The perfect wave

We were standing casually at the front of the plane, talking, Barry, Jeff, Maria and me. The plane was halfway between St Louis and Phoenix. Jeff is the vice president of Nestle, and air-miles heavy weight champion, something like George Clooney’s movie “up in the air”. Barry is a retired entrepreneur, after selling his mortgage business, apparently one in every ten mortgages in America were sold through his company! Maria is a stewardess, pleasant, topping up wine for Jeff and Barry and white coffee for me. “I am telling you guys, I spent most of my life in planes, but never seen this before, to let us stand here and drink and talk’. He was very happy.

All started when I unplugged my laptop from the plane’s socket in my seat. I noticed that the USA-type prongs from the multi-piece adapter I bought earlier at Best Buy had disappeared, was not in the socket, not in the floor, not in my seat…Jeff who was sitting next to me, volunteered to have a look with the flashlight of his phone behind the seat, nothing…Another man, Barry, who was sitting next to us volunteered to help, he said my son will find it, he’s a champion. He was not kidding. We all stood up and the 11-year old boy tear the sit apart! Removed the cushions, the belt, the life jacket, left the metal frame only! It was a good thing we were on Amaerican Airlines plane, there is no way any BA stewardess would allow to touch the seat. But no adapter…! All other passengers who had no idea what was going on, and were looking very curiously. “Thank you so much for coming to our country to visit us” said Barry at the end, one of the extremely friendly Americans you find in many places. He then passed on his card and said my wife Dana and I would love to have you for dinner next time you are in St Louis…! Again, correct me if I am wrong but I think you see this only in America.

I was on a plane left St Louis, where I was invited to give a visiting Professor lecture at the Department of Neurosurgery. My trip started 24 hours earlier, from London with a three- hour stopover in Chicago (which became 6-hour stopover, due to plane being delayed in Minnesota from storm). Saleem Abdulrauf, Chairman of Neurosurgery in St Louis was a perfect host. He is building a young and dynamic department and the Walter Dandy Society he founded in 2012 is thriving. Was a pleasure to deliver a lecture on my awake craniotomy techniques and then have a ride with one of his two sports cars. From St Louis flawn to Phoenix and then off to San Diego.

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OK, this is during landing in the first days of my trips but not sure which airport, am not kidding! I am fascinated looking from the air lit streets and buildings and light beams coming out of tiny homes’ windows.

 

Arrived in San Diego Thursday night invited by the Congress of Neurological Surgeons to their annual meeting. As you get off the plane, a wave of hot air is hitting your face. San Diego is spread out, wrapped around the see. Massive (I mean massive!) hotels overlooking the ocean, boats, bicycles. Despite seeing sea from everywhere there is no beach for swimming. You can take the boat and after a 20 mins ride you get off the Coronado island with a small sandy beach. We found a Greek gyros shop (these Greeks are everywhere!) and watched the first presidential debate on the big screen TV amongts (mostly indifferent) Americans.

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One of the many San Diego marinas, under a hot, hot late September sun. You can rent a bike (like London’s bikes) and cycle across the “beach”, pass the airport (I never saw an airport so close to a city) and go to a little harbour with a pier.

I gave a talk on Saturday morning at 8 am on surgery of tumours on eloquent parts of the brain, along with Mitch Berger, Hughues Duffau, Lorenzo Bello and Richard Byrne. Alhtough my battery was full, minutes before I had to give my talk my macbook died! all battery juice drained! Never seen this before, I did not have an adapter, ok, what do you do? I asked Hughues Duffau and Mitch Berger to go before me and I run out to get an adapter. I had about an hour to go to Westfield San Diego to get another one and come back before the session ended. I got into a cab, gave the address and off we went. The driver, a nice Indian guy, started telling me his medical problems, and that his doctor does not believe him that he has serious brain probelms, while strolling leisurely on the roads despite telling him he had to run like the wind. After a while he started telling me that he had studied engeneeiring in India and could fix the problem by changing my mobile…! OK, not the best time to be driven by a crazy driver!

After several insane technical suggestions, including ordering parts from India! we finnaly arrived at the mall. I run to the electronic store when I realised that it opens at 10 am and it was just before 9…!  OK, back to the conference centre, with the same crazy driver who was waiting outside. I had at least loaded all my talks to Dropbox, not ideal as all conferences run on Windows and will completely distrort my slides, but now was no time for aesthetics. The IT guys were nowhere…! After running into different sessions we finally got hold of them. One guy had no idea, so we found the top nerd : -) who knew what to do and started to download my talk with several videos and photos. “OK, will download in 35 mins“said triumphantly. “you got to be kidding me!” said back.  “OK, I will use my own IP and will download faster, remotely to your session’s PC“, added with remorse. I walkded back to the conference room, an hour and 10 minutes had gone, seemed liked hald a day. Lorenzo Bello was finishing his talk. I waived to Mitch Berger, was ok for my talk.

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My budge (of honour)!

I approach the lectern, I had no idea if my talk was there, and how it will look like. I moved the mouse, the screnn lit up, i saw a file with my name, clicked, it opened, and worled like a magic, not even change of slides from Mac to PC!  All videos played perfectly! “Great talk” Mitch said later, delegates asked questions, good discusiion follwoed, nobody in the room knew what happened for the previous two hours.

Like all American meetings, CNS was big! with more than 3000 attendees, and many speakers including non-surgeons, like Steve Wosniac, co-founder of Apple. Wosniac was happy, chatty, genuine and, of course, super nerdy :-) what did u expect?! Also Daniel James Brown, the author of “Boys in the boat” a hugely successful book, about the American rowing team who won the gold medal in 1936 Berlin Olympics under the eyes of Nazi Germany.

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A jolly Steve Wozniac with his nerdy shoes (left) talking to the President of the CNS Russell Lonser (middle) in a massive conference venue (I am sitting in the first raw) with more than 3000 seats.

The scientific program was also productive with discussions on ARUBA trial on AVMs from Spetzler, where only 6 patients randomized for surgery! And a talk from my friend Mitch Berger on personalized and targeted treatment for glioblastomas. There was also live surgery daily, sponsored by medical companies, good effort but nothing like the surgery was have at the annual neuro-oncology course every summer in London, no I am not biased! :-) During reception I saw my friend Charlie Teo from Sydney, high energy and good spirit as always. Outside the scientific program I had the chance to run by the beach, cycle passed the airport and swim in pools and the ocean. It’s much easier to be active in hot weather, you are outside wearing shorts and tee, by the sea, where everyone is running, all you have to do is walk faster and faster, move your arms a bit more, and this is it! you are running!

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During the evening reception, everybody did the same thing when getting out of the Marriot, stood at the top of the strairs, took a photo with their mobile and then walk down the stairs and get in line for food. I was no exception, so here’s my photo!

Between CNS in San Diego and my next talk in Boston had a full week, time to get a car and hang out in California. The car was a white, cabriolet Mustang, black soft top, bold red lights, still smelling new.

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Driving somewhere in America in a cabriolet Mustang

San Diego to LA is just over a couple of hours, that is if there was no the legendary LA traffic. Around LA cars go fast, lanes are narrow, and there is no such thing as slow lane, everybody goes pretty much with the same speed. That’s good for me (I love speed) but you will never see some of the slow cars that you often see in the right lanes in UK’s motorways.

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Can you believe I took this photo in Venice beach with a cheap Lumia phone I bought in San Francisco two years ago?

A couple of things are different in US, for example, when on crossroads, if you are on the right lane you can make a right turn, even with a red traffic light, this is legal. Also at a stop sign you have to stop completely! I know this is what the stop sign means, but in the UK drivers slow down a bit and carry on. In American roads you have to come to a complete halt! LA is a great city, has everything, great beaches in Malibu, amazing houses in beverly Hills, and trendy shops everywhere. You can go to Santa Monica Pier in an hour, with massess of tourists, or hang out in Venice beach, rent a board and surf in the not so massive (but coooold!) waves. Venice beach is so enormous, tons and tons of white sand, lifeguards are driving red pickups and run like crazy in the beach. Walking around in Venice beach with no surfboard or skateboard under your amr is like walking in Alps with slippers.

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Venice beach at dusk. This is beggining of October…!

But if you are looking for the perfect beach… Driving from Santa Barbara to LA, long lines of RVs, traffic, had to make a stop. Could have been the time of the day, early evening but sun still strong…  or the sound of the waves drawning all sounds…or the straigh line of sign into the infinite…never seen or felt a better beach…the water was cold… but the waves perfect…you could feel a vast ocean, you could be part of it…looked at the sign, Faria beach, a perfect beach… or a perfect moment…!

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You find the perfect beach when you are not looking for it! The feeling of looking at the line where the sky touches the sea was new

From LA took the plane to Boston for my next talk, at Mass General Hospital (Harvard Medical School!) for my next lecture on 6 October. I like Boston, the most european city in US, reminds me a big version of Oxford, intellectual, sophisticated, with rowers in the river, many foreigners looking for a better education, and the new high impact publication in research journals. What a difference from Venice beach, what drives people to do one or the other? Now hang on, am not taking sides, I don’t know what drives people riding waves or studying at a lab, and can’t be sure that pleasing our ego has nothing to do with either. But would like to take the  (naive) view that helping others makes life a bit more worthwhile…!

The nurses and doctors are walking around the Mass General in scrubs, I mean in shops, in the train, even the local bar, Harvard Arms…in the UK many NHS people would freak out. The symposium was great, and made new friends. Two days in Boston was added to two weeks in America, London, Chicago, St Louis, Phoenix, San Diego, LA, San Francisco, back to LA, Boston… time to jump back to BA’s plane to the familiar Heathrow terminal 5 and to my patients. Like a man with a brain tumour deemed “inoperable”. He finally came to my service and had an awake craniotomy and complete tumour removal. His two young children came to meet me with their parents with two handmade “thank you” cards. Adorable!

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Thank you card 1 – Mr Samandouras vs the tumour

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Thank you card 2 – Mr Samandouras, “the tumour destroyer” holding the knockout knife while the “angry tumour” cries Aggghhhh….how cute is that? Both cards posted with the permission of parents and the (young) artists.

So back to London…No surfboards here…no perfect waves…but same people in the core, looking for ways to feel happy and fulfilled (and try desperately to look cool!)…happiness is in the moments…you can capture these moments wherever you are…you just need to wait for a tall wave and jump on it…no, there is no perfect wave! don’t spend all our life at the beach waiting for it…stand tall…feel the sun on your face…the wind on your body…lock eyes with the next big wave…and go for it…!

 

 

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Skyline

It was a long day, several hours drive… Yes I had the SatNav on, how else could I drive around the great lakes, but still not entirely sure. So I googled, “where am I?” In less than 0.136 secs google had the answer Latitude :: 41.03916091992087, Longitude :: -85.24132144166595…turns out I was close to Dearborn, Michigan, about an hour from Detroit. Started from Chicago, two days earlier. I was invited by the American Association of Neurological Surgeons (AANS) to give three talks on brain mapping and surgical techniques in excising tumours from eloquent parts of the brain…the only one from the UK, quite an honour for such a prestigious meeting.

