neither the el paso medical society its members nor pbs el paso shall be responsible for the views opinions or facts expressed by the panelists on this television program please consult your doctor brachial plexus injury is an injury to the brachial plexus what does that mean i didn't know either so i looked it up um it's a network of nerves that conducts the signals from the spinal cord to the shoulder the arms and the hands there are seize fives through sees eights and t1s all kinds of good stuff and we're going to get into that this evening you may have heard it in layman terms in the past as something called backpack palsy or rook sock paralysis which is basically in german backpack paralysis we're also going to talk about spinal bifida today and the up-to-date treatments and the options that have really impacted the quality of life for people and patients who have this condition as you know this is a live program so give us a call at 880-881 pardon me 881-0013 this evening's program is underwritten by el paso children's hospital and we also want to thank some new people uh we have the burrell college of osteopathic meth medicine from new mexico state and it's really nice for you guys to be here and with us today we have we have uh luis zuniga and also gina gilderman and so they're both third years so they know their stuff so by all means please telephone them get some questions their way again that number is eight eight one zero zero one three we also want to thank the el paso county medical society for bringing the show to you each and every month several times a month often i'm catherine berg and you are watching the el paso physician [Music] thank you again for joining us we have uh two specialties here today kind of different but kind of the same lots of nerve endings and uh just connectivity that we are going to be talking about again brachial plexus and with us specifically for that tonight is dr sean diamond and he is a gosh you specialize in a lot of things just talking here this is a specialty because it is breaks break seal plexus month it's hard to say that and again when i got the topic this evening i thought what in the world is that so i did a lot of research but you also are a hand surgeon so you deal with a lot of the complexities of our human being so we appreciate you being here very very much absolutely and also we have and also i have to say dr diamond has a very calming voice every now and again i know that you don't see what happens behind the scenes but things get a little crazy and he was very calm giving directions to people and it's it's nice to hear that so i appreciate that then we have dr guerimo latif who has been in el paso 22 years and we're going to talk a little bit more about him in a moment he is uh specializing in urology urologist and he does specifically specialize in pediatric curology and every now and again works on people that aren't little but for the most part we're going to be talking about with dr latif spinal bifida but again opening it up to other questions too that have to do to pediatric urology so now that i've kind of covered what you guys do at least what i have on my paper dr diamond we're going to start with you if you can describe to the people at home i know we have a topic that we're that we're sticking to tonight for the most part but describe everything that you do i always say to the doctors say what do you do all day every day and it's it's easier for me to say that but that could cover two or three hours but how would you describe your profession yeah um that's a challenge it is a challenge i know you have an hour right we have an hour we can extend it to three or four people may turn out perfect that's okay so it's probably easiest to explain how i was trained and what i was inspired by and how i arrived here okay so i was trained in plastic and reconstructive surgery i trained at harvard in boston and then have a specialization in plastic hand micro surgery which means plastic surgery is this massive specialty most people think of it as botched or the kardashians or aesthetic plastic surgery botox filler facelift which is awesome i'm that guy sometimes but many times i actually trend towards all the reconstructive aspects so plastic surgeons are trained in the specialty of what we call the integuments so skin muscle joints bones all those things fall within the realm of plastic surgery complex wounds and in my case i love hands they're a very complex organ people are tied to them in many many different ways be it a musician or an athlete hands are very important for people's function their livelihoods and they're very tied to people's psyches and when people injure their hands they go through quite a bit of mental problems as well so being a doctor of hands you're really a doctor of skin bone joint tendon nerve blood vessel and you take care of problems that involve all those different systems and that kind of ties in into brachial plexus injuries which are injuries of the nerves that affect the upper extremity and when you have problems with those nerves you have problems with sensation or muscle weakness or the ability to even bring your hand to your mouth so the young babies i see with plexus palsies or injuries often have problems related to an inability to move the arm right and we're going to get into how that happens um at birth often that happens at birth and i know that we uh we're talking about in layman terms and i think that's more in the older days just think about the backpacks the heaviness and and what can happen in this area we're gonna have some graphics to show you in a little while um but it's fascinating to me because like i said i knew very little about this before this program and i thought man there's so many easy ways to have issues with this and it's nice that we have doctors that understand i mean just the it's funny we had a guitar string earlier on the floor because there's a lot of studio production in here but if you're looking at little strings like this that's something you have to deal with when you're looking at nerve endings and everything else so wonderful to have you here dr latif my goodness urology pediatric urology that