Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz.

and Im the president of El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We at El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative, with great medical advice and great medical information.

Thank you again for watching this program tonight.

And have a great night.

El Paso now has a pediatric comprehensive multi-specialty center that can service all of our region.

This means that children with complex conditions are able to see their specialists all at one time, in all at one place, rather than waiting weeks or sometimes months for each separate condition.

And most importantly, families no longer have to leave town for the lots of specialty treatments that they may need.

So how exactly does this level of care impact the landscape of our pediatric health care in El Paso?

And what are some of the new types of specialists we have here, as well as what are some of the new lines of service now being provided here in our region?

All that and more coming right up.

This evening's program is underwritten by the El Paso Children's Hospital.

And we also want to thank the El Paso County Medical Society for bringing the doctors to you and this program to you every single month.

Good evening.

I'm Kathrin Berg and this is the El Paso physician.

Thanks again for joining us tonight.

We're going to be talking about specialty in pediatrics and what exactly is El Paso in our region able to offer Now?

I'm super excited to introduce to you a married couple.

And they did promise that there's going to be a lot of banter this evening.

So this should be a lot of fun.

But with us tonight, we have Dr. Jonathan Chao and Dr. Amanda Chao.

Dr. Jonathan Chao specializes in ear, nose and throat with pediatrics and he is with obviously the El Paso Children's Hospital.

And he is a fellow trained head neck surgeon.

So he's going to have all those questions of surgery coming your way.

And Dr. Amanda Chao is a person who's now an allied health member.

She kind of helps everything that's going on in the surgical world and she's an audiologist.

What exactly is that?

We'll find out from her.

And she's with the all powerful children's hospital and also the Texas Tech Paul El Foster School of Medicine.

So thank you so much for being here.

We've had a lot of fun over the last 20 minutes, just creating our own banter and figure out what we're going to be talking about.

So thanks for being here.

Amanda, Since you're the wife and you're the girl, you get to start, and also because you're on my right hand side, that's how it always works here.

But for people who don't know what a doctor in audiology is, a pediatric audiology, how would you describe that to our audience?

Sure.

So an audiologist, our entry level is a doctoral level.

So we come in at a doctorate level and our intention is to serve a lot of different disciplines.

So certainly, you know, EMT is probably the majority, but we also serve other specialties, including craniofacial pediatricians, Highmark Oncology, and our role is really to diagnose hearing loss.

I'm a pediatric audiologist, which means I specialize only in children.

We're not necessarily fellow training, kind of like similar to medicine, but you really have to become an expert in that.

It takes years of practice and a lot of patience and a lot of will.

And so what I do is as a audiologist with children is I diagnose hearing loss in children who are maybe infants.

So as little as three weeks old up until age 21.

And then the other part of what we do as audiologists is that we are experts in the vestibular system, and that's the other part of the inner ear.

I always tell, you know, patients and parents that there's two parts to the ear.

One is for hearing and one is for balance.

And this contributes to things like growth, motor function and children.

It also can contribute to things like migraines and motion sickness, car sickness.

It can be affected after concussion, as can hearing.

So we kind of look at this very small organ, but this organ's really an important sensory organ for so many things in our lives communication, physical activity, mobility.

So as an audiologist, we are trained to diagnose disorders that affect both of those systems, and then we pass on those results to our colleagues.

And that's typically an ENT and other physician.

Like I said before, all these specialists for different reasons.

And then after that, we really I hope I hope I know I do.

I know that I help inform his medical plan or her surgical plan.

Right.

And then afterwards we can work together.

And he says, Yeah, I agree, and we're going to do this.

And then as an audiologist, our job is to make the function work now with whatever it is.

And that's typically in the form of hearing AIDS amplification.

It can be as things like a surgical option, like cochlear implantation and other types of devices for that.

And then when it comes to the dizziness and vestibular side, we are also trained and we can be specialists more invested with the rehabilitation along with our physical therapy colleagues.

Excellent.

So we're going to talk a lot about rehabilitation, too.

And I love when you said, too, that you can diagnose hearing loss as early as three weeks.

And that's amazing to me because sometimes we don't know what babies cause how do they tell you?

And that to me at Pediatrics is so interesting.

It's like, how do you know what's happening?

If they can't tell you once they're of speaking age, it's like, Oh, this hurts or This doesn't work.

So it's going to be a really great show.

This evening as an ear, nose and throat specialist, also is a head neck surgeon, fellow trained, etc., etc.. You're that guy.

But what does that mean to our audience?

So people who are tuned in, it's like, okay, what exactly does that mean?

So pediatric anti or head and neck surgery is a fellow level kind of trained specialty.

We're a surgical subspecialty and we take care of basically everything.

Shoulders up is the old joke that we always say, okay, everything outside the dura where neurosurgery takes over but above the shoulders.

So we do things in the adult world like skin cancer, like oral pharyngeal cancer.

aerodigestive issues We do a bunch of hearing things all the way from children to adults.

A lot of general ENTs also see children, but the fellowship training in pediatric V.A.

is focused on kind of complex kids or traditional kids with complex needs.

And so things that we offer that general trained ENTs typically don't are things like cochlear implantation for hearing restoration on kids who have very, very little, if any, hearing things like airway reconstruction.

We are we are specially trained in management of tracheostomy and there are digestive track for children.

We also do liver injury interventions where if a child has a disorder where their vocal cord doesn't work, we can help bring that back.

Okay.

Affecting voice affecting swallow, affecting things like that.

So we do a little bit more on top of the general and we focus just on just on the pediatric population with it because their needs are lot different than the adult population.

Absolutely.

So what I'd like to do is both of you all talked about the complex specialties and the specialties that usually are compounded within this area.

So we know that El Paso Children's specifically now has this multi-specialty center.

So I'd like to talk about that because and for those people who don't know where that is, and it was so nicely explained right before the program, but the old Food City that's on Paisano is now the... youre laughing.

But we were like, that's a free plug for, you know, somebody that likes to buy groceries.

But that is the the multi specialty center in it's right behind El Paso Children's Hospital.

So when somebody has an issue in walk me through and Amanda, I'm just going to go to Dr. Amanda Dr.. Amanda, to you Dr.. Mrs.. How you think of how to ask this question.