The meeting was in an enormous venue, McCormick convention centre, that could accommodate thousands of people, and that was McCormick West only…AANS conferecnces are always great success, delegates arrive from all parts of the world. There are so many topics and themes that lectures are broken down to the many conference rooms, and usually meet at the escalators or coffee breaks. The most junior delegates (and some senior ones) are “chicken-heads”… :-) looking constantly right and left to identify people they know, common sight in these conferences…you always give value to people you look at…and always get value when people look at you…one of society’s unwritten rules…

On Friday there was the first international brain mapping course with honoured guest George Ojeman, now retired, Professor of Neurosurgery in Seattle who popularised the concept of cortical mapping during awake surgery in epilepsy surgery. Mitchel Berger, now Chairman at the university of California in San Francisco spent many years in the faculty with the aim to transfer these skills to tumour surgery. Hughes Duffau from Montpellier also visited Ojeman and subsequent Berger starting a movement to removed tumours in eloquent parts of the brain previously thought to be inoperable and untouchable.

So this all was in honour of Ojeman, his intellectual “children”. That was the first time I saw him and shook his hand, humble and pleasant like all great men. In the morning there was a “How I do it” session, 10 neurosurgeons with expertise and experience in awake surgery and removal of tumours from eloquent parts of the  brain, including 5 surgeons from USA, 3 from Europe, one from China, and one from the UK (me!).

At the main meeting, during the oncology sessions there were discussions on Buckner’s paper on effect of adding chemotherapy to radiotherapy in the treatment of low grade gliomas (LGGs). Buckner showed that survival is increased by several years when adding PCV (a chemotherapy cocktail) on radiotherapy…however the responses by the many oncologists were underwhelming…they felt that they would add PCV only when radiotherapy is indicated (which in LGGs is rare)…which means safe radical resection is still the gold standard in these challenging tumours. There were many discussion on tumour vaccines, immunotherapies and vaccines is the way that treatment is going…

During the international reception at Chicago’s cultural centre met with old friends and made new ones. Evey year I always bump to Kwang Tu, current president of the World Federation of Neurosurgical Societies (WFNS), the organisation of all neurosurgical organisations of the world. Kwang is a smart leader and already contributed many positive changes to the WFNS, always great fun to meet him. This time invited me to visit him in Taiwan…yes, will do! And talking about WFNS, the 2017 host, Ugur Ture invited me to speak in Istanbul in September next year, this is the biggest event for any neurosurgeon. I met Ugur in Antalya, middle of April when invited to speak to the Turkish Neurosurgical Society meeting. What a great meeting and an oportunity to see again Yasargil, just turned 90!, running up and down like a teenager.

He said how when he was a young surgeon travelled to see the legends of his time, to see how they operate, how they move their hands, how they move their feet…never heard this before, looking at how surgeons move their feet…! not a lot for a start! but I guess energy flows in the body in the same manner, arms, trunk feet…balance, composure, intensity, focus is the same everywhere…I took a 10 secs phone-video of him talking, capture a great man talking in his own language…

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Arriving at Antalya’s airport 12 April 2016, an advert of the Annaul Neurosurgical Conference in one of the terminals.

 

 

 

 

 

 

 

 

 

 

 

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Yasargil on a shaky photo on my iPhone, standing in front of one of his slides, talking about the “ego of the neurosurgeon”. He spoke about techniques, skills, art, history and philosophy. He influenced more modern neurosurgeons than anyone else…

 

 

 

 

 

 

 

 

 

 

 

 

 

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Catching some of April’s sun in the hotel’s balcon

 

 

 

 

 

 

 

 

 

 

 

 

Back to Chicago, 29 April, was not sunny, at least not for the first 3 days. My umbrella that lasted all english winter broke in the first day, I had to throw it in the bin… when they say windy city it’s not a joke…but the next 3 days was (mostly) sunny. Chicago is supposed to have a good vide with jazz clubs, a sandy beach, cool neibourhoods…was good but did not get the vibe…surprised by how few people were on streets…Michigan avenue is the equivalent of Oxford Street in London…was nearly deserted after-hours, and not that busy daytime…Still the skyline was breathtaking, looking at some of the world’s tallest buildings at night is someting…interesting, the first 10-15 floors of most skyscrapers are car parks, how great would that be for London, that is until… London real estate agents convert them into cozy flats…

The AANS was productive, stimulating, large-scale event! I enjoyed it and of course was grateful for the invitation and the honour…every time I give a talk at the end people come to talk to me and ask me to spend time with me in my hospital or invite me to speak to more conferences and events…so got invites for New York, LA, and Cancun, Mexico…as far of Chicago might have to give it another chance some other summertime!

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Chicago river at a cloudy, wet night

Two days left to have some time off, so rented a car, (a silver mustang!), at the O’Hare Chicago airport and explored a bit of America, country roads, small towns, quite coffee shops. In one of them, somewhere in Indianapolis, a police car parked outside, a few bikers, families with children, couples in a car with windows rolled down so they can attach a tray with burgers and fries, all like taken out of a movie, but very genuine…

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Amazing coffee/burger/ice-cream shop somewhere in Indiana

Friends often ask me how I can drive in America, well with Sat Nav…they still think it is impossible…I have no idea what they are talking about! Driving is so easy, anywhere in the world (well, expect Mumbai…! its crazy there). You can’t feel a place unless you take the detour, drive to country roads, see people sitting at the porch, drinking lemonade, watching strangers walk by, talk to locals, make a bit of noise. Contrary to what you think, the best way to blend in is to stand out! People are the same all over the world, no matter where they live, how they look, what’s their wealth or poverty status, illiterate or highly educated, they all respond to the same things, to interesting (not boring!), genuine (not fake!) people…so don’t think too hard, avoid talking about the weather (or anything similarly boring) and act naturally, how they call it…let me think…yes! be yourself…!

Last week I left my iPhone at the reception of the intraoperative MRI, anything metal should stay away from strong magnets, then at the end of the day I could not find it… there is a “find my iPhone” app which I had activated, was hoping to tell me its under a pile of books in the reception office, turns out it tells you its in London…yea, great, I will now stop looking to find it in china…! I looked at my office, nothing…that’s a bummer…how can u live without a phone? well, looks like its not that difficult…most people text, so I get the messages on my macbook, or they come and find you in person…yes, I got another phone, not an iPhone this time, I got so bored about the same, year-in, year-out design and apps, and the non stop prompts to update the software, “do you want to update now or in the evening”, no I don’t want to update at all!…there was a time when apple was a cool rebel, now its a boring mainstream…so got a different phone and still playing with the new interface and apps…change is good for the brain…! and contacts easy to transfer from iMac to Google contacts and then to android phone even if you lost your iPhone. If I find it, will sell it for charity, no going back now…!

Okay, I know, its been a while, my blog was closed…why and where was I all this time?…I know you want to know… I got hundreds of emails from doctors, friends, patients, asking to grant them access…well, you will find out “why” in its own good time…my life and adventures carried on in the meantime…for now all you need to know is that I am back and will be writing frequently…I know you missed this blog , I missed writing it…! I can’t catch you up on what happened since my last blog, (October 2014, unbelievable!)…but will catch you up with what’s will be happening from now on. A few things coming up, talking to medical students in Sheffield, 11 June, preparing for my fifth annual world course in neurosurgical oncology (this would be a blast!) June 22-26, bigger and better than any previous years, and a week to relax under the July-hot, hot mediterranean sun…and, by the way, if you find somewhere a (slightly!) battered white iPhone, its mine!

 

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Strangers Room

I closed my MacBook Air. I had finally finished correcting the last chapter of the Neurology and Neurosurgery at a Glance. I remember the Glance series since I was medical student. One page text, one page great diagrams. Easy to understand complex concepts, easy to remember. They started with pharmacology and expanded to all sub specialties from anatomy to paediatric cardiology. I was so surprised that they did not have a title in neurology or neurosurgery… When I was in the middle of my residency in Oxford was working very intensely on my “Neurosurgeon’s handbook” so did not have time to take on another project but I knew it was matter of time, months, weeks or even days before someone else had the idea. As a matter of fact many people have great ideas every ideas every day but they don’t take action…I bet many neurologists/neurosurgeons had the idea of writing at the Glance series but they stayed at the stage of wishful thinking…no guts, no glory!… An enthusiastic medical student kept asking me if there were any case reports to write up. So one day I told him, I won’t give you a case report to write! I will give a book to write! For him it would would be a matter of a few months to write and I would correct and polish. Well …the manuscript was ready… nine years later for me to review, and had about a month to finish off in the middle of a chaos of activities and a fed up publisher!

At least I finished it, one a train seat, departing from Lyon. We were off to Genoa, yes, that’s in Italy. The trip started as a business trip in Paris last Sunday. I was invited by a surgical technology company to try and test a new prototype ultrasonic aspirator while its being developed in the lab. What improves surgical technology ultimately improves patient care. So I was happy to help. Then we took the train from Gare de Lyon in Paris to…Lyon. It’s like you take the train from Liverpool street station in London to go the Liverpool…Two hours and a few minutes… Lyon is a big city but without any unique charms, at least none that we’ve seen in two days… The plan was to get a car from Lyon and drive without a… plan to South of France. But all rental cars in Lyon were gone…it turns out Lyon is the capital of sales people, flooding the hotels with their compact suitcase and feed their beer belies at local hotel bars. That was a “without plan” holiday so… new plan. We got the TGV and off to cross the Italian border. The train does not go in a straight line to Nice but heads first south to Avignon, then even more south to Marseilles and then follows the south French coastline, Toulon, Cannes and Nice.

While typing I remembered that last night in Lyon I was watching Tim Cook’s presentation in Cupertino. People were cheering, hysteria in the audience for…a new payment method and…a watch that has internet…Seriously?!! Okay, I am a tech enthusiast, I haven’t read a paper article or paper book in years, I trained (=forced) myself to do everything on a screen and I now find it bizarre to hold paper publications… It’s now such a funny feeling holding a book in my hands…( I do miss the smell of pressed paper though). I even had someone to come to my office and demonstrate the Goggle glass for some projects we are running, I use voice recognition for most of my typing, my office is full of gadgets I use for projects, and I get the most recent versions of advanced software I like, so I do like technology,…(and yes, I will get the new big iPhone, no I will not get the watch, although looks good and will be successful, and yes, credit card payment is very outdated…), but not this love of products…have these people lost it? As you traveling from country to country you see the same images, people standing on shops, bus stops or cafés facing their mobile screen, checking profiles on Facebook, forced friends, artificial lives.

Okay this calls for one of my “Iron Rules”: “develop the skills to distinguish between things that will make your life easier and the things that will make you happy” Put some effort on the first part. Put all your efforts on the second part. A nice house, a good car, the latest gadgets will make your life easier, they will not make you happy. Living in a cool house will not make you cool. Guaranteed! Okay, I am not saying that you don’t need it, but it will not make you happy. But how can you tell the difference? Are you ready? here comes my next Iron Rule: “If something was not around 10,000 or 100,000 years ago, chances are it will not make you happy”. People will not need that either in the distant future when technology will be much more advanced than we can ever imagine. People will always be longing for the same things, in every corner of the earth, when all hunger is gone…when all diseases are cured…when money does not exist…when the concept of salaried work would have  long gone… what made people happy when they did not know how to write or read will make them still happy when when technology will be a transparent bubble around them that they won’t have to wear or even see. So, the new Apple watch won’t make you happy… can someone tell these morons in Cupertino to stop cheering!…

We left Toulon, arrived in Nice, we have 20 minutes to hope on to the next train, then Monaco, and after 10 or so brief stops, we crossed the Italian border photo. Then our third and last train from Ventimiglia heading to Milano centrale, another two and a half hours till Genoa. We crossed from one country to another, no one asked for ID or passport, nobody seemed to care. What a great concept to have a European Union. Trenitalia trains much beer than SFCN but I have to give it to the French, they were on the dot!

