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Ivan Ducic, M.D., PhD

Washington Nerve Institute

Clinical Professor of Surgery - The George Washington University

Past-President of the American Society for Peripheral Nerve

Board Certified by the American Board of Plastic Surgery

American Society of Plastic Surgeons

American Society of Reconstructive Microsurgery

American Association of Plastic Surgeons

Association of Extremity Nerve Surgeons

Croatian Society of Plastic surgeons

National Capital Society of Plastic Surgeons

Dr. Barrett 01:06 Introduction of Dr. Ivan Ducic

Dr. Barrett 02:56

All right. So, tell the audience how you got interested in peripheral nerve and how we are here today.

Dr. Ducic 03:05 Tells his journey

Dr. Ducic 06:12

Very nice. So, I spoke a little bit about how my neural practice evolved. And you can see the orange area is really representing what I do and that is nerve injuries and nerve compressions and nerve kind of problems from head to toe, including lower extremities. I gave here actually the similar presentation back in 2017. And when I say similar, the only similarities the topic and every single slide is different. Even on my flight back to the to Dallas, actually a month ago, I was still editing slides. But there's always some new thing to say there is always a new discovery. And I can't hold it off from not sharing it with the with the colleagues. So, I spoke about things I learned, what I teach and how I changed. I'm a very direct person, I am very direct with my patients, I tell them as it is, sometimes it's kind of difficult, because I'm not someone that will promise what I can deliver. And I put a very big objective note when talking to patients. And I would say over two decades, patients tremendously appreciated that because last thing they need is to have someone selling them successful treatment when treatment cannot be successful from start from the beginning. So that kind of was a pretty nice, nice way to kind of look at the things, you know, moving forward. In terms of nerve injuries, I think this business slide doesn't need special introduction. But either traumas or surgeries can cause nerve injuries, either compressions, or physical damage, loss of function, numbness burning thing, angling anything above. And that can significantly affect quality of life. How patient’s kind of have to deal with that as the time kind of goes. On the other hand, very good. About a few months, a few about a year or two ago, I put together my data from you know, patients I treat in the past and send them the questionnaires and interview them and examine them to define how the nerve injuries affect quality of the life. It was interesting to find about half of the nerve injuries were due to trauma. And about 1/3 of the nerve injuries are related to the surgery that you know somebody fixing a fracture or having dislocation or some other trauma event over there. The number of different ways how the trauma or surgery can cause nerve injury patients can interpret primarily with pain, numbness, tingling, function loss. And as time progresses, that list of the symptoms can significantly expand. It was interesting to see and I'm going to reduce this so people can actually see this better. It was interesting to see that the severity of the symptoms. 86% of the patients reported the severity of the symptoms been profound. And the level on the scale between zero and 10 was about 8.1 90% of the patients have said that they had symptoms most of the time and about 60% of them had symptoms at least a year or more 70% of them felt they should have been referred earlier and 50% of them were told that nerve surgery was not an option to be factored in in their treatment care. About a third of them were told that intervention was not needed, and about 70% of them were told that nothing could be done for their problem. So, we know from evidence-based data, that intervention from the nerve injury or nerve compression to intervention is critical, because the longer the time is present, the worse the outcome and less optimal the outcome. Something years ago, I elaborated on this with patients who have chronic regional pain syndrome and some really complex in their problems, that the ideal time for presentation really was the time of the injury. or soon after that, when the injury is still located in