So what are some of the common issues that a child has it a parent comes to you with that side, You know what?

I think something's not right with my child.

Can you check this out?

Like, what might the symptoms be?

And you talked about three weeks to however many months, but what are some of the more common ones that we can kind of start this program out with and that we can kind of go into more specialized issues?

Sure.

So I would say the majority of our referrals as an audiologist are coming in from, you know, parents concerned about a speech delay.

And so when we talk about hearing and speech, they're they're related in the sense that input output, right?

So especially with young children before the age about two or three, there's a critical window there into which their brains are taking an input auditory.

Right.

And they're developing speech language at us as the output.

And so I would say probably the most common that we share as patients as well are kiddos are coming in who are speech delay and there's a lot of causes for speech delay, as we always say, and hearing is just one of them.

So we get a lot of kids who come in, who have speech delay, and we're part of the role to say, well, let's figure out what the hearing looks like.

Right?

That's probably the most common.

Now we're going to throw in a little bit of a bunder because this is what happens every single day.

And I'm going to say this to you because we talked earlier about myth busting.

Right.

So and we're going to have to have fun with it.

But at the same time, to make that point very clear is that it's not automatically, oh, they can't hear or they can't hold that they're there.

So that's going to kind of not be the theme of the show.

But I throw a lot of those out, especially because parents think that they know, but they don't until they find out what's happening.

Okay, excellent.

So if there's speech delay, it's not necessarily the fact that they can't hear.

Absolutely.

Yeah.

So we I mean, we definitely agree and kind of do we the hearing assessment, our hospital's totally equipped to be able to test hearing in infants.

So you said before they can't raise a head when they hear the beat.

Right.

Well, we had a lot of sophisticated equipment that allows us to do objective physiological measures of the auditory system.

In fact, before the service lines of audiology and anti came, there was no one in our community that was able to provide that level of specialized testing in infants.

And what you have is now children lost to follow up.

They failed a newborn hearing screen in the hospital and now they're two, three, four.

That critical window has closed.

Now, I have a question is if I'm somebody listening at home, the newborn hearing test in the hospital.

Yeah.

Tell me how that test is conducted and how does one know if a baby can hear if there's just like everything going on?

I'm curious as a parent.

Yeah, of all people.

But at the same time, when we're looking at that, just someone who doesn't see this or is around it all day, every day, how is that conducted?

Yeah.

So the newborn hearing screening program is universal in the United States.

So every state has their kind of their own protocol.

But for the most part, what we do in our hospital, at least is for we call it outright brainstem response test.

And ABR is typically automated.

It's kind of a quick push of a button, and that allows for nursing staff, other staff members who are not specialized audiologist to be able to access and do this testing on all children.

And what we do is put some electrodes on the forehead behind the ears and we play a really loud sound in the ears.

It is safe for children.

Yes.

And you know, that's going to come up and it's safe, but it allows us to test the brain's pathway for hearing.

So the sound goes through the ear canal, it goes through the eardrum.

And as soon that the eardrum is moving well and that sound can go to the hearing organ and then the nerve.

And so we're able to sort of test how strong that pathway is by literally clicking a button and having these electrodes on your right.

It's very contingent on all these wonderful factors playing out.

The baby is still in quiet and everyone's trained.

And of course, you know, we as audiologists are there.

If that child fails twice on either ear, then they come to someone like me who has more time, more expertise to be able to really determine was it just other factors.

For example, fluid behind the eardrum, very common in children, or is it something going on with the hearing organ and so those mechanisms and those type of testing that we have access to at our hospital that we're able to do because we're experts in it, has really allowed us to identify hearing loss in young kids.

I mean, I'm proud to say that one of my youngest is a month old.

By Texas guidelines, we have to identify hearing loss by three.

So we're ahead of the game by three years.

By three months.

Oh, by ELO.

Okay.

But we'll take that as a win, especially in our community.

Oh, heck, yeah, absolutely.

And I think it's very important to say also that these automated hearing screens in the you or in the in like before they leave the hospital are not necessarily diagnostic either.

So that doesn't give us very detailed information about their hearing.

And before audiology was established here and doctor Amanda Chaio was able to kind of institute this, they didn't have a diagnostic pathway afterwards.

So when they come into an audiology clinic following, sometimes they can do a more detailed, automated or not automated, but an auditory brainstem response testing that gives them very specific frequency and ear specific information that tells us which ear is not hearing and where are they not hearing and how much are they not hearing.

And that really guides the treatment of us on the medical side of things in order to talk about, you know, like what do we need to do to get them hearing better?

Do they need surgery?

Do they just need treated medically?

Do they just need time and all kind of depends.

But the diagnostic side of things, and especially with complex kids who have behavioral issues, who don't respond to all these ideal conditions, when we're testing them in an automated sense, we have the ability to to help with that.

And a pediatric specific trained audiologist is very important in that role because they have several different tools up their sleeve to be able to help.

And we can also do sedated objective hearing testing that nowhere else in town is doing that tells us, you know exactly where they are, especially these complex kids.

So you hit on a point to that.

I'd like to expand on a little bit more.

We're looking at different complexity.

So hearing loss, behavioral issues, what again, throw me a case study of a child.

No names, no.

You know, maybe an age that might help of what some of these multi specialties bar that a child is experiencing where you guys then come in because then you're diagnosing quite a few things, correct?

Sure.

Yeah.

Okay.

So there's several different multidisciplinary clinics that we're going to be as ENT and audiology starting throughout the next couple of years.

The first two are probably our digestive clinic, which is where I, as an ENT help address the upper airways and pulmonology helps address the lower airways and gastroenterology, helps address the swallow and the GI system down.

Right.

So a lot of the complex kids have issues from birth where their digestive system is kind of like one big system in there.

It shares a whole bunch of whining and mucosa and the same in the same space.

And a lot of the a lot of the disorders kind of relate to each other.

So take, for instance, a child who's like one year old has having difficulty gaining weight, and every time they take the bottle of their coughing, they're choking on thin liquids and things like that in a narrow digestive clinic.

What we would do is we would each kind of see the patient patient comes in, gets checked in, goes into a room, and we as physicians and specialists kind of rotate through there and each check in with the family.