in and of itself is such a discipline and i'd love to explain that what all of that encompasses and i know that tonight we're here because of spinal bifid a month so we'll cover that as well but if you can explain urology as a pediatrician versus urology as an adult and kind of give our audience an idea of that well in as a pediatric urology urologist you deal with a lot of the congenital problems that happen there is all kinds of variants that can occur in the development of the kidney the system that transports the urine from the kidney down to the bladder the bladder itself and then the urethra how you urinate and there's congenital anatomic problems of the male genitalia of the female genitalia and like dr diamond there's all these little issues that you have to pay attention and we in fact intermittently consult the plastic surgeons because there are times when you either don't have enough skin or you have some scarring or you need to augment the structure and and so it is a complicated business and the function of the bladder and we'll talk more as we get into spina bifida the bladder is a very interesting complex structure and it's the the purification of everything that's in and out of the body and that's something too we just think oh it's a bladder um but no i'm very happy that you're here because we're gonna we're gonna learn all kinds of things this evening and what i'd like to do uh because we have two disciplines like i said that are that are relatively uh different from one another i'd like to kind of start with uh brachial plexus and if we could gracie gracie sorry who's valeria valeria's in the back race he's right in front of me and gracie's usually the person doing the graphics and valeria if you would mind queuing up slide number one for us and when we have that up it might help describe to the audience what we're talking about uh when we were talking about rook sock injury or backpack injury paralysis we can see that this is the area of the body that we always throw over our shoulder it could be people that were very very heavy purses etc but what are we looking at here in relation to what we're going to be speaking about this evening so we're looking at a really beautifully drawn medical illustration of the anatomy of the upper thorax and you can see that the clavicle bone there's two words that say clavicle has been split and opened and that's to show that the nerves of the brachial plexus actually run beneath the clavicle they like most nerves in the body arise from the brain they go through the cervical spine and upper thoracic spine at c567 c8 and t1 to form different things namely named trunks and then they form divisions and chords and there's a lot of names frankly speaking it was the most intimidating day of medical school to do this anatomy because believe it or not every single one of those little yellow spaghetti strings which are beautifully drawn in this have names and functions and you can imagine if this wasn't a black and white drawing in a real person you'd also be looking at the cupula of the lung which is the lung apex the subclavian artery and axillary arteries and carotid artery and the nerves that control the diaphragm so it's a tight little area with a lot of important structures and a lot of things and in real life it looks a lot more i think like the spaghetti bowl in el paso it's not quite as neat and tidy as that drawing but i think that's also helpful to show this drawing shows those yellow nerves entering the muscles right exactly when i was doing research on this so on the show we have a we have another in fact valeria if you can pull up slide number two it is more uh cartoon-esque so to speak when i was doing research i was trying to find the perfect slides that would explain to people what we're looking at this might be it's it's a lot easier but i definitely wanted to show slide number one to show the complex you know like you said the spaghetti and the spaghetti's yellow here too how how appropriate so nerves are often depicted as yellow they're more often white in the body they're tough to find at times but let's take an example the upper right hand corner that says axillary nerve that's directed right towards the deltoid muscle the deltoid muscle is responsible for forward flexion of the shoulders so if i could show the audience for this is forward flexion of your shoulder and for a good deal of abduction of the shoulder and when there's injury to that nerve which can happen in adults by means of shoulder dislocations or trauma or it can happen in young babies with congenital nerve injuries like an upper trunk brachial plexus injury and it's very common therefore in a little baby with this type of nerve injury to not be able to raise their shoulder because specifically that axillary nerve which innervates or powers or give gasoline to the deltoid is absent in function and valeria if we can come back uh to the docs really quick so i would love to have dr diamond repeat the motions that you were doing earlier when that graphic was up because it does make a difference to where and how the nerves are raising your shoulders up and down from the front of the back if you can repeat that again if you don't mind so again the deltoid there's probably a ton of yoga people watching the show and they know the muscles way better than i'd ever explained but forward flexion of the shoulder larry if you can put the camera back on the doctors that would be great there we go so um so this is forward flexion of the shoulder and abduction of the shoulder right this is internal rotation when you basically bring your palm or fist into your body and this is external rotation and there's a lot of different muscles around that shoulder cuff responsible for those motions and the nerves that control those muscles all pass through the brachial plexus at some point again such a an intersection so to speak i'd like to right now before we go to urology because usually i kind of bounce back and forth so um and and dr latif he's been great he says you know i've been watching the show for 22 years so he he gets the the the dance that we do so our dance is going to be a little bit different tonight for