Renting a car in Italy requires about… triple the time than… buying the same car in England. I am not exaggerating! They stare at the screens for long periods of time (I wonder if they doze off…), they photocopy everything, write in paper forms and at the same time enter identical data in the computer, make calls to central offices to check if what’s in the computer is correct, then they take more photocopies which they fax to another office, more signatures, more forms, that was a total of about two hours for what in England or USA would take 10 mins tops. Hey ho, at least all was done. You can take a full, “no excess insurance”, but no matter what, they will not insure the rims… I found out later why… From Genoa we set out for a two-hour journey to Manarola, a little village hanging from a cliff with its pink and yellow houses (painted by Paul Klee) so that the fisherman could recognize them from far in the sea.

At the beginning you drive through numerous tunnels, its kind of fun at the beginning, as you see a bit of sunshine and then dive again in the belly of big green mountains with hilltop villages, like playing Asphalt 8… but after a while it becomes tedious…not for long though. The woman in the SatNav with a steady voice gives directions without nagging, pretty accurate. About an hour into our journey the road becomes more and more narrow, it can now barely fit two cars, one on either direction…if a bus or even a van comes from the other side it would be tricky…the SatNav asks to “prepare for a sharp right turn”, okay, I am ready,…but in hundred meters there is no right turn, only a very narrow, extremely steep, uphill kind of “road”, this can’t be it…so we carry on, but the woman in the SatNav in a non-judjemntal tone asks to “make a U turn when possible”…you got to be kidding me, I can hardly drive straight ahead on this country road, how can I make a u turn!……anyways somehow I managed to u-turn and back to this pickle, left now, sharp turn…I eyeballed that goat-road again, that would be a good road for trekking, donkeys would just manage, goats would be okay, but with a car…okay, decision time…time to buy the bullet…left turn it is! Oh boy, I thought the car’s engine was going to give up, this road can hardly fit our car and goes higher and higher… there is no going back now, nowhere to turn or reverse, mountain on the left, cliff on the right…this is some sort of Italian jungle with tree branches on the road, if another car comes our way, any car, we are stuck…there is no going ahead, no reversing…we are going deeper and deeper to this unknown road which looks abandoned…hoping that will be no dead end…

As the SatNav is dead on on every little twist and turn of this tiny path in the middle of nowhere I can’t stop thinking how little brain neuronavigation has progressed during the last 10 years…Neuronavigation is a technology that allows the surgeons to find “where they are” in the brain, but compared to modern car SatNavs it looks like a cassette player compared to MP3…why was I thinking that?…it just came to me…its better to think this than what the Italian newspapers will write next morning when they find us at the bottom of the cliff, about the stupid tourists who drove their car where only goats were meant to go… okay, back to the deadly road, for another 1.5 Km and then another sharp turn, back to some “main road”, that is a road that can squeeze two cars… Manarola, has no beach, just a bunch of massive rocks creating some sort of natural pool good for diving, or plunging, jumping off the rocks.

Driving from Manarola to Coglia, many small villages and endless blue of sea and sky

Driving from Manarola to Camogli, many small villages and endless blue of sea and sky

Then off to Camogli, a town called by Dickens a little pirate place, that’s another hour and a half from Manarola. The road was wrapped on the outside of the mountains, no tunnels this time, no donkey roads, still narrow and steep but fun to drive while having on your left deep blue sea and an infinite blue sky (photo). Inside Camogli, as the SatNav calmy was asking to turn right or left in neighbourhoods with tiny streets, with laundry lines touching the windscreen, I was thinking, that’s someone’s backyard, it’s a dead end, no way this is going somewhere… at the end there was always a miniscule way out where the car could just fit, every now and again I was expecting to hear the noise of a deep scratch on the door. Camogli has a mixed pebbles and sand beach and clear green waters. Then another half an hour drive to Portofino, the jewel of Italian Riviera. Between Portofino and Santa Margarita the road could hardly fit two cars (that now seemed to be a luxury in Italian roads…), in every turn greenery from the side of the road was hitting the car door, buses had to honk in every turn as there was no visibility, most cars were driving on the double line so you had to break and steer the last minute to avoid a crash, and in the middle of all that, add scooters, cycles and motorcycles, joggers and pedestrians totally unaffected by the traffic. Italians do not honk to other drivers often (surprisingly), on the other hand I was honking (and shouting at times!), am Greek!… what can you do about it!…

Portofino at dawn from the hill of the castle.

Portofino at dawn from the hill of the castle.

In the village centre, there was a multi story car park, so followed the signs, the lane was so steep and angled I thought that’s it, either the mirror or the rims are going to get it!… In the village cute taverns, yachts in the port, steep green hills, a castle with the best views of the bay…a tender night was coming…next morning we drove to Milan, another hour and a half and drop off the car by the central train station of Milan. Yes, not a single scratch in these unbelievable (let’s call it) “roads”!…I deserve a medal!… a silver cup!… some sort of certificate!… or at least a “world’s best driver” mug!…from Milan and its spectacular grand train station hall we took the fast train to Geneva and then a plane back to Heathrow closing the circle of our travels.

Seven days, three countries, six cities, I don’t know how many towns and villages, planes, trains, an (unscratched!) car… that was my only proper holiday in two years. Back now to 14-hour work-days, 300 emails a day, non-stop texts and calls but more importantly, back to my patients… old ones and new ones, coming to see me from all over the world, every day a new challenge, a new tumour called “inoperable” by their local neurosurgeons…desperate patients seeking a beam of light…you have noticed that I refer to patients’ cases less and less in my blog. I modify many demographic details, my strictest ethical code is not only that a third party should not be able to recognize the case but the patients themselves should not be able to recognize that this was their case…and I stick to my ethical code.

Patients love my blog and often hope that I will somehow mention their case… patients are telling me again and again how my blog makes them feel much more at ease, a proof that I am not some cold-blooded surgeon but a person who can understand emotions and feelings… their dramas and battles…but my cases have now become so complex and the dramas so intense, its now difficult to modify them… perhaps in a book some time later…being a neurosurgeon dealing with very difficult cases is not being some sort of brain mechanic repairing damaged brains…you have to look into patients’ eyes… take the time talk to them as long as necessary… coach them… give their battles with them…

Back to my blog, I realise how long it’s been since my last blog, 5 or 6 months, things are happening faster than I can think let alone write about them. I can only thank you for reading blogs written months or years ago, I suppose that is part of what I wanted…to write a journal that does not expire like a newspaper article. So time to catch you up on some of the things that happened since my last blog. I declined a few flattering offers to become new the Chairman of Neurosurgery in a couple of countries, one in Australasia, one in UAE and I happily accepted the offer (=honour) to be the new visiting Professor of Neurosurgery in the University of California in San Francisco. No, I don’t need to leave the Victor Horsley Department of Neurosurgery for long, so if you are patients of mine, you are good.

Next, my world course…at the Wellcome Collection Building in Euston Road, a stunning neoclassical beauty built sometime in the 1930s. A museum, a library and a trendy place for coffee is about a mile from Queen Square. This is where people from North and South America, Asia, Europe and Australia came for my third Annual World Course in Advanced Techniques in Neurosurgical Oncology. Although only three years old, this course is considered to be the best course on brain tumour surgery. Three surgeons, one in America, one in France and one in Germany perform awake surgeries so they can test the sensitive parts of the brain before they remove them, maximizing tumour removal and preservation of normal function. The surgeries were projected on a large, cinema-like screen at the Henry Wellcome auditorium, modern and sophisticated, while the delegates, most of them senior neurosurgeons and department’s heads, were looking absorbed trying not to miss a thing. The other two days we had seminars, stunning 3D anatomy shows, lively debates, difficult case discussions.

Mitch Berger giving a spectacular lecture at the Henry Wellcome auditorium

Mitch Berger giving a spectacular lecture at the Henry Wellcome auditorium

and a close up to show how passionately  teaching his unique concepts on tumour surgery

and a close up to show how passionately teaching his unique concepts on tumour surgery

Guilhermes Ribas from Sao Paolo giving a masterclass on cortical anatomy

Guilhermes Ribas from Sao Paolo giving a masterclass on cortical anatomy

Here’s some of the feedback we had at the end of the course: “I could not have imagined a better course. I am impressed beyond anything I can express” The Netherlands – “The course, the content, the venue and the community atmosphere you created, all very special. an exceptional course” USA –  “It was undoubtably a tremendous amount of work putting together the best conference I have ever attended” USA – “I’m very glad to have attended this outstanding and very informative course. It was truly unmissable” Germany –  “You organised an outstanding course of superior quality. I have become inspired to improve my patient care and techniques”  The Netherlabds – An unbeatble  assembly of the superstars  of neuro-oncology”. Germany. When you see the impact that such events have to people’s lives, and subsequently to patients’ lives, it kind of makes you feel good…

Saturday night we had the course dinner at a place that no money can get you in, next to the river with a live quartet under oil paintings…first reception at the strangers room and then dinner at the members’ room at the House of Parliament. As the vast majority of the delegates were from oversees they were stunned by the beauty and tradition of the place. Towards the end of the dinner, before coffee I had to give the …proverbial speech. The course was so hectic, so I gave a very little thought what to say for about an hour before the dinner. I thanked my team for working so hard for this course, I teased a few people, and passed on the microphone to my honoured guests who praised so much this course. the vide was warm and uplifting, what a great way to finish this course! Next year is’s going to be five days long, with the addition of live discussions with the authors of the landmark papers in neurooncology during the last 10 years.

I had this idea when I found out that the author of an important paper, Jakola from Norway was in the audience. When I come up with ideas out of the blue I write them down on my Bamboo app, using a stylus or my finger… I have a folder, one of many, called “ideas” where I jot down whatever comes to my mind and my gut tells me it’s good. Many things I have done and completed now were written down one or two months or one or two years ago.

At the dinner table

At the dinner table

Delegates from all over the world enjoyed British tradition at the house of Parliament

Delegates from all over the world enjoyed British tradition at the house of Parliament

and the proverbical speech I had to give without thinking too much...

and the proverbial speech I had to give without thinking too much…

My “Ideas” folder is password-protected…so don’t try to steal my iPad,  you still won’t be able to read them…!

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Mullholand Drive

I was seating comfortably practicing my talk. I was wearing a suit and a tie. My fellow passengers wore something more comfortable. It was an eleven-hour flight….The stewardess had already asked me a few times if I was comfortable in my suit…yes, yes I was! Some people are a bit uncomfortable on suits, keep putting their finger in the collar, play with the tie knot, unbutton the top button…not me, I feel comfortable in my suits… So I had my MacBook on my lap, and was rehearsing animated :-) … I was off to San Francisco, invited by the American Association of Neurological Surgeons (AANS) to give a talk on “Neuro-oncology in the UK”. Quite an honor… especially as I was the only one invited from the UK. After a couple of hours I was happy that I was ready, so time to change to my long boxing shorts and a T-shirt. Most people came in jeans, slept in jeans and arrived on jeans. I tried a different approach, boarded in my suit, slept in boxing shorts and arrived in my suit again. If you have to travel, travel in style!