And they see speech therapy, they see ENT, they see pulmonology, they see GI, they see a case manager day on that same day, on that same clinic appointment, right in the same space, in the same space.

And that's important because, you know, families otherwise having to take off, you know, like four or five days, just see the different specialists at their appointments.

Right.

So getting these kids in and being able to treat them in kind of a similar space in a similar environment.

And like my wife always likes to say, meeting the parents where they are.

Right.

And what they need is very important.

And so we can kind of address these complex issues that kind of relate to each other.

Audiology is going to be setting up a concussion clinic with neurosurgery as well for mild TBI.

And we're going to audiology in the in t are going to be setting up a multidisciplinary hearing loss clinic where our kids who have hearing needs and complex hearing needs, we can have them come in, they can get their vestibular testing, which by the way she is that exactly we talked about that.

I hear about it all the time and I don't want to I don't want to bulldoze over that.

But let's stop a vestibular testing because that's such a big deal.

Right?

Because that affects so many different things.

It is a really big deal.

Yeah.

Because there's only about four centers in the United States that have the ability to test and the expertise to be able to do this.

And we have one here now.

Doctor Amanda Chao is a doctor.

Amanda Chiao is a nationally internationally known vestibular Specialist So I'm talking her up, so I'll let her kind of talk about this vestibular side of things.

But the next closest rotational chair is probably Denver.

Houston hasn't even set up their clinic yet.

And I think Denver's the closest to be able to do which she can do in her clinic here.

Okay.

So now that you set you up, you can take it away from there.

Thanks for the Segway.

Yeah, I might be a little bit biased, and I do feel like it's a very important sensory system to look at.

Like she mentioned, you know, I trained in this area and again, people think it's such a small organ, who cares?

But it affects everything.

It does.

It does affect, especially in children, vestibular loss.

So again, this is the other part of the organs and the inner ear that contributes to telling your body where you are in space with head movement and balance and what the research has shown and a lot of wonderful investigators have shown over the past, probably about pretty recently, what, 15 years, they've really shown that when a child is born with a genetic condition, that maybe they're missing these organs and they have hearing loss and they have other things, well, they are delayed in their gross motor to sit, stand and walk.

Right.

These are kiddos that would be unsafe to put on a bike and maybe they hit their head.

And now we have a sequel to Head Trauma.

So we're kind of really like learning all of these consequences of vestibular loss in children.

And we know a lot about this stuff in adults and adults fall and everyone's like, Okay, for me, I love adults, but I'm interested in kids because I really want to be able to prevent, right?

That And if they've never felt being steady and they're always not steady, it's something that's not new to them.

So they just, you know, it's a lack of developing.

Yeah.

Yep.

And that's why that's why I want to focus on her early on in the program, because it affects almost everything when it comes to You're talking up to three years and it was a few months ago, about two, three years, because you're looking at crawling, you know, scooting, crawling and then just standing up to walk.

You're not doing that.

Yeah.

And Mythbusters again, right?

Say someone's not walking by a year and a half or two years.

What is it that people are looking for?

And would they think that it's the ear?

Yeah, probably not likely.

Yeah.

There we go.

Is another busy?

Yeah, definitely.

And, you know, diagnosing.

We're really fortunate at El Paso Children's Hospital we have the technology to be able to very precisely diagnose the integrity of these vestibular organs to the level that we do the hearing organs.

You're talking about being able to assess this both system in the same child and how do you do that?

So one of the ones that we're referring to, we call this they call it the concussion machine.

And I think that's probably accurate, but it's actually a it's called a vestibular rotational chair.

It looks really, really terrifying.

But our hospital has wrapped it in like a spaceship because we that's our theme in our hospital.

And every single kid that walks in there says, whoa, can I go in there?

And they have.

Yeah.

So I know that, you know, it's it's so interesting.

Chair where they sit in it, we put some video recording goggles and we actually rotate them kind of like a roller coaster side to side.

And kids love it.

Adults don't, which is why I work with kids.

And so they spend back and forth and we watch their eye movements and we're able to determine the integrity of how strong the inner ears talk to the eyes.

And there's a connection there.

We call it the Ms.. Gibler ocular reflex pathway.

So you're watching their eye movement.

I mean, finding out through the brain what's happening inside that brain.

I move and that infers back to the ear.

There's no way for me to open up the inner ear and look at that integrity, but I can infer it with the eye movements.

And so we use video nice tomography, we call that VNG So are there cameras inside of this?

Yes, there's cameras.

So there is.

And there's cameras are special goggles that, you know, we play with the kids and we put them on.

And so we're able to look at this how, how strong this reflex pathway is, as well as what's called the particular colic reflex.

This is a reflex in the neck that contributes to the spine, and that's for walking.

Wow.

So we're able to look at a lot of and there's other measures, right?

Obviously, we have to do balance tests and all of those things, but we're really looking at how well can they adapt, how well calibrated if their head movements, eye movements to their inner ear and vice versa.

So we're able to do that.

And again, back to, you know, a Jonathan is talking about if we have this ability to diagnose to that level, we can then take it to him or take it to physical therapists or take it to I mentioned human oncology.

Some of the medications that they prescribe are actually OTO and vestibular toxic.

And so we work a lot with our human oncology department to say, you know what, this with a drug that we're doing is starting to change.

So that is brand new to me.

I would never have thought that that would be it.

And so you're looking at certain chemotherapies that do affect well and it and they're known got they're known for that out loud it makes sense but who would put those two together.

Yeah.

You say them out loud.

Exactly.

And so we're able again to be another diagnostic side to kind of say, hey, you know, this is changing and will it change that maybe child's overall treatment, you know, considering their situation?

It may not, but it allows us as a team, human oncology myself, maybe it's anti physical therapy rehab.

It allows us to have the conversation of, okay, well, let's start talking to parents about what to expect.

Exactly.

And you were talking about working with adults one thing, but in a child, things are changing so fast, it's like from zero to we stopped growing, what, around 13, 14, 15, whatever it is, everybody's different.

But the amount of tissue growth that happens and the speed that tissue growth happens, and I'm looking at you as a surgeon right now, right, because you're talking about voice boxes for the lack of a better word.

You're talking about different surgeries that you can do, tracheal repairs, for example.