that reason but two of the i'd like to speak about the birth canal and when this injury happens during birth and the complications that happen there and then maybe we'll take it on to you know teenagers or just people that have weight issues and that's how we have the injury but first let's talk about the injuries that occur during birth yeah so so these types of injuries are not totally uncommon meaning they have been about one to two times per thousand births and that's a national average which in general is going down but we don't know the el paso rate it's not totally documented we actually don't know our own region's rates which is why it's helpful to have built and are building a clinic like ours but essentially the birth canal is a tight area and when there's challenges and birth often times to save a baby's life and to save them from worse problems like a brain injury tools like vacuum or forcep need to be used and they're very appropriate at the time and i by no means my ob training left me in my third year of medical school so i have no bear you know i have no intelligence in that area but but i gave birth to a baby in my third year is awesome and that was it but but the point is is that these are really life-saving maneuvers that's my view on it i wasn't there but injuries can occur and typically they'll occur because the shoulder was either stuck in the birth canal the shoulder was rotated in the birth canal and we call that shoulder dystocia right and at our higher level birth centers like our county hospital at umc each patient will get a shoulder dystocia score for that reason going into labor to see if they're at risk to develop issues no matter what no matter what okay so there are things to look for that can sort of clue you in but the long and short of it is that at some point there is a stretch type injury meaning the arm is pulled the shoulders tweaked the neck is tweaked and there's such a significant forceful pull or stretch on those nerves the nerves do one of several things they either get very injured because they're stretched apart if they're stretched so much they can actually pop and the last type of injury is their stretch so much that they actually pull from the spinal cord and that's what we're really talking about when when we're classifying the injury how bad the injury is and how the young baby's doing as they're coming along in their younger life and if they're torn from the spinal cord i'm just trying to go through in my head how would you go back in as a surgeon then is there is there a natural healing process if you're able to go in and place the nerves back in that place you have to actually somehow adhere it back to the spinal cord how do you how do you do that so that is the million dollar question oh my goodness that you touched upon the toughest question in my field and i'm very lucky because i sort of have a whole community of people nationally and throughout the world that we work together it's called plexus nexus it's a literally a national or international group we talk about cases and what to do but there's a lot of different treatment methodologies the first and the easiest being physical therapy and if babies are connected with the right occupational therapist they can do fantastic oh wow okay and for certain types of injuries about 80 90 percent of young babies can recover fully that's not the same when you have an injury like what we call a root avulsion meaning that spinal cord root is pulled from the spinal cord in that case we often have to perform what's called nerve grafting or nerve transfer type surgery where we literally rob peter to pay paul we use good functioning nerves to put them into poorly functioning nerves that serve more important purposes essentially this is where that plastic surgery training comes in handy when we were talking about that at the beginning of the show that's right so as a plastic surgeon we train in micro surgery which means surgery a very small vessels or nerves and we train in tissue handling and i think dr latif is the same i mean pediatric urology you have to be a masterful masterful tissue handler i like that tissue handler you can imagine a young boy's genitalia after birth whom you need to work on for some reason or not you can hardly even you know no force at all and it things can tear so this is this is very fine motion fine um finesse type surgery that's very well thought out before the operation during the operation this is not sort of the frantic operating room you see on the television that you described not at all no what i'd like to do is uh take things over to dr latif and talk a little bit about spinal bifida because you you did a beautiful transition into the tissue handling uh which means that we can do the little back and forth a little bit now which is great and i'd love to talk too about we describe birth injuries um and then maybe just other injuries that may occur as people get older and what i do want to touch basic on this evening again again this is the apostle children's hospital and little ones when they're born just the rate of healing and the rate of growth and how it's so goodness when somebody's between the ages of one and three how fast that occurs versus if there's an injury with someone who's 12 or 13. it's a lot slower and then when we're old like this you know we've got a whole different thing so bringing that into the picture as well um dr latif if we can explain and if we could pull up graphic number three valeria that would be great um because we hear spinal bifida if it's something that we don't have on our tongues all day every day people what exactly is that so we're going to bring up this graphic and if you can to the best of your ability i know it's not too uh complex and it doesn't have all the the names and words on it um if we can explain what spinal bifida is to the audience and then talk about the complexities that you have to go into well spina bifida is is sometimes a kilometer situation it's unfortunately a problem that occurs very very early in development at approximately 18 days of gestation oh my goodness that early 18 days of just neural tube that forms the spinal cord starts folding