Once finished with practicing on the plane, time to finally watch the… “Secret life of Walter Mitty”! I wanted to see that movie for quite sometime. I have actually pre-ordered it on iTunes. But I could watch it sooner… that is… now! on an airplane seat…my gut was right, what a sweet thing!… a happy, upbeat little gem about courage, about going to the unknown… I also watched the “Wolf of Wall Street”, nicely acted but I was expecting something different… that was a let down, don’t waste time with this one, instead watch something like “Margin Call” with Kevin Spacey…elegant and clever!

Got off the plane, had my ten fingers scanned and that it was, “Welcome to America”, quick and easy. Saturday was dedicated to residents so some free time for me. Yes, you can get in a hundred year old cable car (if you can stand the queues), or walk down the market street (a bit boring) or you can get to Columbus street, rent a bike from “Blazing saddles” to ride across fisherman’s Warf and then cross the (very windy!) Golden Gate bridge (photo). San Francisco has some serious uphill roads, I mean really…uphill…If you get bored (or loose the will!) to ride back you can always take the ferry and arrive to San Francisco by sea having the island of Alcatraz on your left. Rumor has it that no one has ever escaped from that prison, well, except in the…movie!

Around midnight (London time) here's the view from the top of Golden Gate Bridge (I had to hold my iPad with both hands, the wind was so strong I was about to fly with my iPad!)

Around midnight (London time) here’s the view from the top of Golden Gate Bridge (I had to hold my iPad with both hands, the wind was so strong I was about to fly with my iPad!)

 

On the way back you don't need to bike again, get the ferry and see San Francisco from a different angle

On the way back you don’t need to bike again, get the ferry and see San Francisco from a new angle

Sunday lunch at John's, the place of Maltese Falcon. I have seen the Humphrey Bogart movie long time ago...can't actually remember the plot, but the restaurant is quite a pull and they have a ...wooden Falcon in a display cage!

Sunday lunch at John’s, the place of Maltese Falcon. I have seen the Humphrey Bogart movie long time ago…can’t actually remember the plot, but the restaurant is quite a pull and they have a …wooden Falcon in a display cage!

American meetings are big!…really big! 3,000 delegates and above. Conference centers are also big, like football stadiums, but structured, wified and carpeted. Actually some of the carpets of the trade exhibit were bouncy, I mean really bouncy…they had springs, so when you were walking you felt like walking on a trampoline, all they can do to attract attention…Sunday there were some non-neurosurgical talks. Americans are used to spice things up with a few culture, politics and management celebrities, including Bob Geldof, Robert Gates, Secretary of Defense, 2006-2011 (he looked tough…really tough!) and Clayton Christensen, a Harvard Business School Professor and author of many bestselling books on innovation and economy (check him out on Amazon).

I met old friends and made new ones, like the President of the World Federation of Neurosurgical Societies (WFNS) Tu Yong-Kwang… a lovely senior surgeon from Taiwan, he invited me to help with the oncology section of the WFNS and also with training of neurosurgeons from developing countries. Of course I was happy to help with both. While talking to Yong-Kwang a hand was placed on my shoulder and a smiling face… it was my good friend Mitch Berger; San Francisco is his town. As a matter of fact when going from the airport to the hotel, an enormous street poster was advertising the UCSF Medical Centre with… Mitch Berger looking thoughtfully at a brain scan!…Mitch is coming to London as my guest this July for my course. He told me he “can’t wait!”.

I also met again with Bil Couldwell (and his wife), President of the AANS who I met a year or so ago in London, in the retirement dinner of Mick Powel, my senior colleague and friend, an expert pituitary surgeon; David Adelson, Chief of Paediatric Neurosurgery at the Barrow, Phoenix and Chairman of the AANS Scientific Committee. David is also helping with one of the forthcoming projects.

Reception at the City Hall tuesday night. Moscone was a Mayor who was shot in the very same City Hall. Mitch Berger told me that Moscone was a Mayor that was shot in the City Hall. Before entering everybody has to go through metal detector frame!

Reception at the City Hall Tuesday night. Moscone was a Mayor who was shot in the very same City Hall, Mitch Berger told me. Before entering everybody has to go through a metal detector frame!

I also had lunch with David Kline, a living legend and possibly the best peripheral nerve surgeon, retired long time ago. Dr Kline and his wife were kind enough to invited me as their guest at the university of Michigan dinner on Tuesday night at “The View” a lovely restaurant at the 40th floor the Marriott, at the Mission street and fourth. We had never actually met before but we exchanged emails a few times. How lovely of them! On Tuesday night I was however invited at the San Francisco City Hall (photo above), so we swapped dinner for lunch. Dr Kline now lives in South Carolina, took up gardening and helps his community.

I don’t like standing behind the podium, I like to walk around…my talk was received well, very well…a lot of questions about measuring performance of individual surgeons, all these data will go on the public domain in the UK, that means all data on quality indicators of individual neurosurgeons will be available for patients to review on the internet. Americans are a few steps behind on this section, some institutions collect data but not a word about publicizing it on the internet…

At the end of each busy day, the view from the hotel room was spectacular!

At the end of each busy day, the view from the hotel room was spectacular! At the far end one more of San Francisco’s bridges.

There were quite a few, new interesting concepts at the congress: one group from Arkansas showed interesting results when a small group of patients with severe cognitive problems after head injuries underwent deep brain stimulation (DBS); the next step would be to try DBS in a larger cohort of patients and possibly in patients with chronic vegetative status. Its amazing what stimulating the brain can result in!

A second important paper was the results of the BRAT trial comparing clipping to coiling of cerebral aneurysms, weak spots in the brain that can cause subarachnoid hemorrhage, a potentially lethal type of stroke. Nearly ten years ago, another trial, coordinated from Oxford, called the ISAT trial showed better results in patients undergoing endovascular coiling (that does not requite an operation) compared to surgical clipping (that does require to cut the head open). The impact of this trail was tremendous as shifted the paradigm from clipping to coiling and therefore more than 90% of aneurysms in the UK are now coiled than clipped.

As coiling is performed by radiologists rather than surgeons, the ISAT trail resulted in nearly shrinking terribly vascular neurosurgery in the UK and most parts of the world. Except…the United States, where they never accepted the results of the ISAT trial and they wanted to run their own. Robert Spetzler, a legendary vascular neurosurgeon from Phoenix (photo), presented the results of the BRAT trial that showed no superiority of the coiling versus clipping and actually better long term results with surgical clipping. I like Spetzler, skillful and innovative, a master surgeon who inspired a whole generation of neurosurgeons. I also like him as he wrote several chapters on “The Neurosurgeon’s Handbook” and also five video chapters on my new endeavor that I will not disclose as yet!
:-)

Robert Spetzler concludes the results of the BRAT trial. Has ISAT got it wrong? We do need another trial!

Robert Spetzler concludes the results of the BRAT trial. Has ISAT got it wrong? We do need another trial! Do you notice the tele-prompters?!! Spetzler did not use them but quite a few speakers did!

At the congress there were 3D surgery shows; face-offs debating neurosurgical opposites; “top gun” competition for residents (to see who knows more!); and trade exhibit with recent surgical technologies. Most congresses have (inevitably) repeated elements: delegates who always are looking lost; those who always checking their mobiles; others try to find their buddies to hang out; some are headed for the reps stands; and others photograph every single slide projected on the screen. All in all, the congress was a wonderful experience and being member of the faculty and an invited speaker was tremendous! Next spring the meeting is in Washington, DC.

On Tuesday night I saw a man who did not look like a neurosurgeon! I know, how a neurosurgeon looks like?!! Well, he did not look comfortable in his surroundings for a start. Okay, that dosn’t exclude too many! He was tanned, with a stubble and a bit… rough… Well…he turns out he was an actor! (and brother-in-law of the President of the AANS Bill Couldwell). We started chatting, he played in many movies and TV shows, I knew none! :-) except MacGyver! He knew many actors, mentored by Michael Douglas, and was buddies with Nick Nolte (Nolte is tough!…). I told him my plans to get to LA for a day, so he gave me a few insider’s tips.

I had one more day, Wednesday, time to go to LA. For a couple of days the TV news in San Francisco were going on about an impending…earthquake in LA…nothing I can about it, other than avoid forty (and over…) storey hotels. From San Francisco it’s about an hour flight to LAX. I don’t often rent cars, but time was of essence. Upon arrival I checked on my iPad online offers, turns out all cars from major companies were gone. One left, “Budget”, I had no other choice, so “Budget” it was!… When arrived at the rental site I spoke to Raoul, a cool Spanish American. Well, turns out “Budget” has some very nice cars, so Raoul for an extra $35 pimped my ride… a black Merc, not a shabby old Merc but a smooth new one, still had the smell of the new car! Sweeeet!

Descending to LA. The bunch of skyscrapers is the financial district at downtown LA.

Descending to LA. The bunch of skyscrapers is the financial district at downtown LA.

My hotel was downtown LA. I like LA…spread out, disconnected, a bit rough, but somehow honest, and real, at least in certain parts…It was a hot night… good time for a walk through the nearly deserted financial district and the more posh fashion district. Around midnight you can have the best burritos in LA (veggie for me) at a dodgy Mexican joint at Hill Street and 4th, sitting at a backyard guarded with iron rails, and then have a chat with a bunch of homeless people lying under one of several bridges off Hill Street. Thursday morning early start for hanging out in LA before hitting the beach. Before heading for West Hollywood check out the silver, futuristic Walt Disney Concert Hall on Grand avenue and 1st Street, there are parking spaces but you need coins to park!, so no time to check out the interiors this time…then you can head to Hollywood Boulevard and see the Kodak theatre (where Oscars ceremonies take place) and next to it, the Chinese Theatre. You can walk on the “Walk of Fame” on a few of some 2400 marble stars…you would expect to be a bit more glamorous…parking here was easier, $15 for a day (or in my case, after haggling! $10 for 60 mins). Then driving through Sunset Boulevard time to do the ride I was planning to do since I arrived to LA (and the main reason I rented a car)…

Driving downtown LA...

Driving downtown LA…

then crossing Sunset Boulevard while heading to my ultimate destination...

then crossing Sunset Boulevard while heading to my ultimate destination…

I first saw the dark, bone fide David Lynch’s masterpiece “Mulholland Drive” on a DVD as a junior resident some 12 years ago. The movie starts with a limo’s headlights showing parts of a dark road while the Angelo Badalamenti’s melodically imposing and peacefully powerful score will glue you to the screen (I can’t describe the score in a different way, you have to listen to it to understand what I am talking about…) The movie has many stories, some linked more obviously than others. All stories are dark and difficult to interpret but somehow they draw you more and more into the movie. If you don’t understand what this movie is about, not to worry… nobody else does…but this will not stop you to absorb the atmosphere… pure beauty…some powerful scenes (from those I can describe here…) is the scene of the “cowboy”… how can someone have such an effect and be so potent using the most simple words…and of course the legendary phrase “this is the girl!” Classic!

So yes, time to make the same journey, some 24 miles of bends and turns, on a very narrow, steep, uneven and, at parts, damaged road. Some things you cannot only see on a screen, you have to feel with your body, like being pulled back and to the front, every time you speed up and break, being pulled on the side with each sharp turn, glancing for a second downtown LA, San Fernando Valley and Hollywood before getting your eyes back to the dangerous road. There are no streetlights and I can imagine driving fast on this road on a dark night, like on Lynch’s film. I don’t have a bucket list (can’t tell you why…) but if I did, that would be one in the list to take off: drive on Mulholland Drive! Check!