So with all of this, I'd like to somehow incorporate what you do as a surgeon in this area.

So when you're looking at what's to talk about, our audiology, so we're talking about the cochlear implants when it is discovered that with all these tests and it's amazing to me the diagnostics that you're able to make here and I think all of us have seen videos of a child that hasn't been able to hear and all of a sudden they have a cochlear implant and they can hear and it's like the whole world opens up physiologically during these surgeries.

And I know you've got a lot out there, but how how do you do that?

So again, as a layman, my little brother, I'm 57.

He's 54.

He had to have tubes in his ear is completely not related to hearing.

But maybe yes, whatever the situation, words are infections.

But that's what I know about ear operations.

You know, my daughter had constant ear infections.

She had mono when she was young.

She always has tonsillitis.

This is what ENT means to me because I didn't have to go through anything specialized.

So now take that to what the common everyday child ear, nose and throat doc does versus what you do in all your specialty care.

Are you following kind of how I'm I'm I'm throwing that out there.

I think so.

And okay.

So hearing loss specifically.

Perfect.

Great.

So with hearing loss, there's a wide range so your brother needing tubes that is on one end of the spectrum of kind of ENT care.

So that's something that we do.

We do ear tubes, we do tonsils, we do everything in that space as well.

Ear tubes are something that can help the ear breathe through the eardrum.

We all have kind of natural breathing tubes of our ears.

I always tell parents in the back of our nose cutter Eustachian tubes and those Eustachian tubes are developing, developing, developing until around age 7 to 9.

And when they are maturing, they don't function as well as they do as an adult.

So often we get children with recurrent ear infections or retracted eardrums or difficulty with their hearing because of that fluid behind there.

And so ear tubes are indicated in a lot of these kids.

But when hearing is isolated to kind of the inner ear or the cochlea, the hearing organ, that's something a lot different.

There's several different reasons that that can happen.

Some we can offer interventions.

For some there are just no interventions for like if their inner ear has not grown or they didn't develop it when they were when they were growing in utero.

For cochlear implants, the hearing can change over time.

So we have a two year old that had meningitis and was in the hospital for it.

He was treated, he was out of the ICU and the pediatrics team appropriately consulted audiology for a hearing test to make sure that everything was going okay.

The mom had noticed he wasn't responding as well or things like this.

Meningitis is something that causes inflammation of the inner ear and the inner ear fluid in there, and that can create scarring.

It can actually turn our hearing organ the cochlea into bone called labyrinth.

Itis specific cans, and once it turns to bone, that's it.

There's nothing we can do to restore the hearing on that side.

So this child was a week out from his meningitis.

We identified a profound or the most extreme level of hearing loss on him on both sides.

He was previously starting to talk, He was making sounds and stuff like that.

And then he just regressed.

So meningitis wiped all of that out, that meningitis was starting to wipe it out and his hearing was gone.

His cochlear was thankfully not a bone yet, but there was scarring, especially on one side.

But we were able to get him to surgery within four days, I think, and get him bilaterally implanted.

And now he's saying, Mama, he's into music, he's dancing to music.

So we were able to save this child's hearing like that.

The surgery itself is a lot more complicated than in your tube surgery, right?

Oh, yeah.

And how does the cochlear turn a bone?

Is it scar tissue that's hardening it or what is it that that is happening?

Pretty much.

It's it's ossification from inflammation in there.

So the inflammation causes a reaction in the tissue, in the cells that then just basically scars off.

So like if you have a scar on your body or something, it feels a little bit different.

Right.

It's fibrotic, it's hard.

That happens inside the cochlea and then the cochlea is natural reaction is to fill that space with bone afterwards.

But like even the different degrees of scarring in there can affect the hearing.

And we actually notice it even before the scarring has happened, which in this case, this child, we were able to get in there before it got scarred to the point where it was irreparable.

So you said this, but tell me the age again.

He was about to write about that level.

Okay.

So right where you are, and I'm embarrassed that I don't remember.

So when in a in a typically developing child does speech start to occur, I know it's different with everyone.

I respect that.

But a range kind of expressively.

I mean, really about one month we start to see those milestones babbling, making vocalizations.

That's considered a speech and expressive speech milestones mimicking a mimicking, then making first words about 12, 15 months.

And this particular child he actually was born with hearing.

So the meningitis just took it out for this time.

And our goal is to get in there quickly so we'd have less time without access input output.

Right, Right.

So in these cases, his outcomes are a little bit different and they're positive, thankfully, because he also his brain knew what sound was like.

Right.

He actually had it.

So those milestones, yeah.

Oh, it's a little bit different.

And I kind of want to make a little personal note.

You know, I'm from El Paso and born and raised here, and they think that this case was also a really good example how we can do audiology and ENT and we always see this in our community that's very different than how we would do it and other places that we have trained and we've been really fortunate to train, you know, great places, but to adapter medicine and adapt your practice to this community is super different.

And for this particular family, it took an orchestra and I mentioned to a ton of people I'm like, There's no way that and another place we could just boom, boom, boom, boom, boom, get all these things.

And time was critical.

Yeah, you know, So to get to work with our hospitals teams who, you know, consulted us, get in there again.

We can go.

We can do theater testing.

You know, this is a two year old.

He was obviously not well, he you know, he was moving a lot.

I couldn't have done two traditional hearing tests to know.

So we were able to go into the operating room to a sedated hearing test, like I was mentioning.

Where Jonathan In the room we can only do those things because we have the ability to do it right.

And we were able to diagnose that hearing loss within two days of me saying I have concerns.

And then from there we worked, you know, with our our surgical teams, everybody.

And it was a really beautiful opportunity to kind of show like you can have these great outcomes speech and language wise, but you really kind of need to also have the people in the room know what they're doing.

They were willing to work together to get it done.

And that, I think, is a really big piece of like that case particularly, but also I think transcends into when we expect outcomes of children of hearing loss or cochlear implants.

It's all family based, right?

It's support based, it's team based.

It's not just he puts an implant in and boom, it works.

So following that, that path, I would love to know, like, how long has this idea been in place?

How long is the multi-specialty center been there?

Because I know that when something like that is fully functioning the way it is now, it started a decade ago or seven eight.