from the head gradually all the way down the back to the tail and any abnormality in that fusion that's a very delicate process of two layers of tissue coming in and folding it just right at the right time if that doesn't happen the nerves that are encompassed within there don't form adequately and what you see in the representation here is a defect and these defects can vary this is a single vertebral space that you see right there but it could be two four six vertebral spaces that are open and there are times when the nerves literally protrude into the sac in times when the nerve defects be it bladder function motor function lower extremities things like that each one is different and you have to evaluate each child individually to know exactly what their injury is how it's affecting the bladder function the other thing that happens is that in this defect since the nerves can come down and relax you get obstruction at the base of the brain right so you get a blockage in the drainage of cerebral fluid from the brain down to the spine and you get what's called hydrocephalus uh valera if you can bring the camera back to the doctors that'd be great so you were talking about when there was fluid here because you were pointing to your head and then down to the spine and repeat that portion of it we have what are called ventricles these are spaces with cerebral spinal fluid this is secreted and it has to travel and get reabsorbed when it can travel and get reabsorbed then this gradually swells pushing the brain against the skull and you get damage to the skull so the neurosurgeon like dr jimenez who was here some weeks ago exactly he not only has to repair the injury to the spinal cord right but he also has to evaluate and sometimes place a drain to provide this drainage so that the brain can develop normally and i remember when dr jimenez was here we were talking about uh the amount of time and i know it's different with every patient i respect that completely but the amount of time once a birth occurs and they were looking at how to teach parents to look for something that's off you know the the head just appears a little bit larger than it should be um he was talking about a spongy feeling to the head etc so that it doesn't get to a point where um not that there's a point beyond return sometimes there could be what is it that you have parents look for if everything appears on the outside to be fine so you talked a little bit about when we were looking at the graphic if it is a protrusion outside of the skin that's easy to see and you said sometimes that may not be the case is there is there always a breakage in the skin or how does that so okay so there are all kinds of variations on the theme so you can have a close skin defect with a palpable defect so the skin looks normal the other thing that can happen is you get a development of a fatty tissue so you get what's called a lipo meningocele okay and so this is something and you get a deformity the other thing that you look at which is interesting is there are abnormalities in the gluteal cleft the way that what we call that break between the two buttocks there's abnormalities it curves to one side right or it's blunted sometimes that can give you an idea that there's an abnormality gotcha the other thing that can happen is that you get a tuft of hair and so you get this type of abnormality and and that would indicate then that something either hasn't been formed correctly or is timing the formation of my timing might be off correct exactly correct okay and then there's other times when there really is very difficult to ascertain so part of my physical exam every time i examine these little babies when they have some type of urologic problem urinary tract infections you always need to be very careful in your assessment of the lower spine to make sure that you're not missing what's called the spina bifida occulta which is a hidden spina bifida so here here's the the million dollar question for you i know we were joking about the million dollar question right dr diamond but dr latif when you when the pediatrician babies just born babies may be 20 minutes old um and there's the score and i forgot the name of the score but the score that every baby gets um when you're looking for something that might be wrong you're talking about urinary tract so the fluids the fluids not draining or being absorbed correctly how can you tell if a little tiny itsy-bitsy brand new person has an issue urinary-wise just just as a pediatric urologist what do the parents look for well there are two things that are very obvious one is the child that is born and 12 hours have passed and has made no urine and so you need to know whether it's urine production or obstruction right okay and the other is the child who every time he does every little any little effort leaks oh actually the opposite and so it's the opposite they tend to leak in the form that they shouldn't right right you and i are sitting here chit-chatting we have no qualms about worrying about our bladders right it's doing its job wire just so it functions beautifully exactly but any fault in that wiring can lead to significant problems this is so interesting i almost want to have separate shows on each one of these uh because there are so many different issues but you know we're talking about i like the spaghetti bowl that happens in both of your your practices but when we're looking at spinal bifida like you said the graphic that we have uh has one but it could be several but very important to note too that they could be completely hidden and palpable you were talking about the word palpable which means feeling what's going on absolutely um and this is this is where it's so important for moms to come back to the doctors several days later you know to adhere to that scheduling of making sure everything is is is going well with the little one i'm going to try to transition back now because we were talking about itsy bitsy tiny ones and so now i'd like to go to dr diamond again and talk about um this braxial plexus and maybe not affiliated with a newborn sure like i said in layman's terms and i remember looking at that and i'm thinking i i have a