the periphery, their arm or leg in this case, or so. If that valuable time is not captured, then the symptoms, unfortunately, would progress and create much more complex presentations in terms of complex brain syndrome. I actually elaborated this in a paper I published together about two years ago with a set of the reputable colleagues across the country, specifically talking how timing for intervention is very important. If one would be striving to get the optimal outcome. Quality of the life patients reported due to nerve injuries, at least 84 to 97% of them said they're the moderate to severe, negative impact on the quality of life. So, with all things together, it is very clear to understand that these patients in quite a bit of trouble impact on nerve surgery on this patient, about two thirds of them can be actually reversed from their chronic condition, I'm sure audiences asking themselves now, why is not 100%? Well, the reasons are number. If nerve injury was 11 years ago, and I'm about to treat you tomorrow, it is going to be much challenging to reverse it. And it would be unrealistic to expect from me or from the patient, that they will be 100% cured. So, there is unfortunately some leeway or some grace range that a nerve surgery might not be as effective, as we all want, primarily due to number of the time, amount of the time that elapsed from the nerve injury. Similarly, if you're looking at the number of the number of the medications, what patients do over half the patients took at least three medications and 100% of the patients that I've seen, could this many medications and none of them was completely effective. Nerve surgery managed to reverse this, that over 50% of the patients who had nerve surgery, did not require pain medications afterwards, with opioids is even worse. And I would say the biggest issue that we see opioid crisis in this great country is that the golden question was never asked what is causing the chronic nerve injury and pain, everybody's focused on this drug, or that drug or this device or that device. But look at this slide here that it says 54% of the patients who took they have a chronic pain took opioids daily 97% of them said that narcotics did not resolve their problem, if the if it helped was in the range of about three or so out of 10 and 61% of the patients who took opioids had the side effects due to them. I think this is incredibly sobering slide that teaches everyone that something has to be done, and that drugs are not the solution for treating nerve injuries, we have much more powerful thing, but we need to be synched when that is done, and who does that because the surgeries are also not kind of freebie and for everyone to practice them. Nerve surgery actually can effectively address also utilization of opioids to reduce them. And only about 1% of the patients who had the surgery still required opioids after that is really significant. So overall impact I would say, nerve injuries following trauma or surgery pose a huge burden on the society and on the patient themselves. Nerve surgery is being looked sometimes as like, you know, if you have a nerve injury, don't do the surgery. That's I've heard many colleagues even saying that that's a wrong concept because if you We have the roof leak, a leak in the water in the into the ceiling, you really need to patch the hole you need to physically do something about it. Me putting a sunglasses that you don't see that we will not help. And unfortunately, medications end up being a sunglasses in this case here. So, in terms of treatment options for patients of the portfolios to understand, obviously, nerves, the surgery should not be the first treatment choice. We all know that there is a period of observation, there is a supportive care of physical therapy and there is a grace period of few weeks to three months that patients can tolerate it depending how acute the impact of a nerve injury was, then there is a huge crossroad. Most of the colleagues or many colleagues, I would say have automatic referral to the pain specialist. And those patients might never see the Nerf surgery because they go to the medications, opioids, epidural blocks, radiofrequency ablations nerve stimulators. With all due respect to our pain, specialty colleagues, none of these interventions is able to physically address the cause. Because treatment Yeah,