At the end of long-winded road on Mullholand Drive through Santa Monica mountains, look at the top of the mountain across...can you read the sign?...

At the end of long-winded road on Mullholand Drive through Santa Monica mountains, look at the top of the mountain across…can you read the sign?…

Then time to head to Santa Monica, a beach town with a legendary Pier with carnival games, amusement park and beach sports. Also fabulous fish tacos served at the bar by the beach. Perfect lunch! Santa Monica was a pitch stop only to my way to Malibu. If you love the beach this is the place… Drive along the Pacific Coast Highway having 27 miles of gorgeous natural beauty to your left…listening to some pure rock songs on the radio… like “come a little closer” from “Cage the elephant”… of course you can stop at the Getty Villa, a first century Roman Villa replica that attracts the crowds, but if you are not into touristy things… carry on for the Malibu town, stylish, affluent and laid back…you can almost see Charlie Harper’s imaginary house from “Two and a half men” somewhere there, amongst other houses…but if you want the most stunning beach you have to drive much further, El Matador’s state beach is stunning… rock formations planted on golden sands. Malibus’ best beach! By far!

The drive back was a treat, you can actually park on the road by the beach…in a little while outside LA one of the usual LA traffic jams…if I had a bucket list (again!…), that would be another one…get stuck on a LA traffic jam! Check! Bucket list or no bucket list I didn’t want to miss my plane, that was enough for a day, time to head back to LAX (much less glamorous than you may imagine…I have yet to see a better airport than Heathrow’s Terminal 5). One last night in San Francisco before boarding Friday afternoon for my flight to London. We left Friday around 5 pm San Francisco time, arrived Saturday 11 am London time. Got to my car, started driving, for a second I blocked, which side of the road I am driving, right or left?!!

I am not working for “Trip Advisor” but here are a few tips for when traveling to America. First, to avoid jet lag forget your original time zone from day one. If you feel sleepy daytime, sit it out until its dark. Then sleep. That’s it, you will wake up in the new time zone. Same when you come back. Second, do not use your own phone or payphones. Buy an AT&T pre-paid phone. $15 for the phone plus $20 of international credit will get you 750 mins; for this amount of time you would need more than £1000 if you were to use your own phone (£1.5/min). Third, tip and tip well. This is the local culture, its bizarre not to. America is built on customer services, and they are impeccable! I’ve never seen better customer services anywhere in the world. They will take good care of you and the people who will come after you.

And last (I need to finish this blog, got things to do… :-) but not least! do not attempt to imitate the locals, do not pretend that you are one of them, that you belong there… because you don’t! and that’s okay, contrary to what you see in movies and TV programs, Americans are very open and friendly to visitors, foreigners, even to drifters and outsiders…feel comfortable in your skin and people will accept you…that applies to wherever you go…so what if you are not one of the locals? the locals are hanging there all of their lives, they just happened to be there… you! are the traveller… the curious…the adventurous… you! are the one that will have stories to tell after you leave…and then go to another place and another one…and from one traveler to another, I wish you travel far and always come back, every time, a little bit happier and a little bit wiser…and one day you may reply like “explorer” Walter Mitty, in one of his dreams, to Cheryl Melhof when asked “where’ve you been?”… (with hilarious Spanish accent)…“testing the limits of the human spirit”…!

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Ripples

My car’s fuel light was on for about an hour…it was yellow by the way, shouldn’t they make it red? It was 9ish on a Friday night. I don’t like activities that waste time, like pumping petrol to a car, going to the grocery store or watching telly. But you have to do them from time to time…Time to get some fuel, not a great idea to break down because you run out of petrol in central London…I pulled over at a BP petrol station in Perivale. You have to walk through a full version of Mark and Spencer food section before you go to the tills…whole chickens, racks of lamp, vegetables and fruits, birthday cakes…all I wanted was to pay for a full tank of petrol.

I always have a little talk to the people behind the tills, they are usually bored to death with the same vocabulary they’ve being asked to use. “Sorry to keep you waiting Sir” “Did you have any petrol today?” “Would you like a big Canterbury chocolate bar for just a pound?”….“How was your day?” said back to the young woman behind the till. It turns out she was stock trading during the day! How about that??!! Stock trading during the day and serving the tills at night. Be careful my friends, some of you might have the fate of your shares in the hands of this lovely but (I think…) not very experienced trader…

“What do you think about Lehmans brothers?” I asked her while the queue behind me started to grow. She didn’t see to mind the queue, so she said “who?”. “The bank who nearly busted the financial system in 2008”… In September 2008, Lehman Brothers, USA’s fourth biggest investment bank filled for bankruptcy, the biggest in the history of US. It was also the first time in history that the Federal Reserve Bank, and in reality the Government, did not support bailout of the investment bank hemorrhaging money. Many other investment banks were on the line, including Merrill Lynch, Goldman Sachs and AIG, actually an insurance company.

The movie went straight to number 1 at the Box Office in UK and USA. I can't remember the last time I went to a movie theatre, I prefer HD downloads. It won;t be long until we can watch movies online the day of their release.

The movie went straight to number 1 in the Box Office in UK and USA. I can’t remember the last time I went to a movie theatre, I prefer HD downloads. It won’t be long until we can watch movies online the day of their release (at least that’s what I am hoping for). The movie I want to see now is “The secret life of Walter Mitty” but it has to wait a bit…

It was all decided during a rainy weekend in New York, 17 to 19 September 2008. The CEO’s of America’s biggest investment banks were at a meeting under the director of Federal Reserve Bank trying to solve the problem with no success…by Sunday night it was all decided, they would let Lehman Brothers sink and drown, hoping that they could contain the crisis. Do you think that movie scripts are more excited? Yes, “The Wolf of Wall Street”, a new Leonardo DiCaprio blockbuster is meant to be good,…but watch instead the real deal, a two-hour Hearing of Dick Fould, the then ruthless ex-CEO of Lehman Brothers testifying to the “Financial Crisis Inquiry Commission” set up by the Government.

No movie can capture the events of that period…youtube some of these names, and watch it, no adds every 15 mins like TV…gripping! no movie script can ever measure up to real life events…thing is that in real life events and dramas…acts of heroism and sacrifice…acts of greed and ruthlessness… lived by everyday people and will never make any viewers to feel touched or lifted…inspired or motivated…appalled and discussed…other than perhaps the very close circle of people involved in it…

Most people have no idea how banks work, how credit is created, how money is created. Politicians are mostly clueless as they all strongly suggest savings, which in reality would shrink the economy, as banks create money by loans and mortgages. Do I care about money? Why would someone love money?…I was raised with the principle that money is not important, helping other people, that’s what matters…and this guides me still…

These were going through my mind as I was driving away from the petrol station…people I helped during the last week…patients who came to see me from the four corners of the earth, Canada, Mauritius, Nigeria, Rome…Patients with brain tumours, spinal tumours…a young man in his twenties paralysed for three weeks from a tumour inside the membranes wrapping the spinal cord…nealry hopeless case…at the end of a five-hour operation after removing the tumour I saw the spinal cord trying to pulsate…was there still hope? Two days later he was walking unassisted!…how’s that for a bonus my banker friends?!

Holidays have gone but London’s Oxford Street still got the Christmas lights up, everything that can help shops sell more and people buy…how do you feel when you buy something new and shiny?…and for how long?…an hour? a day? a week?…a couple of weeks earlier there was Sales panic in the streets…outside London many shops had even velvet ropes to create orderly queues outside the shops and security guards at the doors to allow shoppers inside like there was  some exclusive venue… What I found even more extraordinary was that people were actually queuing patiently to get to the shops…I despise queues, I wouldn’t queue for anything in the world! I find incomprehensible that people would queue for an hour to get into a restaurant or a bar…how little do they think of themselves to do that…

People queuing to get to a SuperDry store. What the world has come too?!

People queuing to get to a Superdry store. What the world has come too?!

The only queue I would tolerate for a few minutes is at a coffee shop while waiting to pay for a sandwich…and I usually strike a small talk to the person in front or behind me in the queue…life’s too short to waste it with standing still…unless of course you are doing it to look inside you, quietly, and peacefully…most people when standing, at a queue or while waiting for the lift, or sitting on a train, they are focused on their smart phones, checking their connections? reading text messages? sending emails?…if you notice most of them they are actually playing games, bursting balloons or align coloured squares…pushing simple buttons for stupid rewards… have you seen monkeys in a lab pushing buttons to get bananas?…same thing!

Last Saturday was the Name day of Gregorios, the Orthodox Archbishop of Great Britain. He kindly invited me to the celebrations in Craven Hill and to the celebratory but elegantly simple dinner table with other distinguished guests, ambassadors, benefactors and the Nuncio (Pope’s ambassador) to the Great Britain Antonio Mennini. On the ground floor there is a beautiful small church with hand-painted icons and wall art, small windows allowing sharp beams of light to get in, and peaceful colour combinations. Antonio Mennini told me that archbishop Gregorios has been like a father to him… archbishop Gregorios has served the Orthodox communities of Great Britain for five decades now and still remains energetic, wise, humble and a great new friend.

Archbishop Gregorios on a peaceful evening in the small church of Cavern Hill

Archbishop Gregorios on a peaceful evening at the small church of Cavern Hill

I know its been a while since I wrote my last blog…and I will let you into a little secret, I was thinking to stop my blog…so many things are happening, I could write a blog a day…but when? and most importantly why?…but looking at the statistics, the number of readers remain rock steady, every single day, from all over the world, no matter if the last blog was four months ago, people looove this blog…so I won’t let you down, I won’t stop, until not for now, I promise…I know that there is nothing similar anywhere in the world, an open journal, I know, partially! but still open!

The postcard I received Thursday night.

The postcard I received Thursday night.

Thursday night I received a post card from a patient who had a difficult but successful brain operation. I won’t tell you all there was in the card, but two sentences read ” Words and gifts could never be truly enough to tell you just how thankful I am for my family and I, and the fact that we found you to be my Neurosurgeon”… “Liked the quote in this card, I feel it sums up what it truly is to be in many ways “radical” as you indeed are”.

The same evening we went with a few medical students and my team for a drink at Perseverance, an old pub at Lamb’s Conduit Street, close to Queen Square. They wanted to take me out on a dinner, how adorable!, but life’s short, so drinks it was. People who come to spend some time with me, students, residents, qualified neurosurgeons, from all over the world, always tell me before they leave, how much it meant to them that they have met me…I know it sounds kind of strong, but I have heard it so many times, it has become normal, so no!, I am not bragging, that would be weak…just quoting a fact. When these doctors leave to go to their countries, sometimes I feel that parts of me go with them, our lives as human beings are linked…and some parts of them stay with me…the miracle of genuine human relationships!

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Mr Nobody

A text gave another little nudge and woke up my iPhone. It was from secretary this time. The “Pearl” had closed. What?! My favorite place for business lunch had closed!… Housed in the neoclassic Renaissance Hotel in Holborn, stunning interiors, understated luxury, and amazing food made by Michelin-starred French chef Tanaka. And only five minutes walk from Queen Square…This was my regular for business lunches. I like business lunches. I find them very worthwhile! No, I am not a businessman closing multimillion pound deals :-) and I don’t close deals involving money (how boring!) but I do close agreements and collaborations. No better way to close than during dessert. That means do not go for a hard sale, rather ease into it… leave It leisurely for the end…If you don’t have a regular restaurant where they know you, by name!, then find one!…you need one! trust me!