daughter she's not 24 but she's tiny and i think that because when she was going through high school there's lockers aren't a thing anymore and she's carrying around a backpack with you know 50 million pounds in there and she's got her sports bag and this and that and the other night i keep looking here like please don't break today please break um but injuries that can occur after birth you know i think again that there's a reason it's named but what are some of the other injuries that can happen so um it that's got to be a really heavy backpack yeah i mean that's got to be a heart but you look at some of these kids and they're twigs they have ipads now it's going to be fine so the deal is that when you're an adult and have a plexus injury you're doing something pretty intense okay we're seeing them in people who are going 110 miles an hour on their ducati and then they happen to hit a semi truck that's the level and degree of force you need to have an adult brachial plexus injury and we see them in very very what we call high velocity high energy blunt traumas which we take care of at our level one trauma center and they happen typically for motorcycles sometimes from atvs sometimes from car crash there are very very severe blunt trauma where the arm gets yanked in some fashion and same thing gets yanked and pulls on those nerves those nerves are extraordinarily protected so in a young baby it happens in the birth canal in an adult it happens with very severe trauma okay you asked earlier what makes kids um amazing and they are amazing i call them little trucks they get right and just keep going and growing and they heal like gangbusters they make us as plastic surgeons look great because their scars look better they heal great they don't get infections you deal with adults and they come with a lot of baggage some are smokers some are using other types of substances some have diabetes all those things are challenges for every level of nerve nerve but wound healing so nerve healing tendon healing wound healing etc so you know how quickly little babies heal things you know it in adults and older people it can be a challenge to get difficult wounds or problems to to get healing so that's kind of the big difference between the two and that makes sense to me too when you're talking about trauma um i don't know how often in a newborn that a bone would actually break and i'm thinking with trauma we were looking at that clavicle earlier that there could be breakage of bones and then also suturing of muscles back together etc etc um i don't know if you have a case study that was really bad that you'd like to talk about so there's um you know fractures during birth are not uncommon you probably see more fractures than i actually see plexus injuries nerve injuries so fractures of humerus or clavicle and there's other types of nerve injuries that happen peripherally meaning you break an upper arm bone and you get an isolated nerve injury right at that same level but we're seeing a lot of different variants of plexus injury and we're lucky in el paso now to have a capable operating room and colleagues from anesthesia to neurosurgery to occupational therapy who can handle this problem and really take care of it well thank goodness for use again i know i'm repeating myself and i shouldn't but the more i looked into this the more fascinated i became in the idea of how in the world you said you know the the idea of tissue handling and we're talking the spaghetti bowl there's lots of nerves in there but you're also looking at the pulmonary system and you're looking at muscles you're looking at bones um when you're looking at when you said earlier too you're a specialist in hand surgery anything that happens to do with the hand and psychiatry too because that's how people talk they communicate you watch other people what are their hands doing you can kind of figure out what's going on um and and dr latif i'm going to come with you as well because when we're looking at spinal bifida we were talking about the bladder and urology but you are also you know the idea of nerve endings the idea of what might be happening with the pulmonary system as a urologist what else do you see in the area of spinal bifida that that kind of occurs and i'm trying to marry these two disciplines together if that makes sense of all the complexities and the tissue handlers when it comes to this well in our setting we luckily don't have to handle the nerves okay the nerves that are injured are far away from the bladder those are in the spinal cord and the neurosurgeon has dealt with the initial closure the other thing that is interesting is that now dr jimenez for example is one of them who is using a special substance as he closes the spinal cord to prevent scarring because that's one of the big issues right for example in the tiny little babies as they grow that spinal cord is going to migrate exactly and if you could i'm going to interrupt you only so we can explain to the audience why scarring is not a bad thing but why scarring is such a big deal because when something scars it becomes hard and it the flexibility is taken away and so i remember when dr humanos was talking about this it helps playability if i'm saying that right um which is why scarring and you were talking about scarring too with plastic surgery i mean it's a whole different thing with little ones again that's a lot easier because that they're created to become more and more and their tissues are happening more but um talk about how important the scarring is oh it is very very important especially in the spinal cord because clearly the newborn when you close the spinal cord is going to start stretching immediately and one of the common problems that we see is called tethered cord where the nerves get scarred in place and as the child grows the nerve is under tension and so that's why dr jimenez is using this new substance to try to avoid that to allow the nerves to heal within the sac which we call the dura and that allows tissues to slide and hopefully we will see less of that problem and in any surgery when we do reconstruction we try to borrow tissue to cover to allow for motion on top and stability