Dr. Barrett 16:16

No, you're right there, those treatments are masking.

Dr. Ducic 16:21

You know, and I'm saying this with full respect, it's not about you know, who is smart, who is not smart, or whatever it's about really helping the patient and the, the indefinite symptomatic treatment without addressing the cause, that roughly I mentioned, will simply not help the patient. So, if the physical evaluation determines that there is a nerve compression, or there is a nerve damage that would benefit from excision and reconstruction that should be done. And those patients should not be then pushed into indefinite symptomatic treatment with medications and cetera. So, I think this is incredibly important concept to understand for everyone, for the patients and for the providers. Because if this concept is not understood, and somebody's just doing one thing on everything, that's a problem. And I'm going to underline one more time. It's not that if you're the surgery yesterday and develop a chronic pain that you should have a neck surgery day after that, clearly, some evaluation, recovery time supportive care, some physical therapy, and cetera could be done and two thirds of the patients plus are going to be fine on their own with that, the one that doesn't get better, is the one that is dangerous to say under that symptomatic treatment arena only. And they definitely need to see the neurosurgeon then to evaluate them. If that doesn't happen on referral from either original surgeon, or from the pain specialist, patients should find a way to look for themselves because nothing hurts to get extra opinion, absolutely nothing. I see sometimes patients who see me and I said, look, let's give some time, no surgeries needed, you're going to be okay, that's 50 million times better scenario than if I see the patient. And I say woof, you know, your injury was two and a half years ago, and my ideal time for intervention was within three weeks and three months. It's a pretty harsh, you know, words for the patient to to understand to kind of accept that because the valuable time is gone. From surgical perspective not to kind of drill too heavily into this, I just want to kind of say that there are two variables that surgeons should consider when repairing nerve injuries. One, they need to understand how the nerve should be prepared and to what reconstructive options are available. There are a number of technical things that have to be considered that surgeon needs to understand in terms of trimming the damage nerve events, aligning the nerve ends properly resecting bad part, creating no tension repair. That's important. And then once that has been acknowledged, then no reconstructive options are important to consider. And they can range from all kinds of different options from putting the nerve together primarily all the way to the nerve transfers and everything in between in 20 years of practice where I find a problem and that problem is that some colleagues get to be married to one or two of these procedures mostly and they will try to tailor it to fit every nerve problem. That's a perfect prostrate prescription for failure of the surgery and creating more problems to the patients. Every one of these options here has a role in surgeons’ role is to educate the patient explain and apply probably proper Properly suitable treatment to the specific nerve problem the patient is presenting other issues that nerve surgery doesn't work 100% some even if you put in there directly together or if you use their outer graft, meaning taking your own nerve tissue average 75%, the most 80% outcome you could expect. For few decades, hollow tubes have been introduced to bridge the small gaps. The problem is that if the if these devices are used for larger defects, you can you can have a very highly variable rate. Some four or five years ago, I published a study looking at placing a small connector or small protection around the nerve cooptation site, you actually improving the chance for that surgery to work better. So that actually per evidence-based data is indicated to provide better platform in terms of outcome than just putting the nerve directly together. On the other hand, especially when we are training more junior surgeons or cetera, they can be prone to misaligned the nerve ends. If you're using this connector assisted repair that would actually be small cuff of the nerve of the other of the protection device around the nerve that will allow nerve to be lined up nicely and pretty much completely eliminate the upper portion here and there of misalignment. Similarly, there is any tight tension you can slightly detention it and it's important to know that the variability as I mentioned hollow tubes that are called conduits crossing over a tsunami or gap can vary significantly. Versus if you take the outer graft or nerve allograft. In this particular case, that is processed donated human tissue that doesn't need immunosuppression, the consistency of those data is much more significant. Currently available only one on the market is the process nerve graft. It's called advance and as you can see fit with generous people who donated their body to the science and for the benefit of mankind technical and humanity. Carefully filter and process nerve and selected healthy, healthy without healthy meaning without compromising med past medical history, nerves would be removed and process so that carefully Ultra structure of the normal nerve the way that we have it in our body is actually preserved. And then one can expect some 80% effectiveness from that if you compare you're taking your owner and comparing this process neuronal graph you can actually have fairly similar outcome based on this latest comparable functional outcome. In the second issue is when we are doing therapeutic oppressions, it can be advisable to also use the nerve protection and this nerve protection can technically provide a shield around the scarred area, especially for example with the newer devices that are now available to have technically even a gel area there that can provide even additional smooth gliding around the nerve, especially with the cases that have been redo where you encounter lots of scarring. So, one would not generate additional scarring with a with a subsequent and neck surgery there. This is just showing how it is gliding. I'm going to skip that. I would just say important concept about nerve injuries and neuroma management. Even myself personally went through the evolution of this process going from just the removing them nerve to now reconstructing actually the nerve end because if you cut the nerve and leave it in a scar, you might not unfortunately accomplish what you want because it might still grow into the scar and create the repeat of the nerve problem and symptomatic neuroma. So, a few years ago good friend of mine Kyle and I stepped together and wrote one of the probably very important and landmark papers when you have injured nerves. So, neuroma is technically injured nerve that get to be formed in a scar tissue and scurried itself internally that is giving you pain burning and functional loss event. And one needs to look at that in two ways. This purple area illustrates just schematically obviously what would have happened in the real life it damaged nerve that you would have either damaged nerve, the lower distal end nearby or you have a damaged nerve and nervous still in continuity. If we have this scenario, surgeons, every publication, frankly, let me put it in this way to, to rebuild that nerve, because it is going to give a chance for the patient to restore the sensation that they lost. I'm going to talk later on about the scenario where that is not the case. And this distal end is not available, and you have to deal just with a stump the robot, but in this case, one can resect, the damaged segment of the nerve, as you will see on a series of cases after that, and the call, and then you can rebuild it. And the nerve allograft actually ends up being really handy. Because one doesn't need to go back in the leg or some other parts of the body and harvest the normal healthy nerve for this from the same patients to repair other damage nerve in the same patient. So pretty much you're not borrowing from Peter to pay Paul, you're more or less robbing Peter to pay Peter, obviously, even third grader would say, Man, that doesn't make any sense. Right? Why are you doing in the first place? But I'm just trying to illustrate.