So my secretary couldn’t book a table…I was expecting Roger Stupp, Professor of Oncology in Geneva and President of the (very prestigious!) European Organization for the Research and Treatment of Cancer (EORTC). Roger came to deliver the Annual Lecture at Queen Square on 19 September, a lecture given every September to celebrate the memory of Victor Horsley, father of modern neurosurgery and the world’s first brain surgeon! Roger is the man who introduced Temozolamide, a chemotherapy agent that prolongs substantially the life expectancy of patients with Glioblastoma, the most aggressive tumour that affects the human brain, one of the biggest discoveries of the last 80 years.

World-class oncologist Professor Roger Stupp delivering the 5th Annual Sir Victor Horsley Seminar at the lecture theatre of 33 Queen Square.

World-class oncologist Professor Roger Stupp delivering the 5th Annual Sir Victor Horsley lecture at the lecture theatre of 33 Queen Square.

So I could not take Roger at the “Pearl”. I asked my secretary to book the “Axis”, at One Aldwych. Understated but with gravity, perfect for dinner with good friends (like Roger) or for business. Top service and food is what you expect from top restaurants but little touches make all the difference. For example they brought the complimentary, after dinner, sweets in two large, square heavy glass bowls, with a thick layer of brown sugar (and four chocolates) and pink sugar (and four marshmallows). I don’t eat sweets (have my reasons, no I am not on a diet, and no, am not diabetic! :-) but they got top marks for presentation!

Next day I was operating in theaters, then back to my office to look at letters, answer emails and see visitors. I went out of my office for ten minutes, when I got back, I had forty seven new emails in 10 minutes. I usually get a couple of hundred emails a day. No I can’t read them all…I scan the subject…perhaps read the first line and see whether I need to read the whole email…so, if you want to email me (or anybody else whose reply is crucial to you) here are the email rules:

First, choose an attractive (=not boring! title). Avoid abbreviations (such as “TMC outcomes”, “TGM board”, Ref 92321). Sum up in the title the purpose of your email (i.e. Spanish Neurosurgeon seeks fellowship, or “Second opinion from Italy”). Second, be brief. One paragraph is the max. Avoid introductions longer than your arm, avoid complex explanations, be very brief and to the point. Third, make sure the person you are emailing is the right person. Don’t email me if your paperwork for your observership is not ready, I can’t help you there. Fourth and last, speak with your heart, no need to polish or follow etiquete. Enough said…

While in my office during lunch time, I glide my fingers on the trackpad and wake up my gorgeous 27 inch iMac. While munching for ten minutes or so, I watch the 3 daily movie trailers from iMDb. During these ten minutes I get knocks on the door from Hilda, my NHS secretary, my registrar, other registrars, fellows, medical students, observers…Its okay, my office door is always open, well it’s actually always closed physically, but you know what i mean :-) One of the three two-minute movie trailers got my attention…”Mr Nobody” was the title, so I clicked on my iTunes icon and downloaded the movie to watch a few days later in the week.

I can’t watch a whole movie, don’t have the patience…usually takes 2-3 installments…so I watched “Mr Nobody” in three parts, in bed, on the bedroom floor and in the bathtub…the movie starts with “Mr Nobody” a very old man, the last man about to die in a society where everybody else has become immortal. Mr Nobody starts to remember his life as a child… at a train station with the train slowly departing…his mother is on the train…his father on the station (called “Chance”)…his parents are separating and he is torn, which path to take, what decision to make…years go by…snapshots from his life appear…his marriage with a woman who change faces…they are different women…different families…different decisions…whole new different lifes…The young boy does not want to decide while the train with his mum on the train and his dad on the station is departing…he thinks that if he does not decide all possibilities are open…but this does not change the question, which path to take, which decision to make…

Have a think about how many decisions you are taking every single moment. Why are you reading now this blog now, what brought you here and you are not in front of a TV or talking to your friends on the phone or being on a plane to visit Peru for the first time in your life?…Think about the things you do every day, every hour, every minute…Are you govern by the fear of the unknown and you stick to something familiar?…do you follow the path of least resistance and least effort?…you do what you do because everybody else does the same and you want to appear “normal”?…Imagine being “Mr Nobody” of the movie, seconds before you die, imagine things you wanted to do and didn’t do because you weren’t brave enough… because you were afraid of pain…because you worried about what other people would say…think! you are about to die!, where are these people now? and how’s the pain of not having tried what you really, really wanted…So back to the original question, “which path is the right path”?… here’s what Mr Nobody says: “Every path is the right path!”…comforting thought but not sure I agree…

On Friday around 12 pm I was in the coffee room on operating theaters. A quick pit stop as my anesthetists were putting my next patient to sleep. I like to sit cross-legged on a chair in the coffee room… no I don’t meditate in coffee rooms… I do meditate, but usually sitting on the white carpet of the bedroom floor. Not sure what people mean by meditation…well, I know the theory but I don’t particularly care… I have my own method…I like to sit quietly and reflect on my day, thinking what type of person I’ve been during the day; and what type of person I want to become the next day. As you evolve in your life, it’s not important what you learn (some dry facts, short-lived news, destructive gossip…) or what you get (objects you buy from fancy stores or money you earn) but what type of person you are becoming… Everything stems from your identity…what you think of yourself…what’s the opinion of you for… you!… that’s the bottom line of bottom lines, nothing else matters!… Does this sound arrogant?…its one of Mr Samandouras Iron Rules, so get over it! I am not talking about work environment, I am talking about the core of your being!… Do you think confidence is based on feedback, “constructive” criticism, opinions of others? Don’t think so…

So no, I was not meditating, I was chatting to Bob Bradford, one of my senior colleagues. Suddenly the recovery nurse came in and very politely and rather hesitantly told me that my previous patient who had been in recovery for an hour, after he woke up he was not moving the right hand side of his body! I had performed a complex brain operation using a blue dye called Gliolan that is taken up by the malignant cells of the tumour but not the brain. Under a blue filter on the microscope the tumour looks bright pink, like a hot coal, so you can see better the distinction between normal brain and abnormal tumour. My philosophy is aggressive tumour removal, I don’t believe in timid debulkings, is this patient has one chance to prolong significantly his life is by starting with radical tumour surgery. And this can come at a price, a neurological deficit, weakness or paralysis.

I turned to Bob who was sitting next to me. “That’s not possible! Complex brain tumour surgery has a 5% chance of paralysis in all big series, but not mine…”Well, today is the day!” Bob said back to me with the quite wisdom of his 25+ years experience…”No, today is not this day! can’t be” I am sure that everything went extremely well! I went to see the patient myself, he was still drowsy and not fully assessable, I lift his right arm up and left it fall floppy to the bed! Yes it was… paralyzed but I felt a whisper of antigravity resistance, no scale can measure this but I did feel it, I was certain!… “ give him more time” said to the recovery nurse and went back to operating theatre to carry on my case.

If my patient was still paralyzed after an hour, the next step would be to do a CT scan. Was there a haematoma? Did I damage some of the neural circuit? I remember an old boss of mine who every time we were taking someone with a post-op deficit for a scan, while waiting in front of the monitors for a minute until the scan is done and the images appear suddenly on the screen, used to say “I hate this minute”… you don’t know what the scan will show, did you damage this patient or it is just swelling that will settle in a day or two…Two hours later I went back to recovery to see my patient. He was now fully alert and was moving everything, back to normal! I saw Bob in the corridor, “my patient is now intact! Today was not the day!” Bob smiled pleased.

Tuesday evening I just made it to Euston Station on time. I had finished the neurosurgical consultants meeting a few minutes after 6 pm and grabbed a taxi from Guilford Street. I sat down on my train seat, number 3, coach G. While putting by bag on the rack a young woman sat opposite me. “How’s your day” asked her relaxed. “ I am good” said and added “I am sitting here, so you will be seeing my face for the next 2 hours” in a cheeky way. I thought her accent was from Liverpool, it was actually from Manchester. Anyway I can’t tell the difference, other that it was not from London and it was from somewhere North. I was off to a 24-hour trip to Liverpool, invited to take part to an Advisory Board. I normally drive but I had to read a bunch of papers for the board meeting next day so I wound’t mind a couple of extra hours. But my fellow passenger was chatty, so I had to cut down reading time..oh well, nothing goes perfectly as planned, you have to adjust!… but she gave me her… cocoa cookies (how adorable) autographed with her name :-) that was worth the lost reading time…

I got in my room after 10 at night, the Crown Plazza was overlooking the river, it was dark outside, I could see a string of yellow lights in the harbor, I could feel the open horizon in the dark…I couldn’t have for dinner three cocoa cookies, so room service it is. There was no fish on the menu, so Keighley from reception called the chef and in 20 minutes I had in my room a lovely decorated monkfish with green salad, orange juice and a fruit salad. The meeting was good, made new friends from America and got back to train an hour ago. It’s dark outside my window, yes, I am writing this blog on the train, approaching London.

Friday night I went to see my patients who I would operate on Saturday, three complex brain tumours, two spinal cases. Yes, I know, …whole Saturday… My list of patients is so long and…so I have some catching up to do, hence the Saturday list. While walking out from the “Lady Ann” Ward on the 4th floor, a woman with a probe attached to her brain stopped me “are you Mr Samandouras?” I though she was an old patient of mine. She told me that she never met me before, she was under the care of Mr Watkins, one of my very capable colleagues and President of the International Hydrocephalus Society. She’s been in and out hospitals for twenty years…but she’s been reading my blog and recognized me from my photo…apparently my blog is quite an… inspiration and wants to start her own blog with her experiences as a patient! Bless! (PS 25 October: This patient has actually started her blog about donating unused shunts to underprivilledged countries with the help of  Lewis Thorn, one of my colleagues. So she kindly sent me an email, observing all my “email rules”! and with the link of her wortwhile blog, and how she saw our meeting in the ward, http://www.jordantheheadcase.wordpress.com/2013/10/22/theres-no-place-like-home-dorothy-was-right-about-that/

On Tuesday afternoon I went to Lincoln Inn Fields, home of the Royal College of Surgeons. I was running a cadaveric neurosurgical course. Sixteen selected trainees from London in a laboratory with microscopes and instruments dissecting systematically the human brain, one part at a time, once a month for nine months, the whole academic year. the College has a stunning building, history, tradition and gravity…I parked outside the college 10 minutes before the start time and walked in 2 minutes before we started ie on time! Do you ever notice how the same people are always late? How’s that possible? Being late is never factual, is always subconsciouss…Its always the same people who are always late and the same people who are always on time. Anyway the course was tremendous success. When you operate in real patients you can see a small part of the brain through a small corridor, in a cadaveric head you can see the whole picture, vessels, nerves, fibres. Our trainees loved it and wanted to do more but at five we had to stop, my parking time was running out :-)… Next installment is beginning of November…

Sixteen selected London neurosurgical trainees are preparing to start the course at The Royal College of Surgeons on 15 October 2013.

Sixteen selected London neurosurgical trainees are preparing to start the course at The Royal College of Surgeons on 15 October 2013.

Thursday evening of the same week we had a training session, again!, at the operating theatre learning  how to use an ultrasonic aspirator, a sophisticated “hover” that removes parts of the diseased brain. We practiced using oranges (photo)!