underneath and i'm sure dr diamond does exactly the same thing is the the care of once you reconstruct this you can't just leave it there right you have to very carefully place a defense from the scarring that's going to occur so as the motion starts happening as physical therapy takes on you have to have that freedom of movement and that agree you guys are good at transitioning into each other so when we're looking at again i keep thinking plastic surgery fine but it really is all about pliability right at the end of the day with the different tissues and you were talking about hands and i'm just think of it you know hands feet anything that's got all that going on and when you're borrowing from peter what is it robbing peter to give to paul vice versa that's right um where are you so when we're talking about babies let's go back to the babies because this is a children's show or pediatric show when you need to borrow some tissue from somewhere with babies it's easy because it seems like anything can just regrow how how are you doing that where do you usually what's the most common area that you usually take tissue from and that might be a question for you as well um just when you're trying to rebuild something that went wrong sure so um in plastic surgery we we say we really operate in four dimensions you know three physical dimensions and time and time is extraordinarily important particularly for anybody but in kids especially because growth is such a challenge or can help depending you know plastic surgery's roots were in taking care of burn injuries for example and for a long time we tried to figure out how to get skin grafts to work then people were trying to put skin grafts from other people on to very severely you know burned people and they figured out that you can't do that because there's a immune system and then joe murray who you know i come from his training program developed immune suppression and as a plastic surgeon won the nobel prize for the first kidney transplantation to bring it back to urology so plastic surgery has always been interested in movement of tissue transplantation of tissue participated in face transplant penile transplant hand transplants etc so we take where we can so in a little baby with a nerve injury who i have to borrow nerve from elsewhere right exactly i'll typically take it from the lower leg it's there's a nerve present in all people named the sural nerve it's not a motor nerve it's a century nerve that runs behind the calf and it's too bad we don't have pictures because i do it minimally invasively sometimes with an endoscope i leave three tiny little bandages that look like hearts but i take about 15 20 centimeters of nerve 20 centimeters is about 2 millimeters in diameter wow and that nerve leaves the child numb on the outside of the foot but it doesn't reduce walking it doesn't you know no major function is lost they're a little numb on the side of the foot but and where that goes where that goes that's going to restore a bicep right right so that's that's what we talked about and other common surgeries i do other common things i do skin grafts i just took care of a young burn victim from afghanistan as you all know we have over 10 000 people and they are our people and they are our patients and they are guests somebody had used that word earlier and i thought that was a great they're amazing yeah and beautiful and one very young girl had a bad burn injury and the burn injury was so bad that her elbow was flexed like this oh gosh and in order to extend her elbow i needed to bring skin from elsewhere so i did almost like a tummy tuck for a two-year-old and took all the skin from the bottom of her tummy and hid the scar well beneath her underwear really and he put that on her elbow and she's going like this and it's like the best you know these are like the best days of our life when you give her a lollipop and she reaches out grabs it puts it in her mouth no kidding it's a big smile it's like there's nothing better give her an approximate age she's like i have an idea she's two so she's brand new as well goodness gracious okay so you were able to do that and again that's that pliability portion of it um so motion is life right motion is life and you were talking about too when you take away and maybe i'm just picturing this in my head and you take away motion in your hands and your arms it really is so much how we communicate oh yeah in every way shape or form um especially with little people you know you're talking about sign language before they can even speak so that's awesome um dr latif we are probably at like a 15 minute mark so i want you to kind of in the back of your heads think of some things that we haven't touched base on yet this evening because again your specialties are so specific um that i don't want to go through the show and miss something if that makes sense with dr latif if we can talk because you're a pediatric urologist and we were talking about tissue healing not included with spinal bifida but what are some of the congenital issues that babies are born with that you have to deal with completely unrelated to spinal bifida because you were talking earlier about if you're talking about a little boy that's born and there's a lot of structures there and i know sometimes things aren't formed exactly right to begin with and they need to be fixed immediately because if urination doesn't happen as a newborn then the body basically gets poisoned i know that's a dramatic way of saying it but if you can explain some of the things that you've seen and that you've dealt with well one of the common abnormalities that we see is called the hypospadias and the hypospadias is when the opening through which the boy urinates is not at the very tip but is further down on the penis on the ventral aspect on the lower aspect and concomitant with that we also get penile curvature which is where a lot of the plastic reconstructive work comes because you have to straighten the penis provide local coverage thankfully the penis comes with extra skin exactly it allows us right it gives us some some freedom however occasionally you have some kids who tend to scar unbeknownst you have