Dr. Ducic 26:25

That’s actually funny. So, in any event, there is going to be a serious now I have cases here that I'm going to show and those of the that they cannot see the pictures should not look for the moment, but the patients that are listening to this. So, if you have a nerve injury, for example here,

heavy brick fell on the patient and the head the injury technically with a burning and numbness and pain on the top of the foot. So, I can selectively come on the top of the foot define the injured nerve and the reconstructed with nerve allograft and connectors so that nerve gets to be rebuilt back again. Similarly here is this is the back of the leg where patient had the gastric lengthening the couldn't dorsiflex meaning lift the foot really well. And the surgeon was extending the length of the posterior flexion apparatus. And unfortunately, a damage to the one of the sensory nerves have happened. You can see in the center over here, how that sensory nerve technically in terms of magnified here, that sensory nerve is basically thickened and injured. So, once you resect that you can rebuild that to allow the patient to have the function back again this is similar case just want to tell you how ugly damage this nervous you can appreciate how normal nerve is you can see nicely ultrastructure the nerve, even vascularity next to that and then we remove the damaged part and rebuild it. Similarly, this is unfortunate patient who had a fracture of his leg and for nine years was living with the pain as there was this heavily scarred and sutured nerve here specially scarred nerve on the outer portion of the lower leg. I removed the damage segment and rebuild it with the process in our group that allowed this patient to move on with life. This unfortunate patient had the plantar fascia surgery, where the inadvertent injury to the nerves innervating bottom of the foot happen called medial lateral plantar nerve. And reception of this nerves was done and reconstruction with the allograft allow the nerve to regenerate. This is similar case just more troubling that the Morton's neuroma surgery was done on top of the foot, then that patient created a true neuroma, what about 5% of the surgeries the patient can have, then the surgeon went in and did the cut on the bottom of the fruit to try to remove it that recurred again. So, I went ahead then and had to reopen all of that identified damage nerves, and in this case, rebuild the continuity of this nerves. This is a bit quite a bit of painful because it's in bottom of the foot in there is actually more elegant way to do that, that can be done through the orange. So, the second scenario that I mentioned about 10 minutes ago, or 15 minutes ago, is where you have injured nerve. And there is nothing below that. So, imagine that, let's say injury of the nerve happened at the mid calf level, or actually at the ankle level. And that nerve has no continuity distally. So, we have a couple of options over here with some of the abbreviations that are used, that can help resolve that issue. The problem is, there is a quite paucity of the cell consensus, which of these is the best for what scenario and as I said, again, some colleagues might be pushing one procedure more than the other one, without actually having a good, good explanation why one would be the other one, and then they can err towards even more aggressive surgery rather and less aggressive surgery. So, one needs to be very thoughtful how the neuroma is managed when there is no distal end available in some of the potential flaws related to the regenerative peripheral nerve interface where you take a small piece of the muscle, put it around the nerve, this patient can actually have a deficit in the hand function if you use too much of the nerve at that area. And look how big a big dissection of that nerve is required. Similarly, this is a patient who is an amputee and they had chronic pain and beauty pain, something I actually close to my heart because back in 2008, that's 15 years ago, I published one of the first studies how surgically to manage the chronic pain in the amputation population of the patients. So in this case, this patient was treated elsewhere and develop it through neuroma, you can see how stump painful neuroma is, you can only imagine how difficult it was in surgeon did what's called targeted muscle regeneration that unfortunately failed. And John Felder friend of mine, and I wrote about couple of these failures because the concept of plugging nine times bigger proximal nerve to the millimeter or so recipient distal nerve, as quite a bit of issues. A number of the failures of these procedures, unfortunately, is lately rising because many colleagues really do not get a good grip on what are they doing with this. This is one of my patients that had a ribbed arm from the shoulder with a conveyor belt, incredibly challenging case where I used