Practice on oranges before you use on real brains! some of our trainees in an operating theatre training session.

Practice on oranges before you use on real brains! some of our trainees in an operating theatre training session on Thursday 17 october 2013.

At six I had to go, another committment around the corner…and then back to the hospital to see my patients. People often ask me, how do you find time to do all you do? I have no idea, sometimes I think to myself “is this really me?…is this really happening?…” and that’s for what is in this blog, but mostly, for what’s not here!…but I do feel the delight of every small and big success, I do feel the pain of every challenge, so yes!, it is real…Its late now, but the night is still young, time to go out…in a few hours another big day in a big city will start…

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Summer’s dream

My flight to Athens was delayed for an hour and a half. It was the 28th of June. At least BA’s lounge at Heathrow’s terminal five was one of the best I’ve been. Individual armchairs, floor lamps, quite carpets. I was lounging with my MacBook on my knees. Every now and again one of my neighbors would stand up to go and refill their breakfast plate with pastries and muffins, and more coffee, and then some more. I know it was free but still can’t comprehend how much these people are having for breakfast! You know what they say: “The most important meal of the day”. Rubbish! Nothing more than some easy pleasure before starting a (potentially) difficult day… I had my usual breakfast at home, thank you. A glass of water. And a glass of milk. “Breakfast for champions!” At least that’s what one my senior colleagues told me once, when after an early morning run I was having my “breakfast” in operating theaters coffee room.

I was looking at the screens. Two more hours delay! I looked at my MacBook, half of the battery’s juice had already gone. And the mains had already been checked in in some plain’s big belly. Time to start chatting to some people. I regularly talk to strangers… I never met anyone who wasn’t friendly, or at least someone who looked annoyed. I like to give more credit to the people even if they look a bit withdrawn. I like a brief chat. But genuine. Not, they haven’t got a clue that they are talking to a brain surgeon. Sometimes I don’t feel like it but I still do, I want to do what might feel uncomfortable, every day! I have my reasons!… More delay on the screens! Now my fellow passengers were gearing up for lunch. How much can these people eat?… Our plane had some technical issues and a plane from Stockholm was diverted to Heathrow to save the (my) day. We finally sat on our seats. Do you know what is the best moment in a flight? When the wheels are spinning on the ground, the plane has its maximum ground speed and the plane just lifts up to cut through the air. If there is one moment when freedom takes some material form, this is it!

When I arrived at the conference hotel it was after ten at night. The smiling receptionist typed my name to check me in, and then continued to type and type and type…I was thinking unless she is writing a novel, something isen’t quite right! Sure enough after five minutes of typing and typing she reluctantly said that could not find my name…But let me take you back, there is a story behind it…A week ago I had called the hotel myself. I used to make hotel bookings via booking.com, superfast and easy. But I then started using Julie, my agent, who has connections and can find the best rooms in the best prices. With the conference hotel in Athens the price Julie found was still high, I had left it for the last minute, so I thought to practice my Greek and call the hotel myself. The woman from the hotel I called myself was very helpful, I chatted to her before getting to business (I always do that, not because I expect anything in return… again, I have my reasons…) and she gave me a great price, but then she said, “you should get a balcony suite, 792, is great!” but the price was too high. But she was insisting “please get this one…” and I was thinking to myself “was are you insisting? I am not going with you…:-) She was so nice, so she gave me the balcony suite with the standard price! That’s the background, so when the receptionist could not find my name, I thought, that must be it, they gave it away…then the manger came, they started making calls, and then the manager said, “I am sorry Sir, we will give you our special suite for no extra cost”. “Special suite? How big is it?” Asked. “Its bigger than my house, Sir”. Oh boy, it was big! With dinning room, study, three sofas, stunning views of Acropolis! Plus complementary wine brought every night…

The welcome reception of the International Hydrocephalus conference was on Friday night. They had some (very basic) nibbles, dry bread with olives, tomatoes and mozzarella (I checked around, no, I was not in Italy, what happened to feta cheese?!) and that’s all! Not very impressive my greek friends despite the €700 registration fee, the most expensive I’ve ever seen (and paid!) in any conference, anywhere in the world! That’s one for the Guinness book! On the same evening there was a talk by a Engineering professor on antikythera mechanism, an extraordinary ancient analog computer that could predict astronomical events and eclipses decades from present time. The mechanism was phenomenal and someone said it is “more valuable than mona Lisa” but the talk was over an hour, far longer than my attention span for anything outside the human brain…

The conference was international with delegates from different parts of the world but quite a few Japanese. The men are very polite but they speak with a very firm, sharp, nearly… angry way. You think that they might pull a sword and slice you :-) But they are lovely! I was talking to a Japanese rep from Tokyo. She’s spent a few years in Boston before moving to Tokyo. Instead of saying who I am and what I do I asked her if she’s a fun of Kurosawa, a legend of Japanese and world cinema. It just came to me…I wanted to hear from a Japanese what she thinks about “dreams”, a very old movie based on eight (real!) dreams seen by the “master” Kurosawa. She… never saw the movie!!! What?! Its like an American who never saw “Casablanca” or an Italian who never saw “La Dolce Vita”.

So I had! to tell her one of the dreams…”The blizzard”…On a mountain top four men are trying to find their camp in the most horrible snowstorm…they can hardly see anything expect dense snow, they can’t hear anything but the frozen wind…they been struggling for three days…they are exhausted and start to hallucinate. Two already lied down in the snow and died. One tries to walk but has no idea where he is going. Then, suddenly, a beautiful Japanese woman in a kimono comes and talks sweetly to him urging him to lie on the snow and sleep. With her elegant, white hands is covering him slowly with sheets of fine silk, saying (nearly singing) “the snow is warm, the ice’s burning…” luring the man to sleep in the snow and ultimately death… seconds before this happens the man thinks “no! I must not sleep, I will find the camp!” and stands up. Suddenly the beautiful woman transforms into a horrible creature, the great gripper, and in front of the man’s strong will, evaporates in the snow. The man carries on and within the blizzard he finally spots the camp…he’s saved! The Japanese woman who was listening to me completely quite, put up her arm in front of me and said “Look, I have goosebumps!” that was kind of adorable. I find this a slightly better way to introduce myself than providing name and occupation…

The hydrocephalus conference was good, if I say I was excited it wound’t be accurate. Some talks were interesting, some were dull…that’s the norm with most conferences. But I saw so many old and new friends, we caught up. I got many invitations to go back and give talks to different universities in Greece, I happily accepted. One of the evenings we went with a couple of friends to eat in lovely little tavern near Mikrolimano of Piraeus, which was handy as the conference food was, well…, you already know…We drove by the sea, and ate fresh fish overlooking the sunset in the east coast of Saronic Gulf. My friends read my blog regularly and every time we were passing through some nice scenery they were saying “look! that’s a beautiful shot for your blog!” :-)… The following night we went with some other friends to walk in old plaka, a neighborhood beneath the slopes of Acropolis, narrow streets, cute taverns with tables arranged in stairs, smell of barbecued food, tourists eating frozen yogurt, live music every 2-3 minutes walk, people strolling leisurely like they have all the time of the world, all swimming in a hot, hot night.

Colourful taverns under the slopes of Acropolis, live music, on a hot summer evening

Colourful taverns under the slopes of Acropolis, live music, on a hot summer night

Four days later I was back to London. On Tuesday afternoon, 9 July I was giving a talk about present and future of Neurosurgery at the Queen Square Alumni, neurologists and scientists who excel all over the world having been trained at QS. They came from America, China, Australia, Africa…I told them about the recent past, our present, what we have achieved, what we expect from the future! Here’s a photo form that day.

Talking to Queen Square Alumni from all over the world on Monday 8 July 2013. I prefer to walk up and down rather than hide behind the lectern.

Talking to Queen Square Alumni from all over the world on Monday 8 July 2013. I prefer to walk up and down rather than hide behind the lectern.

On Thursday morning at 8 am, on the first floor of the education centre, I was standing in front of one hundred and twenty delegates who travelled from the four corners of the earth and along with guests and personnel were adding up to hundred and forty people. Ninety percent were senior neurosurgeons, Professors of Neurosurgery and Chiefs of Departments who came from Brazil, Argentina, Hong Kong, New Zealand, South America, Africa and all over Europe.

First day of the course, Thursday morning, setting the rules of the game with our 140 guests.

First day of the course, Thursday morning, setting the rules of the game with our 140 guests.

What we were about to do on that Thursday morning never happened before, anywhere in the world. We had live three operations from three countries (France, Germany and USA), one after the other, performed by three top surgeons (legends) in their own operating room with their own teams. Although we have been working on this for two months you would be surprised for how long it takes to solve technical problems. A huge number of people was working behind the scenes and except Germany the day before the course we had not done the final tests. “Four months ago I had a crazy dream…” told to my delegates starting my talk. “…”that today we will show you live in London three operations, three awake craniotomies from three of the world best surgeons…and you will be able to talk to them, ask questions and see their operative secrets….”. “Although a huge number of people have been working behind the scenes, with crews moving across France to Montpellier, and equipment shipped from Boston to San Francisco, the truth is that I don’t know if this will work today, there are so many steps that this project can go wrong…” “but I am prepared to take the risk…in life you have to take risks…if it doesn’t work I’ll be telling you stories for eight hours…”

Looking at one of the two screens and commenting on live surgery from Germany

Looking at one of the two screens and commenting on live surgery from Germany

We started with Hugues Duffau who was operating at an insular glioma on a young patient who travelled from Brazil to France the day before. We had picture-in-picture, big picture the brain, small picture the awake patient’s responses. I was talkative but Hugues not so much…(he later told me he was a bit nervous as he didn’t know if everything will work), I was describing was he was doing as I did spent sometime with Hugues a couple of years ago and know his techniques…for a few minutes we lost signal from France but I continue talking knowing that the signal will come back (and it did!). The first case finished in three hours, all went well. I sent everybody for a coffee break and got ready for the second country, Germany. Professor Stummer had two cases lined up, one asleep case using Gliolan and one awake again using Gliolan to identify a malignant focus in a low grade glioma. So we had to switch from one theatre to another which was great but the split signal lowered the resolution. My German guest-surgeons were very chatty, so there was a lot of banter and with two cases time flew…Both cases were successful, delegates were asking questions, the vibe was great.

I told everybody at the beginning the house rules, no talking, no commenting to people sitting next to them. I did tolerate a few whispers every now and again but three senior surgeons were talking at the back. I made a general comment to be quite, nothing, then I ask them if they had anything to ask. They said “no”. “Then stop talking!” I said back and didn’t think much of it. Later that evening, my registrar Sophie told me “that was fantastic, only you could have said that!”. I am not sure what was the big deal…but I had to be strict many times… with so many senior people around it is not difficult for a big meeting to get out of hand. I also put out a friendly vibe to the discussions, like a group of friends who discuss interesting questions…I’ve seen people being difficult and unpleasant in conferences and this is not what I wanted for my course, hence the challenge of striking a balance between friendly and strict with the balance tipping over to the latter…

The last live surgery for the day was from San Francisco, with a surgeon a legend, Mitch Berger. We had signal from America, Mitch appeared on our double screens with his scrubs (photo) and we had a little chat. In video-conferences there is a couple of seconds delay, so you need to give the other person a chance to talk but you get used to it very quickly. Mitch was moving without rush, talking without rush, with authority and experience. He explained the case, showed us the scans, introduced his team. He then started. His cameraman could not zoom in (!) and there was too much glare from the theater lights. For the first part we couldn’t see much in the surgical sight but we could see the set up, the choreography of movements…but when he brought the microscope in the views were spectacular. The awake patient was talking and performing tasks while Mitch was temporarily paralyzing the brain to map eloquent parts that had to be preserved.

