering where we want them to go the um the babies or the children that aren't are the ones that we may think about as surgery and I do a lot of different types of operations and everyone is kind of custom or bespoke and we're looking to improve functional things like a baby's shoulder moving forward or their ability to flex a bicep or hold their wrist straight right and so we're targeting our nerve surgeries towards those different functions and we can sometimes do very very targeted surgeries meaning not Rob too much of Peter to pay Paul and sometimes we kind of have to do a lot if they're if what they're given is a paralyzed arm and we don't have a lot to work with so we may have to do more intense surgeries and reconstruct major nerves so one of your videos and I didn't get to see it for very long maybe 30 40 seconds or so but one of the videos was a a bicep that was not working if I remember that right right um and so we're transforming a little bit now from fingers and toes to now muscles and tendons but still what was it that you were doing with that again I just saw it for a moment so if that doesn't if that doesn't count what we're talking about I gotta just say go away Catherine let's talk about something that's amazing so um what we're talking about is the long-term outcome of a plexus problem could be failure of the bicep and what that means for a person is Imagine um try on yourself to put your hand to your mouth without using your bicep can you do it I can take it with my other hand yeah so you take it with your other hand right and that's what a baby with a plexus issue would but you're even using your bicep there more importantly the bicep what else does it do it supinates the wrist that means it rotates the wrist into position that's Palm up right so a baby with a plexus problem will be palmed down always Palm down with an extended elbow okay and we call that a waiter's tip position because they're waiting for their tip behind their back like a writer right so in that young baby their outcome was that they were not recovering their bicep on their own interesting and it's really important to get a bicep because it rotates the hand right and it can bring the hand to the mouth so it changes someone from whose arm could not help them brush their teeth or comb their hair or even wash their hair into someone that can't so it's critically important to get that nerve working again and so I did a operation that borrowed from their wrist flexors meaning the nerves that help the muscles Flex the wrist forward because you have two wrist flexors and you have multiple nerves going into those wrist flexors you can borrow one without borrowing too much right and so I borrow one of those which is running right alongside the bicep nerve okay and I re-route it into the bicep nerve so it's literally like unplugging a cord and plugging it into new socket and it takes it's not you're not really taking anything away from functionality exactly okay so that's what it all comes down to that's my life every day in a nutshell right there you said something uh at the beginning of the show when you said you were able to split an artery and split a nerve and I didn't want to stop you from talking because I tend to do that I I hear something I don't understand I stop you because I think like you know we're going to get way too far into this and I won't understand but when you said split an artery and in in essence make that into two in my understanding that correctly and if so how do you do that are you are you because you're you're lessening the size obviously so is that artery just a lot thinner now and maybe I misunderstood you I think we were talking about the um separation of fingers where there was an artery splitting into the two fingers and I'm preserving those two okay but you can for example and we do this with those transplant operations is bring an artery from somewhere else and connect it to the side of another that's called maybe that's what I was thinking about and it's a side connection if you pictured it it's almost like a tube running straight right and then a t Point meaning it's a t point off that tube to reconnect it to side and get blood flowing in several directions geez okay and same thing with the nerve same thing with the nerve so those transfers are literally splitting the nerve and then I will sew it either into the end of a nerve that I cut that's not working right or into the side of a nerve that's partially working but it needs a little more um for gasoline to it got it and you said earlier too all surgeries are cutting and sewing cutting and sewing that's it yeah I was uh I was joking about mash for those of us that are old and uh hot pads Houlihan was trying to describe to someone who had to do a surgery that wasn't a surgeon that you just cut this and you sew that that's right uh so when you said that that that really kind of made me uh giggle a little bit I do want to uh let the audience know that we had a couple of doctors that were sealed to be here this evening but again this is a pediatric surgeon show and sometimes things happen and we have two doctors actually in surgery right now and so I wanted to give a shout out to Dr William sperbeck who is the chief of pediatric surgery at the El Paso children's hospital and he is in surgery as we speak and then we also had uh Dr Jonathan Chao who is the Pediatric ENT at El Paso children's they were both going to be here and Dr Chao is helping Dr sperbeck with the surgery so on that note guess what you get now Dr Diamond Dr Diamond I know we sort of beginning of the program probably a call into the or you're going to get a call to the ore and or you get to answer some ear nose and throat stuff that we completely know is not your specialty perfect right I know it and so in this program too there is always a disclaimer saying whatever you said you can't be sued for because this is the opinion of what's Happening here so I I say that just so the doctors are like all right it's not my specialty but this is what I think it is um some of the most common pediatric surgeries aside from what you do I know we talk about micro surgery we're talking about hands but common pediatric surgeries that your team deals with if Dr spurbic were whispering in your ear right now yeah what would he be saying for you to say yes so I mean as far as the ear nose throat work I would say tonsils and adenoids we call them TNA I would say ear tubes very common to decompress chronic ear ear infections although I I don't even know right again my brother had those I remember so he is now my goodness he's now 50. exactly when we first came to America I remember that being one of the first surgeries I ever heard of exactly and he had tubes put in his ear and we're like how do you put tubes in the ear as far as general surgery meaning General pediatric surgery that Dr spurback would perform things like hernia so inguinal hernia or umbilical hernia very common yeah if you can kind of talk a little bit about that I know it's not your specialty I get it I do respect it but describe what a pediatric hernia is so an imperial hernia just describe what it is and even just physiologically not how we would do the surgery but what the surgeon is trying to do to remedy that sure so again preface it with I am a plastic surgeon I did train in general surgery