actually combination of the allograft to extend the length to in order to be able to provide a targeted muscular innovation and help resolve the problem. And lastly, you have so called vascularized innervated muscle target. And this is the actually area where you’d dennervate. The small section of the muscle still keeping it on blood supply, and then you introduce the resected nerve in there that would actually get silent and when you create a chronic problem with that. And ultimately, and I have a few more slides to go there is so called nerve cap and the nerve cap is technically a sealed, blinded, hollow tube that is been with the blind and that you can put like electrician put that plug in at the end of the virus so it doesn't electrocute you. So similarly, here you apply that and that can be actually very handy. In you know for following reception of Morton's neuroma, the redo after that or some other nerve injuries or the resection of the nerve is deemed necessary and no reconstruction of the continuity of the nerve is possible to minimize the dissection of the nerve. This is how you technically apply it. And I will go And I bother you with HS with technical detail, but you pretty much introduced the nerve into this cube. And once you put it in there it serves as a shock absorber to the environment. So that does not get basically consumed or interfaced with the with the surrounding scar. I use this quite a bit for patients with partial need innervation some ankle surgeries, patients who have chronic groin pain after hernia surgeries, breast surgery, C sections and cetera. It's a very elegant because it because allows me to execute the neurosurgery in fairly reasonably small incisions. And similarly, here I was mentioning, this was a patient who had the two amputation in develop chronic pain, and then you can take these nerves to the inner arch or pull them back technically in a very selected then in a targeted way. And then you can use a nerve cap and place this live under the nerve into that protected environment into the arch of weight bearing area to minimize the pain recurrence due to symptomatic neuroma. So, a number of the issues related to that, as I said, as I said, Really, it is related to the single effectiveness reported rather than comparative study. And further insight into the effectiveness of each one of these options should be available in the future. Yet at this time, I have tried every one of them and in selected areas. They certainly work. And whenever I can be minimally invasive, that's my choice, usually with the cap. Rather than creating a large incisions in the sections for this patient's last few slides, I want to say why is it important to acknowledge that donor morbidity is not something that happens occasionally. Few years ago, I put a study showing what happens if you have a nerve biopsy. Or if you ever use the nerve out of graft, you can appreciate sensory deficit, this slide bars on the bottom meaning arose. And also, about a third of the patient can have a chronic burning or numbness on the bottom of the foot or any other part lateral part of the foot for nervous harvest. So whenever we harvest the nerve, or remove it, if the defect is less than seven centimeters, you should use a nerve allograft in pain patients occasionally if the defect is longer is autograph in a defect is longer than that, you can actually use a nerve cap. This is one of my patients who had the this is a neck area, she had the lymph node biopsy that unfortunately resulted in the loss of shoulder function. And I, she opted to have a neural autographed reconstruction. And I told her when we take the nerve from the leg, this is a lower leg, this is ankle here, she's gonna have a permanent deficit in the right lower side of the scar. So, I said, what if we rebuild the donor defect as well, and you will not have a deficit there. So, this is a pre-op, as you can see, very affected right side of the shoulder, she couldn't lift it. Already. 10 months later, I managed to restore her function really well. And then over time, her donor defect that I also reconstructed, shrunk, and she technically ultimately didn't have any sensory deficit there. So great progress. With all of that I think this slide over here speaks about proper inflammation of the options that the patient can choose the viable option that is suitable for their problem. And I would say that I personally witnessed incredible progress in nerve surgery in the past 20 years, applications available. If new technologies and techniques only they need to be individually tailored for the selected patient problem in order to provide that patient optimal care aiming towards the positive outcomes. So this is Steven about quick summary of what I provided Washington nervous today and my practice and what I shared with you guys at the at the meeting in the in the in south in Dallas about a month ago. Now