no idea you haven't done surgery before you do the surgery you're very careful like dr diamond says tissue handling you're very careful you're have knowledge of the blood supply of the tissues you know to preserve all that blood supply you know not to burn the tissue you have to use very careful cauterization when you do have tiny little bleeding and yet six months later you have this not very elegant scar right and then you have to deal with and we invite the plastic surgeon sometimes to participate in you try to as much as possible borrow local skin but sometimes we do have transfers from different places so we have that type of abnormality and then we have all types of congenital problems in drainage of urine from the kidney to the bladder there is a child that for example recently had this hugely distended tube that came all the way from the kidney down to the bladder and from the kidney down to the bladder okay so you're trying to picture what you're saying the urine has to be transported from the kidney which is in the higher aspect of your back and be transported down so there can be obstruction anywhere along that too so we did surgery to correct that obstruction but in doing that i had the vague suspicion that there was obstruction higher up as well well you can't disconnect this tube at the bottom and at the top and expect it to do well so you do one part fix that part leave an indwelling tube to drain the system and then come back later and correct that second part and when you say come back later you close the surgery finish that surgery and then see i usually wait for around six months that all the vasculature return you have that lower part where you cut you have to let all those vessels start creeping into the tissues develop new circulation so you know that there's good blood supply when you go to cut the other end our bodies are miracles i mean they really are um dr diamond i i and maybe it was today maybe it was a couple of days ago but you were talking about kidneys earlier and you were talking about borrowing tissues and uh am i correct in hearing that there was a first pig kidney transplant in a human being am i am i making that up am i i think you have to ask dr latifah dr latifah okay because i think that's so just i say this because every time we have one of these shows there's something brand new and and hope for the future so yes there the credit does not go to the pig or the human or the doctor that did the transplant it goes to the scientists the geneticist that's been working with that pig right over a period of time to change the genetic composition of that pig so it is very close to the human and so what you do is you work very carefully painstakingly in trying to modify the antigens that are carried by that tissue so that it can be easily treated and you don't get a what fascinates me about that many things but the reason i thought about that is you were talking about burn victims and burn victims who were trying to accept graft skin from other people sure and it just wasn't working because it was another person and in my head i thought about this this pig transplant so and that that's where it comes in i mean to accept i i just had heard a speaker um in las cruces earlier this week his name is john o'malley he was a burn victim when he was nine and he was so inspiring number one but there were also photographs of him when they were on the table of trying to graph skin and trying to heal and fix and that was in and of itself such a process i don't know how old he is but this was easily i'd say 20 plus years ago sure when i say that and as a plastic surgeon or just in general when you're taking tissue from one place to put it somewhere else and you were talking about so i'm just thinking about the tissue on the back of my arm is very different than the tissue on the front of my arm sure and so when we're looking at internal and scarring is such a big thing too finding again where to take tissues from how do you do that and let's say you have a very complex hand operation that you're doing on a child so it's itsy bitsy time sure um and i feel like child skins all you know pure and they haven't been wrinkled yet and the freckles aren't around yet but how do you think about where that comes from and just again i love case studies because it's like you know what i had this case that a b c and d that might do with what i'm talking about no it's got to be right i think you've touched on so many things just in that little bit i get to yeah maybe just take one of those i'm sorry about that but from a tissue engineering standpoint burn has changed tremendously meaning we are now tissue culturing your skin if you are burned growing it and then spray painting it back on you so there's a tremendous amount of technology in plastic surgery and then it's this specialty where it's like the least amount is the best meaning i fix a cleft lip and all you need is a scalpel a knife and a toothpick with some methylene blue to mark your marks and make it really good and really awesome and and so it's a cool specialty in that way but to give you an example you know i had a young man he was involved in a rollover vehicle accident he lost pretty much all the back of his hand including the tendons all the way down to the bones and the joints and like dr latif said these are staged surgeries we are thinking about the first step second step it's a chess game we're 50 steps ahead and i'm thinking not only about what i'm going to do now but what it's going to look like and in 15 years what it's going to look like for him so in his case i transplanted a piece of his outer thigh the outer thigh has a very conserved what we call vascular angiosome meaning one blood vessel provides blood flow too and veins right right right and transplanted the outer thigh to the back of his hand reconnected the blood vessels with my microscope with your microscope then come back six weeks later to do the tendon work meaning took again peter which was functional tendons with less impact to give him big bang for the buck meaning extend his thumb fingers he's um about six uh eight months out from everything i thinned his flap i did the plastic surgery