How did that all work?

Because I think to your point, as in El Pasoan, and I think we don't give ourselves enough credit.

Our community does not give our community enough credit.

Again, in the opening I said that there because of this multi-specialty clinic, there are people that would have for other specialties have to leave town and or I can do this in El Paso, but I can't do that in El Paso.

And to that point too, in the opening, it's like sometimes if weeks go by in a two year old, weeks are fast.

I mean, it's way too much time to pass.

So I don't know if either of you kind of know the building up of how the multi-specialty clinic was to come about and how long has it been around.

So we started here about a year and a half ago.

I started in September and my wife started in November of 2022.

And at that time my clinic was on the corner of El Paso Drive and Paisanos there.

Okay.

And we had a total of seven rooms and we had a total of seven rooms for all the specialties at El Paso Children's.

Wow.

And so we were kind of like jockeying position to try to, like, you know, get more patients in.

And but, you know, there's two other clinics running at the same time and this sort of thing.

So we were really limited by space and by allowing everybody else to come in.

So in March, when we opened March of this year, when we opened the Multi-specialty Center, we're now more than 40 rooms.

I think it's like 45 rooms.

We have four separate pods where collections of physicians who kind of work similarly and share patients and work together kind of can share that space and have all that space and access to help.

So how long it's been planned?

I have no idea.

Yeah.

However, the the difference between what we started that when I and that was that was two year like one and a half two years ago, which is almost like yesterday in this type of situation.

And then to actuate it in March of 2024 and to be able that I saw 39 patients there today.

39 patients today.

Yep, 39 patients before we came over here today, with the help of my NP and my team, they make the world run.

But I like the ability to do that is really based on kind of that support and the whole team based approach, you know, and we talk about El Paso, but this is really the whole region like you were talking earlier.

I mean, your specialty, Denver's the closest.

So if you're looking at New Mexico, Mexico, other parts of Texas.

So, yes, it's a rah rah for El Paso, but it's really a rah rah for all the people, you know, for states and states around us as well.

So kudos to El Paso Children's for doing that.

Yeah.

And I think, you know, we're certainly excited to be able to have this beautiful space and to be able to walk down the hall and talk to each other.

And I mean, I can get a hold of him at any point, right?

I'm his wife.

I can make you know, he has to answer, Where's the banter?

I keep waiting for the banter.

You guys are throwing nuggets at each other or anything like that.

You know, for that to I know the phone rings and we're like, well, he doesn't want to get in trouble.

He was giving you praise and outrage in early.

I know.

She's a rock star.

Oh, I know.

We were talking about two.

So you were talking about seven rooms originally.

And there are new specialists there going on when you were talking about your team, maybe introduced to me just verbally, some folks that are on the team that help you do what you do.

Oh, 100%.

So my NP, Maggie Diaz is really my right hand.

She sees patients independently, she sees patients with me.

She assists with patients in the hospital.

She's there for my surgery.

She's checking in, checking out my schedulers, my emails.

Sandra Para Patricia is my other one there now.

And they, they keep my life in line and they keep the patients focused in everything.

So they're the ones that are really organizing and making sure these patients are taking care of.

It's very patient centered, which is the important thing.

So when something is going wrong, when I'm running 2 hours behind in clinic, they're the ones that look at me and say, Hey, you know, you got it, you got to do this, you got to do this and keep me in line with that.

It's like she's your wife and they're your moms.

Exactly.

No, 100%.

We're texting like he had that meeting today.

Oh, 100% snack.

Does he like and, like, I'm busy.

There's some cashews in the operating the operating room team to, like, the operating room is a whole different environment over there.

And having people that know how ENT works, how audiology works.

When she's doing a sedated hearing test on someone has been very important.

Maya Martin Thomas is one of the ones that I work with every day, and I know Sarah was always in Mayo are helping me out too.

And there's a there are whole teams over there that work with me all the time.

Jeanie She's the manager of our operating room at Perry.

Operating together?

Oh, hell no.

But the really, it's the surgery is a very small part of things.

Even with the cochlear implant in, my wife is saying, like the surgery for two of them takes about four or 5 hours and.

But that's four or 5 hours in this patient's now years of treatment.

And it's audiology, it's speech therapy.

It's it's the parents.

It's watching out for those ear infections from the pediatrician like it's the team is really what makes it and you know, being able to do that in this center and kind of having this support and these people to kind of keep me in line to do that.

Yeah, I'd like to expand on that.

And both of you all bring up family.

And to your point to being El Paso family, is everything here.

And it's not that it's not everywhere else, but it really is here on that point because you really do.

When it's pediatrics, you have to involve the caregivers and you know, hopefully there's parents.

Sometimes we're not lucky enough to have parents.

But let's talk about let's talk about the first meeting with the parents and going through all stuff you might have to do.

So in the reason I say that is there's a lot of mental and emotional happenings in this situation.

It's my child, it's my baby.

What's this mean for the rest of their life?

What does it mean for the next month?

Maybe go through a case study or talk to us about how the very first baby steps occur to all the stuff that's going to happen?

Yeah, I look forward.

I think we have our ideal case, right?

You know, we had another two year old that was sort of lost a follow up and maybe was misinformed about the status of their hearing.

And so we're the first ones to say there's nothing there.

And you're a candidate for a cochlear implant.

Oh, wow.

And there had never heard this before.

Yeah.

And there are two years old, the child's two yet.

And oftentimes I'm the lucky one that gets to, you know, share the news.

But to your point, it's really important in our culture because family is everything.

And a lot of times you're having to get the family equally on board to the medical plan that we as the professionals feel is appropriate.

And sometimes that takes time.

Sometimes you want to run and you want to say, I want to do this now, and you got to have to be patient and let that grief cycle happen for that family to be to be ready.

This particular patient that I'm thinking about, you, when we were able to say, this is what we're going on, this is the plan.

They were so, so much on board and we were able to get this kiddo implanted and and give them, you know, what they needed.

And the outcomes are definitely improving and getting there.

But I think one thing that really resonated with me was just how our hospital and how kind of to, you know, Dawson's point is very patient, patient centered.

And that's a really important part of what we do, allowing 14 different family members to be in the room when we activate the koala implant in different family members.