Dr. Barrett  39:39

And I think you made some very valid points that I want to try to circle back on because we've got a little bit of time here. But one is this perception from non-nerve specialists about well just wait, you know, wait a year, see what happens with it. Maybe that's not so bad in a case is where you just have a sensory deficit, or you know, they're not in horrible chronic pain. But if you're doing anything with function, that seems to be a pretty primitive take on things. And it's really not optimal for the patient, as you point out, and you made a comment about three weeks to three months, would you? Would you say the same thing on, let's say, a decompression? I mean, if we have a damaged nerve, that that's in a different category, then and excuse me, because a compressed nerve is damaged, but in a different way, and to a different degree. But if you have a compression and you wait a little bit longer, would you agree that you could maybe get away with that a little bit better than then something that is, frankly, injured or cut?

Dr. Ducic  40:52

Yes, but I will tell you this thing in again, 20 years practicing, and I'm sure you can echo that, the biggest enemy. And the most humbling experiences I had there, if surgery were late interventions, meaning when patients presented late. So, it takes a little bit of the artist, you know, to make a proper and ethical judgment, that not everyone who shows up with nerve injuries taken to the operating room next day, because that could be abused. But at the same time to tell patients in this day and age, you know, if you wait a year or two, that's going to turn out fine, and nobody's going to recover on its own is absolutely very dangerous gambling, because as the time goes by your chance to reverse that compressed nervous less, and the frequency or probability of chronic pain patients to progress into the complex. This pain syndromes exponentially goes up. So, you're losing in every possible way. That is, that is out there. So, for that particular reason, I would say decompressions. Obviously, one needs to see what's their medical status, but they'd be the diary to fine tune that. See how long was the severity was the progression, there are some patients who have extremely slow great of progression? There are some people who are deteriorating in front of your eyes, little in span of, of weeks or months. So the the judgment of the intervention time needs to be flexible, and needs to be again, pain patient individually suitable, because not everyone might fit the same bill.

Dr. Barrett 42:45

No, I totally agree. And I think that's what makes peripheral nerve surgery. So, complex is not necessarily what happens intra operatively. But what happens preoperatively? Because it's not just a nerve issue, or pathology or injury, it's a nerve issue, pathology or injury in a patient that has other things going on. And you know, so you have to look at these patients globally. Where are they from a psychiatric standpoint, a chronic pain standpoint, what is it that they want, you know, some of them will come in way down the line, and they'll say, you know, I just have, yeah, I've got numbness, and that doesn't bother me so much, but I just have this this tightness, feeling that just drives me crazy. They won't necessarily label it as pain, but it, it drives them crazy. And then sometimes that throws off the practitioner, because if they say, well, it's not painful, but it's, it's affecting my quality of life, because there's this constant pressure or tightness, or whatever their descriptor is, and then then I'll follow that up with them. And I'll say, on a scale of one to 10, how much does this affect your life? And if they say one or two, it's like, Well, okay, let's, let's manage this medically, and we'll go from there. But sometimes they'll say, I want to kill myself. It's driving me that bad, even though it's not painful. And it sets up our, our framework or our paradigm a little bit differently. Just because of the nomenclature, that of what they're describing versus Whoa, it's pain, we got to take care of its pain. But there's other aspects. Now, that was long winded to get into this question. But one of the things that I've seen in clinical experiences is truthfully, very educated, and it's also very humbling. And one of the things that at least in our clinical experiences, were really pretty good and get rid of pain. We're not as good as get getting restoration of sensation. I wished we were but again, we're not.