I am board certified in general surgery so I did some but I'm glad that there's a disclaimer at the beginning of the show yes um I'll explain my limits but a hernia in general is an opening um in any place but let's say abdominal hernia it's an opening in the abdominal wall you can think of it kind of like a sleeping bag and if there's a hole in your sleeping bag something can punch through like a hand or a fist right and in the case of a hernia in the belly like the belly button that hole never quite closed and would all chunks of fat from inside the belly or even intestine can escape out that's not common oftentimes umbilical hernias actually resolve on their own meaning they go on to self sort of heal my son had one and yes it healed on its own that's right and they occur in different areas meaning belly button is umbilical hernia inguinal which is groin which my wife had as a very young baby and had fixed and I know that I wish Dr sperbeck was here because he would explain that for all the older people in the audience who have incisions on their belly because they had surgeries when they were young young babies for these types of problems like hernia or pyloric stenosis very common things sure now Dr sperbeck and others are able to do a teeny tiny micro incisions and again we talk about cutting sewing tubes Etc but on the flip side is instrumentation and to do micro surgery we need amazing microscopic instruments and to do general surgery they now do it with amazing Optics meaning little tiny video cameras which have great visualization of all these little structures and little instruments so that they took things that were big incisions on bellies and made them tiny micro incisions hiding them in belly buttons so we were talking about pyloric stenosis so we were talking about how to fix it but what is that and I remember my my brothers now 58 has that nice big scar on his belly oh he got it when he was you know a couple of months old at that um what is what is blocking what's in the way what's happening there just by just and how do you how do you know as a new mom or a dad those are the big questions perfect so let's go to how you know first okay and we'll start from there okay so how you know your child may have a pyloric stenosis is their projectile vomiting and I'm not talking about spitting up milk or you're patting baby a little milk spit up I'm talking about across the room hitting your face hitting the wall projectile vomiting that is very very very important not green not green not green okay that in and of itself asks questions why what's the green portion of it perfect so in pediatric surgery there's green vomiting and not green vomiting and that triage is a huge difference in the problem okay and the reason being is that the pyloris separates the stomach and the duodenum which is the first portion of the small intestine your gallbladder enters into the duodenum so imagine if you were throwing up and had a normal pylorus the throw up can be green because the stuff in your small intestine gets into your stomach up your esophagus out your mouth if you have a pylorus that's blocked that has a muscle that's just spazzing out and super overgrown blocking the stomach from the small intestine you're just throwing up the contents of your stomach so that's why it's non-bilious which means not green and it's just the stuff in the stomach and it's going right to the other wall in the other room type of vomiting oh God okay but that makes sense when you describe it that way that makes that makes perfect sense um we were talking about uh umbilical hernias we talked about that abscesses I know this is gross but abscesses in general as a surgeon but it happens with kids all the time happens in hands and fingers all the time okay describe a little bit of that infections at the end of the day infections are common yeah and infections in skin and soft tissues are common meaning in feet where kids step on glass or splinters and get infected and hands where splinters go into hands get infected or Thorns Etc and um down near someone's bottom and the kids that are a little older and will have the little bit of hair in their gluteal cleft often a very common source of infection you know what we never talk about that because it's gross and we're here to talk about gross stuff because that's what we do on medical shows so again as a parent and let's talk about ages too so as a parent how do you know this is going on if the child doesn't know what's going on obviously it creates some kind of pain there's some kind of an abscess there's some kind of etc etc what is the parent looking for so how would they know I mean mostly an honest conversation because again these kids are of speaking age usually in their teens Etc okay and they may have drainage on their underwear they may feel like they get wetness on the underwear or foul smell on the underwear that's not you know when they're defeating teenager is he going to go tell Mom or Dad probs not yeah so that's that's one of the that's one of the reasons I'm you know how does one know I think just having an honest conversation yeah yeah so asking the kids every now and again what's going on in your life yep um we we have a whopping two minutes is there anything we haven't talked about yet that you want to like throw out there really quick man that was a huge array I'm just so bummed I didn't have my buddies here to talk with I know well we'll we'll do this again this would be a lot of fun because there's so many things that we can talk about with pediatric surgeries you have a very specialized discipline it's true and it's fascinating to me and I can't wait to go back and watch this and and check out some of the things that that our rock star Diego so we have Diego Munoz here munis Munoz minis munis geez Louise can you tell it's been a long hour um but Diego is the one that intercepts all of these things and finds videos and then we also have Daniel with us and who's doing audio in the back uh Mike hi Mike thanks for doing Mike Mike appreciate it and who else and Victor Mike and Victor too so these are the rock stars at Star City uh Studio where we're able to do the El Paso physician um over the last several months and it's really been fun to do that so again I want to thank El Paso Children's Hospital uh they underwrote the program this evening and it's been really a lot of fun for me to learn more and more and I'll tell you what this fibia and other bones that that we're using to fix things is absolutely amazing if you only caught part of this program and want to watch it again you can do that at several different places you can do that at pbselpasso.org just look for the uh whatever show it is that you want to see if you want to go to the El Paso County Medical Society that's epcms just think of the acronym that's a.com and you can also go to youtube.com and look up the El Paso position and the nice thing about all three of these places that you can go back and find different programs that you might be interested in I'm Catherine I appreciate you joining us and thank you very much Dr Diamond for being here and we'll bring your buddies along next time awesome Catherine thank you you're very welcome this has been the El Paso physician goodbye [Music] thank you [Music] foreign [Music] foreign [Music] [Music] [Music] thank you [Music]