That's so El Paso.

That's very El Paso, right?

Yes, it's very El Paso.

And I have to stop and think that, you know, there was grandma and greeting grandma and cousin and there was all these people in the room.

And what a luxury it is to say you can bring anybody.

But if this kiddo had to go to Dallas, they they can't all travel, they can't have the money.

But having all of that family support is what this child lives with every day.

He stays with grandma who, you know, lives with cousin.

So this is it's really important that, like, we are adapting our clinics and our practice to and I keep harping on that, but it's just really important for what we do.

Communication is incredibly crucial to culture and our culture As a Latino.

You mean we don't shut up?

You know, we're constantly talking.

That's how we show our love and how we express.

And so I think that's a really important piece that I think we're trying to really develop, but really unique to El Paso.

Then I think about the other patient that we were just talking about who had the meningitis and mom had to be told he had meningitis.

He's deaf.

Do you want a cochlear implant in about 4 hours?

Oh, dear Lord.

And so we don't have that time to go through that grief cycle.

You don't have that time to council on to the risks.

This is what we cannot promise.

This is what we can do.

This is what's expected of you.

It was so it's got a whole team laying this out on the table.

You're leading the team.

You've got, again, all these assistants that are helping out.

So, you know, deer in the headlights type situations when they have to make these decisions.

How does that come about?

Yeah, I wish I could I wish there was like a perfect recipe.

And you know what?

I this is classical our community to right.

It looks different for every family.

I think in an ideal world you sit around a table and you have all the specialists and now towards the center, you know, we can do those types of things a little bit more.

But in those moments it just really is all boots on the ground.

And I think like to your point, know for that particular kiddo, it was 9:00 at night.

We had made the diagnosis.

Mom was in the recovery room waiting and it was really all the O.R.

staff, myself, Maggie and Pete.

But I think that's also kind of just showing, you know, that we're all sort of when it comes to this this type of of intervention.

It's a lifelong journey.

That's what I tell parents.

It's not something you just turn on and turn off.

It's there and you got to work at it.

So we really lean, I think, a lot on our own sort of values of wanting to be supportive for our families.

And how human is that right at the end of the day?

And there is again, I been doing this program for almost 27 years and I don't remember which doctor said it, but again, the day it's like I'm just treating a human, you know, yes, I've got this medical, but I'm just I'm just treating the other human and I want to be good doing it.

When we talk about hearing I want to talk to Dr. Jonathan Chao for a little bit about some the surgeries that you do that are not hearing related, that are not audio related.

But you said earlier that you do surgeries on trachea, is on airways.

Give to me some of the pediatric situations and maybe maybe congenital versus because I know we can go into accidents.

But let's talk about stuff that that may be congenital with the child that you might have to deal with in your specialty.

Yeah, And a lot of aunties will do this.

But with kids, we always worry about airway, foreign bodies, something that a child has been running around with their in their mouth and then they have a coughing fit and then there's something stuck in their trachea, their bronchus that, you know, is blocking their breathing.

So that is one of the things that honestly almost all pediatric ENTs has had in their past that got them interested in going into pediatric.

I have a story to tell you about.

Oh, no, it might be after the show, but yes, but but also what we do is there's a lot of kids in town and a lot that come actually through the NICU.

You are transferred from other hospitals that now that kids are being born earlier and earlier and they need different life sustaining options.

Tracheostomy is something that we do a lot at this hospital.

And complex tracheostomy care is a lot like doctor manage.

I was talking about kind of meeting the parents where they are and their family in it because basically a child can't go home from the hospital with a breathing tube in their mouth.

When I'm talking, child we're talking a brand new, itsy bitsy, tiny little baby.

I mean, the micro surgery, I almost pictured that way.

Well, the airway is really small at those ages.

The youngest they've done is one day old and that was an emergency.

But.

But, yeah, it's it is a lot smaller than the adults.

And there are a lot more risk than in the adults.

And having a center that kind of understands that and can talk to the family about that is very important.

And we've had good support through the community and good support from the other hospitals to kind of transfer them in.

And there are other kids that get transferred in where it's not necessarily that.

And we have our multidisciplinary approach.

I remember one where they were transferred in from another.

NICU you after having an esophageal atresia and that was repaired, but then the kid just wasn't doing as well as they thought.

And so they got transferred in.

And my pediatric surgery colleagues, Dr. William Spurbeck, who's probably been on this show before, has been well.

And then I were able to take him to the operating room.

We found a tricky esophageal fistula.

We fix that.

They're working on fixing the esophageal stenosis down low from the repair site because the kid had a little bit of a leak, which happens with these things and really kind of working with GI pediatric surgery and ENT to kind of like bring that kid back.

And now that kid doesn't need a tracheostomy.

It doesn't need anything like that.

But tracheostomy care is something that we do a lot here.

And it's something that families are really, really involved in.

And we've had some great families come through here.

Oh, I there's no question.

I bet that and I'm thinking, too, when you have these type of surgeries, because and I know Dr. Superbug, we're talking about different types of implants and just things that you have to do.

So when you're looking at child tissue, again, it's ever growing up until the, you know, middle teenage years.

So when you are doing these kind of surgeries, how do you factor in the growth that has not occurred yet?

And, you know, because to me, that's fascinating because you have one year and there's an awful lot of growth that's happening.

But if you had the surgery a year ago, do you have to have multiple surgeries until that child gets to full grown age where tissues aren't growing anymore?

How does all that factor in in the surgeries that you have to do?

So in surgeries that I have to do, a lot of that is kind of dependent on the type because ear, nose and throat all kind of develop differently.

The ear is almost adult, size is 95% of adult size by age five.

Okay.

But the trachea will continue to develop as the child gets longer and the child gets taller.

And so often children who have really bad tracheal Bronco malaise are kind of collapsing in the airways in their tracheostomy is one of the things that allows allows us to provide them pressure at home to keep that open and keep them breathing at home, either on a ventilator or on some high flow oxygen or something like that.

But having a tracheostomy also helps stent that collapse open.

But like you said, they grow their trachea gets longer, it gets bigger around.

So any of these put that in?

Well, it's I mean, we take surveillance.

So I always look at the tracheostomy as I take him to the operating room and I look through their mouth down at their area, make sure they're not scarring.