stuff made it look right lasered the skin lasered the scars made it look awesome made him happy yeah and he's back like this and before that you're opening your hand like this before that when he came in would he have been like this was not able and missing everything and missing everything on top that is amazing and again you're looking at taking tendons and i'm thinking skin grafting right when you're taking tendons from one place to another how many years did you you look like you're like 20 you must be like 900 years old no you have all my goodness no but we trained a long time i bet i bet um i i would like to stop here for a minute and dr latif if we can go to you and this is the time of show where i'm not going to ask a question other than what is it that you'd like to to talk about because we're a little bit less than 10 minutes out we're about five minutes out there you go anything that we haven't talked yet about that you want to throw in there really quick before we wrap up the show this is one of those you know when the show goes fast you know it's been interesting being that it's spina bifida a month and that's what we came to talk to the long-term care of these patients because once you have a neural nervous injury this is long-term care and the vast majority of these kids have some type of reservoir problem the bladder is a reservoir they either can't empty well or they leak too much right and the management the delicate management of these kids and the follow-up because you have to change doses you have to make sure their volumes are correct i always tell my patients i worry about you not now i'm not i'm not worrying about you in two years i am worrying about how you're going to be when you are 44 right right at 44 what kind of bladder are you going to have the bladder that you're going to require to go to work have a family travel the things we take for granted the things that we sitting here take for granted and so the management many times we have to manage these bladders by paralyzing the bladder catheterizing them to empty the bladder and every time i tell a mother that they're going to have to put a catheter through their child's urethra into their child they look at me with square eyes and they say you are crazy and 99 of the time these mummies become experts they learn to handle and they follow right and they they're our kids and they are our kids and and you you hit on such a point too again pediatric show once they hit the age and i always think okay when is pediatrics end you know 18 25 depends when they stop growing but then that really is the body that you're going to have going forward and the healing not that we we heal beautifully and again we are miracles that way but when we're looking at the kids and how quickly that goes um same thing with you anything that you want to get across before we close up this evening you know i think we didn't touch upon what these injuries can look like and i think if there's moms and dads out there that notice that you know maybe their child isn't moving their hand maybe not grabbing something maybe not raising their shoulder right let your pediatrician know and we're really trying to reach out to the pediatricians to know that we're here we're not in houston or dallas where kids went before were right in their backyard and the benefit is that these kids need a lot of help and care to get as good as they possibly can to reach their best self and best potential with this type of injury which like dr latif said may not be exactly like everyone but it can be an olympic snowboarder or et cetera meaning they can do great and if you notice that when you do all those fun reflexes with your baby you sweep their hand or palm and they don't grab or one hand's a little weaker or you notice when they startle and most babies when they startle as you know it's so it's sort of fun i don't mean to play fun with the baby's reflexes but you know they start i know it's with you but they start on you notice you know maybe one arm is not maybe one arm is just going like this and the other's hanging down so so those are the things to kind of take note of and then the last thing is as you mentioned that the body is so beautiful and you can then imagine every permutation of a difference can happen with the hand people can have two thumbs three thumbs two pinkies fingers attached all those things i'm happy to take care of that is why i'm here and toes too i know that you're in toes i respect it you're a hand guy but i guess uh you know we call the you know i don't mean to offend every podiatrist in town but we do call the foot at least hand surgeons do the dumb hand oh stop that's just you know you're gonna get phone calls tomorrow i might even get i'm directing your way just saying um so i think that we're kind of down to a point where i don't want to ask another question but i want to give praise to both of you for being here again you've been here for 22 years oh i have to have to say the audience really quick um dr latif just went to uh switzerland and rode his bike from switzerland all the way up to amsterdam not in one swoop but nine days so congratulations for that thank you for coming el paso you've been here a little bit over a year you said and to the el paso children's hospital because the whole idea and the goal of the children's hospital was to prevent people from leaving you hit that spot on earlier there is so many things going on in el paso right now medically that really we're going to get to the point where people aren't going to have to leave here for most of anything that's right anymore when i first got here my my partners would say where are you getting all these patients and they said they were here all along that's right i have to i'm sorry we're closing up so i have to i have to finish up really quick i want to say thanks again very much to both luis and gina who have been here to help man the phones and again burrell college of osteopathic medicine in new mexico state university which is new for us so i appreciate you guys being here i'm katherine berg and you've been watching the el paso physician that's the hardest part of the show and i was [Music] [Music] you