Dr. Ducic  44:45

Yeah, look, there are a couple of things you touched in the last few verses that you said. The problem that I am seeing that patients are caught in between unfortunately is that for over the past decade, providers got so buried into the computer screens EMRs. All kinds of this test testing, I can't tell you how many patients that I've seen, you know, especially for chronic headaches or whatever else other stuff, who says, You know what, Doctor, you actually the first one who really looked at me in the eyes for 10 minutes, and put your hands on me and examined me, everybody, were just looking at my tests and checking boxes on a computer. And this is, you know, frankly, ABCs of medicine, we started that way. And I can tell you personally that probably about and I'm sure you do the same thing 90% plus of my decision making is based on what I hear from the patient, and what I find it my targeted exam on them, all of the million dollar studies out there, that that seemed to be very cool. And all that other stuff, ultimately, unfortunately, are not the confirming part, what you really need to do with that patient. So that patient doctor relationship and listening and talking the examining goes long way along the lines.

Dr. Barrett 46:18

Right now, there's so much power in history of present illness, if you just listen to, you know, usually these folks have very long arduous journeys, and by the time they get to our offices, their medical history is pretty thick, and to listen to them and take the time. They'll give you clues. And that's a very beneficial in your decision-making process. What have you. I mean, your clinical experience is vast, I mean, you you're treating everything that you can imagine from a nerve standpoint, from gunshot wounds to, you know, metabolic compressive neuropathy. Is there one clinical experience that you've had over the last 20 plus years that that kind of stands out that might have changed the way you perceive or, or look at your treatment algorithms.

Dr. Ducic 47:09

So, I'll tell you, so interestingly, you know, as a plastic surgeon, first nine months of your practice, you go to, you know, what we called board collection case period, right. And at that time, you know, examiners are looking pretty much into your genetic code, almost anything and everything that you do is magnified million times. And I at that time, I was obviously young, just here to attending and you're actually attending and I remember I had one patient with very bad diabetic neuropathy, incredible burning on the feet, and just couldn't, couldn't walk, sleep so much out of pain. And I was like going by you know, we are going to do this, we're going to do that, you're going to audit the nerve test. And then I will see you in about three weeks after this done and are there I'll never forget the patient look at me in the eyes, since it said to me: my pain is 20 out of 10. So, if you want me to have a painful nerve test, you can have it yourself, I'm not doing it. And I have to tell you, that patient changed me forever, because that's the last time that I was doing something to just check the box. I'm just admitting to that was over 20 years ago, ever since then, I will do whatever the clinical judgment requires to be done. And if it doesn't, I'm not going to expose patients to the cost and time wasting, you know, you know, diagnostics or material is not fun. I know upfront, it's neither going to help me or it's not going to change the care that is already set with the presentation what needs to be done. So that event is literally now over 20 years old. But I have to tell you, I still live with that. With that. With that kind of conclusion forever. And I'll tell you another anecdote. This is kind of relevant to all of us. About four or five years ago, I was treating one of the unfortunate young soldiers who doesn't matter where he was last to last one extremity on one lower extremity, one upper extremity and the remaining lower extremity had so much pain, they were entertaining amputation. And I figured out that there was a nerve problem and I tried to actually say to the patient, you know, I'm sorry, you're dealing with all this kind of stuff. And that patient looked at me and he said, you know, I have some of my friends who have neither of the arm or leg so I still have one arm and leg long legged dog, I can still kick your butt if I need to. So, I'm actually good. That positive attitude to be honest with you also changed me forever that people want to live, people want to get help them. On the other hand, when I'm driving home and thinking I had a bad day, I always have to say myself, I had a good day. So, I have to say, impact on the patience of the patients that had on me, both professionally and personally is just incredible. And it's a really privileged position to be in.

Dr. Barrett 50:30

Now. There's nothing better than having that patient come back. And they tell you, you saved my life, because I was thinking about ending it because I couldn't deal with this, this pain anymore. And, you know, it. People asked me when, when they're starting to look into nerve practice and that type of thing, how it is from a professional standpoint? And my answer is, its life changing, and in only a beneficial way compared to maybe a general practice where you're trying to take care of everything. It's certainly much more demanding because the patients are just far more complex. The issues are far more complex and usually multifactorial, but you know, what, what a privilege and an honor it is to be able to help somebody like that, you know, that's, that's why we do what we do. But Ivan, thank you so much. I love anytime I get the opportunity to listen to you and get some basically just cutting edge advice from you. And I hope you continue to publish and do what you're doing because it's a great benefit to all of us. So, thank you very much.