If there's scarring, I take it out or I can dilate or they can do a whole bunch of stuff with that.

But I also have to size it.

So it's almost like their shoes, you know, their feet are growing.

You get a new pair of shoes.

So for my kids, you know, they get a new they get a new longer track, they get a new, bigger size check.

If they're having problems with mucus plugging, they have we can go from cuffed where they need a lot of pressure to help keep it open, to cuff less, where they can help speak better, and it can be a much more natural for them and less irritating.

So yeah, these these surgeries, sometimes the more complex ones sign you up for more surveillance care in the future, but that's more so the the complexity of the child and the complexity of the process that necessitated them to need that surgery rather than the surgery itself.

So going on that.

No.

And I love and see, look, we aren't for 30 minutes already.

It happens fast on that note.

So what I find in what I'm hearing is the follow up is so vitally important.

And so we're looking and I guess it's different with every person, every three, every six months down the line and then the team that's brought in.

So I'm assuming that there is some physical therapy that that happens or a speech therapy that happens and feel free to kind of whoever wants to take that one.

I think audiology You were talking about speech earlier, too.

How does that work out?

And there's certain ways of breathing in general.

Say you have to give a surgery to someone who's three and now they're ten.

What has happened between the age of three and ten?

How many times do they see you?

How in again, surveillance following up.

Yeah, and again, that depends on the type of problem or the type of issues that they're dealing with and type of surgery that they needed for a cochlear implant patients.

We really involved the whole team both before and after.

So we have a monthly meeting where we discuss with auditory verbal speech therapists audiology and ENT all the patients that we are coming down the line working up for cochlear implants, expectations, plans for aftercare, these sorts of things.

And so we meet monthly on that.

And then in terms of seeing the audiologist afterwards, that's on that's on her schedule.

But speech therapy is very important.

That happens, That happens.

I don't know how much it's like weekly at least twice a week.

So that's one thing.

The situation.

Yeah, yeah, absolutely.

Yeah.

So it just depends on the on the on the, the issue in the surgery itself.

My kids I like to see every 3 to 6 months.

Depends how they're doing, depends how long they've had the triggers.

And so any issues they've had, I take them yearly for surveillance looks to make sure that there's no complications inside, that there's no scarring.

And that needs to be addressed.

And I have one patient that when I was in fellowship in Houston, I was involved in placing his tracheostomy.

He lives in El Paso.

He had come to Houston for complex cardiac care.

And we did the tracheostomy there because he was having issues with with coming out of the heart surgeries.

And then I'm taking care of him here now and his airway is getting bigger.

We're dilating him.

I just injected him with some steroids and dilated him Again.

He's he's making noises now he wasn't able to do before and stuff like that.

But for him, I'm taking you know, I see I think I see him every three months and I just love seeing him.

So.

Yeah.

But he's I could tell just the way your your your body language is right now too.

Yeah.

But that continuity of care really depends on kind of the problem and kind of what they need help from us with.

And we're just, we're like one day every couple month visits.

But parents or parents are doing the hard work at home.

I think in talking about the family, I want both of you all to think about something either that we haven't talked about yet or something that you want to expand on.

In the meantime, what I'm going to do is talk about the specialties in the services that you guys do have a children's M.D.

special clinic here.

So we've got the allergy and and behavioral health.

We have brachial Plexus.

We had entire show on that, which was fascinating to me.

We also have cardiology, the CARES Clinic, that provides medical services for emotional support, cranial and facial cystic fibrosis, Dermatology Empower Program, which provides personalized dietary plans, your nose and throat, which is you guys general surgery, which is a little bit of you.

Neurosurgery, Dear Lord, spinal bifida, urology and vascular malformation.

That's just a few of the things.

And again, today we're focusing specifically on ear, nose and throat surgery specialties, neck and head, and then also audiology and all the stuff that goes along with that.

Now that I've gotten all that out, Dr. Amanda Chiao, who is a medical doctor.

Dr. Jonathan Chao.

Dr.. Mr. Jonathan Chao Again, there's no banter.

I see.

People will not know that you're a married couple.

You got to throw something out.

Is there anything that we have not talked about that you'd like to touch base on?

I think one of the important things, especially with the hospital in these specialties that we you know, you kind of like listed here is there are pediatric based so a lot of adult care can cover kids, but a lot of these like pediatric dermatology is one of it's one of the rarest specialties to have.

And for El Paso to have a pediatric dermatologist on staff at the hospital is huge.

She manages the Vascular Malformations clinic, so she's kind of the director of that.

We share a clinic together so I can see him NGO as that may be also in the airway and that are on the face pediatric urology like, I mean, that's specifically focused on problems of kids when they're born and that they develop over time.

We didn't specify a specific, specific pediatric allergy.

It was fascinating to me.

All the things that I had no idea was an issue.

Yeah, but all these are just very pediatric focused, so we're not like we're not doing adults on the side.

We're not going to do an a facelift.

And then we're doing, you know, a cleft palate where we're actually just focused on the kids, which makes a big difference and kind of the care that kids get and kind of the environment they get that in.

So I think it's much more comfortable for families and much more comfortable for the patients.

Just having a pediatric area, without question.

Yeah, And I, I guess I'll kind of piggyback on that to say from kind of the family perspective, you know, to be able to and we were talking about this, you know, we're identifying these kids or putting traits in when they're little and then they grow with you, right?

You get to kind of see them grow.

I mean, one of you not fall in love.

Yeah, I had one of you kids today that, you know, shows up and take a picture of that at his clinic and showing them.

And so it signifies, though, that, you know, we have are able to sustain these specialties.

We have a longevity to say you can I'm your practitioner, I'm your provider.

From a family perspective, I think that's really, really meaningful.

These families sometimes get bounced around to, you know, Dr. Charles point.

You know, they see this doctor and then all of a sudden they stop seeing something happen.

So that continuity of care, being able to say, this is my pediatric ENT and I've been with him for this long is really, really important for families.

And the infrastructure in which we've created is to facilitate that.

You know, even at the at the specialty center, you've got people that walk you in an escort you to your doctor, you know, And again, going back to the our culture, that's everything.

Feeling comfortable to say I don't know where I'm going getting yeah vacation through the parking is better.

Yeah.

And you know and being able to sort of connect and somebody face to face and say let me get you to where you need to go facilitates that.

I want to come back and I want to come back and I love going to see them and it's not an issue.

So I would say as much as we're excited to kind of be pediatric focus, I think it's also a testament to the fact that our parents and our families feel very comfortable to stick with us while they are kids.

I like that.

And so I was just I was looking at this nice little book here.

I was hoping that there was a phone number here and there is.

So if people are listening to this right now and just have questions, you know, and this is a program that every walk of life.

So I didn't tell you this before the show, but when when you go back to work, people are going to know, hey, I saw you guys last night and you mentioned my name.

Isn't that great?

So people who are watching and tuned into this, if they have any questions regarding children and health in general, that telephone number to call 915298544 for all the specialties that we did mention.

And again, we do still have a little bit of time and I will talk about when I think about pediatric ENT and I think the general populace may think this, you think about tonsils and adenoids, which my my son had out when he was 19, but I still considered him a kid.

But just quickly, because that is such a huge area, talk about when that is something that needs to be discussed, when is somebody really need a tonsils out?

Because for us, we we belabored it for years until we did it.

He was my lord.

He just was what do you call that?

Strep throat boy?

Just constantly like four or five times a year.

And your ear infections.

But talk about how kids come to you and that ends up being the thing.

And the reason I'm talking about is because it's so common.

Oh, yeah, But nobody ever talks about it because it's like, Oh, yeah, that is horns.

Is that okay?

It's like going to the store and getting broccoli.

So tonsils being taken out is one of the most common procedures among kids in the United States.

Over 300,000 are done a year on kids in the United States.

The way that we have approached tonsils has really, really changed over the past 40 years.

So 1986 was a big switch beforehand.

We used to take tonsils out just because kids had them and they were big.

Nowadays that has changed dramatically.

The number one reason that tonsils are taken out of kids is for symptoms of sleep apnea.

So obstructive sleep apnea as a child can lead to later on health consequences, but also they're not getting restful sleep so they can be sleeping.

I always tell parents you can be sleeping for 20 hours if you have obstructive sleep apnea, but you're not.

You're waking up every so many times.

You're not getting rest from that.

You're not going to wake up, have energy, be able to pay attention in school, be able to kind of like come home from school, have dinner with your family, that sort of thing is very important for the development of the child.

So obstructive sleep apnea is one or sometimes very loud snoring that we notice pauses and breathing and that they also have symptoms throughout the day, such as falling asleep in school, getting in trouble in school for not focusing or paying attention, coming home from school and having going right to bed or having nighttime accidents at an age that might not be appropriate.

Those are all things that relate to bad sleep.

Strep is the other one that really kind of changed in 1986.

And a physician, his last name was Paradise.

So we call it Paradise Criteria really dictates how we take it out for strep now.

And what the research says is that if you have seven strep positive infections in a year, you can have benefit from having your tonsils out.

That's when we were five and a year for two or more years, 3 a year, three or more years.

So these different criteria tell us, you know what to expect and what can we tell parents?

Because without tonsils, you can still get strep.

Right.

And that's an important thing to notice and tell parents, because if you do a surgery on a child, they go through a really hard recovery for a tonsil.

Yeah, it's a two week recovery.

But in they go through this and then a month or two later they get strep, they're like, would you do to my kid?

So it's very important that, you know, like we understand these different like nuances.

Statistics tell us, yes, we'll have a 90% reduction in our strep rate.

However, every child is different and we do see the complex immune system.

You don't need to be fighting strep all the time.

We I mean, the reason we did is COVID.

If you get sick, I want to make sure he has enough of his immune system fighting all the other stuff he has to deal with.

So to your point, yeah, he got it again the first time is like, what?

But then you look into it.

That was really loud.

Sorry.

But anyway, to your point, that was definitely there.

And a lot of what we do with the basic stuff, the tonsils and the ear tubes, is getting kids off of antibiotics because we don't want kids on the antibiotics for the first five or six years of their life.

We want them to be able to kind of go throughout life.

Yes, they'll have a sore throat once in a while, but 95% of those are not strep.

If they are having strep over and over and over, they're getting antibiotics every time they do it and they need that or it can turn into complications.

And there are other more rare reasons to get tonsils out.

But we and we do those I've done I probably done seven or eight of the more rare reasons at the children's hospital in the last year and a half.

But yeah the where tonsils are tonsils are thing.

Yeah.

Adenoids.

Adenoids too.

Like when I was a kid I never heard why did not academic was and now it's like tonsils and adenoids which I think there is a doctor wants to so it's kind of like tonsils but they're up higher and in your nose.

I'm like, Yeah.

So I guess in your nose you could do.

I know this is our dinnertime, you know.

Yeah, this is our dinnertime conversation.

So I kind of love that.

So for those of you quickly describe when adenoid is Adenoid is exactly what you said.

So it's tonsils or tissue in the of the nose, eyes on the back of the nasal pharynx back there and it gets the it grows and grows and grows.

But then around puberty it starts to get smaller and smaller and smaller and atrophy and it should go away.

In your son's case it didn't.

But roundly, adolescence.

I've done three adenoids on on adolescence this year because it just didn't go away.

Right.

But when kids noses are as small as they are, it blocks up the back of their nose.

So often we see kids mouth breathing when during the day their nose is constantly running and they're talking like they can't lose anything through their nose.

So we want to we want to really get them breathing through their nose because that affects their mid face development.

That affects a lot of things.

So you don't you don't want go to have hearing loss and there you go.

And here they come they also by the audiology audiologist I see I see all the parents.

Yeah that's fine.

Thanks again for tuning into the show.

In case you didn't get to see all the show or if you want to watch the show or any other topic of a show that we've done in the past.

There are three different ways that you can do that.

One is through pbselpaso.org, another one is through the El Paso County Medical Society and that is EPCMS.com.

And that also good old fashioned YouTube that I feel like you can almost find everything on there, but it's YouTube.com and then just go to the word the El Paso physician and all of these you can find the El Paso position on there and access any one of those programs at any time.

And we will see you soon.

I'm Kathrin Berg and this has been the El Paso physician.