Talking live with Mitch Berger in San Francisco just before he starts his awake surgery.

Talking live with Mitch Berger in San Francisco just before he starts his awake surgery.

On our London screens master surgeon Mitch Berger while operating live in San Francisco on Thursday 11 July, 7:30 am California time.

On our London screens master surgeon Mitch Berger while operating live in San Francisco on Thursday 11 July, 7:30 am California time.

The delegates were holding their breath seeing this unusual sight, a grand master surgeon in action. Its like hundred and forty people were standing behind Mitch Berger’s shoulder in the OR. In reality, even if they were physically present in San Francisco they wound’t see so clearly as they were in London. We started at 8 in the morning. It was now after seven in the evening. Mitch had not finished yet but he was close. Our delegates did not move but they had three more busy days so I let them go to get some rest and then go for drinks and nibbles at the Blu Radisson Hotel across the Education Centre. When the first day was over, I thought “that’s it”, the most difficult part is over.

Before we did this, every friend and colleague who knew about the project was telling me two things: first, “what a great idea!” and second, “it can go wrong big time!”. Yes, sometimes you do a simple presentation and you have glitches more than hot lunches, and now with this massive project…the kit could have problems, the signal could have been lost, the cases could have been cancelled because a patient had a chest infection, there might have been a major complication during surgery, the patient might had fits… And that’s times four, in four different cases in three different countries! But guess what! Everything that could have gone wrong, went well! But I was prepared, I was thinking if something had gone wrong, so what…human activities are full with imperfections and mistakes, if you are afraid to make a mistake then you wound never achieve anything…the fear of criticism stops about ninety nine percent of people trying to achieve anything worthwhile in their lives…

Here’s what I think: with the exception of patient care, its okay to make mistakes, its okay to fail, again and again, people who want to be “perfect” they “exist” but never “live”. When it comes to patient care you should always do what you would have done if the patient was a close relative, a beloved friend… but outside the operating theatre, be bold! accept your imperfections, accept your rough edges, only objects are super polished… And if you accept you rough edges, if you accept that you vulnerable and go for it anyway, a strange thing happens, people will support you and they will be attracted to you! That’s a fact, why it happens I don’t know… but I suspect! it is because only very powerful people can expose themselves openly and publicly to failure…

The following day, Friday the 12 July we had 3D anatomy shows. The 3D screen was made for us in America and shipped (just!) in time. The linear polarization 3D glasses with our logo which arrived the night before(!) despite ordering them a month earlier did not work! But I had foresee this and I had asked Guilherme Ribas and Antonio Mussi to bring spare pairs from Brazil. This could have been a disaster as all images are blurred unless you have the right glasses.

On Friday my guest surgeons had time to get in the plane and travel to London for the weekend’s lectures. Mitch Berger arrived the same evening. I met him at the lobby of St Pancras’ hotel. That’s the first time I met Mitch in person. Tall, tanned, silver hair, looked like a movie star. We met Hugues and took a cab to go for drinks and nibbles to the top floor of the Center Point in New Oxford Street along with the rest of delegates.

I wanted this course to have the best of everything, scientifically and socially, so the venues were outstanding! From the top floor with wooden floors and glass windows all around you could see stunning London, Saint Paul’s Cathedral, city’s sand Canary’s Wharf skyscrapers, the lit west end, an eye candy. Delegates were taking photos, eating nibbles, moving from window to window to indulge the night summery London.

Top floor of the centre point on Friday evening.

One corner of the top floor of the Centre Point on Friday evening.

On the 31st floor of Centre Point, having a drink (=water) with Hugues (left) and Mitch (right)

On the 31st floor of Centre Point, having a drink (=water for me) with Hugues (left) and Mitch (right)

View of the Centre Point Friday night

The city from the top floor of the Centre Point Friday night

The weather all days was fabulous, sunny days and hot evenings, you could see parts of London miles away. One junior resident from Croatia looking at this glorious view from the top floor of the centre point asked me “how did you come from Greece and made it here?”. Now, that’s a question!… Hard work? High IQ? Dedication? Lots of energy? No, that’s not it, many, many surgeons have these ingredients, (that’s the absolutely minimum), but they don’t go very far…”You have to be able to tolerate pain…” I told her. She looked me surprised…No, I was not talking about backstabbings, that starts even from medical school and carries on (yes, I have quite a few deep scars in my back and a few in my forehead, but its okay…), I was referring to something else. Every time you go one step further, every time you push your limits… every time you risk to stand out, you risk to stand alone… and this can hurt…failure is uncomfortable but so is success…  at least until your mind catches up with the new reality… until your next challenge and your next success! anything outside your status quo can hurt! this is how brain is designed, to keep you where you are now! your primitive brain does not want you successful, wants you safe, and that is where you are right now, stagnant…you also need people around you, people who like you and share your dreams…but do not expect for other people to believe in you unless you believe in yourself first, and I mean really! believe in yourself.

On Saturday 13 July, I was standing in front of the delegates to introduce Mitch Berger. How I was reading his articles and books during to my residency years to the present time, how he influenced thousands of neurosurgeons worldwide and how he shaped neurosurgical oncology all over the world… I also told them about the time as a junior resident I emailed him for the first time asking him to write the neuro-oncology chapters in my (bestselling!) “Neurosurgeon’s Handbook”. Me, a completely unknown resident and him, the most well known oncological neurosurgeon on the planet. I’ve sent him an email expecting to get an answer days later…I saw a reply in my inbox within two hours… That must be a quick “no”, I thought! It was an easy “yes”!… Then I asked him to come to the lectern and give his talk with rounds of enthusiastic applause for the eager delegates. Mitch did a beautiful introduction and thanked me saying that “George since his residency has evolved into a wonderful colleague and wonderful friend”. I know I was running the course but while sitting there I was thinking to myself “is this my residency hero Mitch Berger talking about me?!” Mitch is a great speaker, speaks with ease, authority, and pace.

I had invited to the course the best neuro-oncologist in the planet, Roger Stupp who validated the use of temozolamide in glioblastomas, the most important advance during the last fifty years. Roger, a passionate Swiss was an animated speaker and his contribution to round tables was lively! I had also invited the best neuro-pathologist in the planet, Andreas von Dieseling from Heidelberg, the man who discovered the 1p19q prognostic deletions in oligodendrogliomas, the IDH1 mutations in transformed low grade gliomas, the EGFR amplifications, you name it, he found it!

Co-ordinating questions after Andreas von Diemling's lecture

Co-ordinating questions after Andreas von Diemling’s lecture

Round table discussion with our expert panel

Round table discussion with our expert panel; I am coordinating standing with (left to right) Stupp, Duffau, Berger and Rees.

Every afternoon was were having lunch at the Blu Radisson at the top of Tottenham Court Road. I had striken a good deal with the managers, so we had three course hot buffet lunch. But I faced a little problem. The queue of 140 people was straitening from the restaurant to the pavement. And with three courses the had to queue thee times. This wasn’t a goer! So I asked them to put starter and main on the same plate and keep moving, this was not time to chat. We had one hour only before they went back to the course.The food was excellent, great presentation and impeccable service.

Lunch time at the Blu Radisson Hotel

Lunch time at the Blu Radisson Hotel

On Saturday afternoon we split the delegates into four groups for four hands-on workshops: cortical stimulation, ultrasonic aspiration, fluorescent dye and topographic skull anatomy. The program was tight, so I was strict (again!) to move groups from room to room in time.

Professor Ribas from Brazil discussing the topographic anatomy of the skull

Professor Ribas from Brazil discussing the topographic anatomy of the skull in one of the four workshops

In another workshop, discussing cortical stimulator with Mitch Berger

In another workshop on Saturday afternoon, discussing cortical stimulator with Mitch Berger (standing opposte to me on the left)

One of the brief coffee breaks

One of the brief coffee breaks

Do you know what impressed me more than anything watching all these great surgeons and clinicians, the best of the best, during my course? Here it is. How these extremely knowledgable people, when they were not lecturing and were just sitting in the audience, they were completely absorbed by the speakers, sooo eager to learn! They asked me for copies of other speakers presentations at the end! Professor Ribas told me the only downside of his anatomy workshop was that he couldn’t attend the other workshops! Professor Berger was dissapointed to miss Prof Ribas’ lectures during his flight! The stamp of great thinkers is that they always want to learn more, no matter how much they know and high they have climbed. A couple of years ago I attended a 7 am toastmasters workshop in central London. Do you know who were the only other ten people who attended the early morning workshop (open to all)? Very, very articulate top CEOs while their “busy” employees opted for a an extra hour of sleep or just they couldn’t bother or they think they were articulate enough, or any other excuse that came to their mind. But you see there is a reason why some people are CEOs and some are not, life always works this way, its never chance or luck!

During the discussion Mitch Berger stood up to make a drawing at a flip chart. I wasn't sure if Panos (the medical student who was taking the shaky photos) would get it, so I used my iPhone to capture the unique moment.

During the discussion Mitch Berger stood up to make a drawing at a flip chart. I wasn’t sure if Panos (the medical student who was taking the dark, shaky photos, okay Panos you took some good ones too) would get it, so I used my iPhone to capture the unique moment.

Faculty and delegates on the first floor of the UCLH Education Centre. Look at the attention of Mitch Berger and Hugues Duffau

Faculty and delegates on the first floor of the UCLH Education Centre. Observe the attention of Mitch Berger and Hugues Duffau

Saturday night was time for the formal dinner. I asked them all to dress formally, tie for the men and evening dress for the women. Some of them had to leave the last workshop to go to the shops… One neurosurgeon from Norway sent her husband to buy her a dress! The dinner was at the top of Milbank tower, in Westminster with breathtaking views of the Big Ben, the river and House of Parliament and greater London. This is a place you cannot go privately, its only booked for big functions.

Having a drink at St Pancras bar with Mitch (right), Hugues, Andreas and yours truly before going to the Saturday night dinner.

Having a drink at St Pancras bar with Mitch (right), Hugues, Andreas and yours truly before going to the Saturday night dinner.

On the way to Milbank tower with Mitch, Andreas and Hugues, Mitch could not believe how many people were in London streets. We got off half a mile before the venue to walk by the summery riverside and also for Mitch to light up with Cuban cigar we got earlier at the St Pancreas bar. I could not join him, I haven’t smoked cigars in years and I hadn’t had alcohol in five years… At the “360 view” restaurant delegates from all over the world were beautiful dressed, sociable and very happy. When the years go by, they will remember seeing live great surgeons performing awake craniotomies. But they will also remember stunning views of a summery London on a few hot July evenings…everything matters!

I’ve opened publicly one of my dropbox folders for you to browse more photos from the course: https://www.dropbox.com/sh/4urfgfasvmg9i9i/MeKTs50V6_

Saturday night dinner at the top floor of Milbank tower.

Saturday night dinner at the top floor of Milbank tower.

The German group: Prof Szelzinsky, Prof Sobel and Prof Stummer among others. Look at the view at the back: Big Ben, House of Parliament, and the wheel. Which other place can offer these views?

The German group: Prof Szelzinsky, Prof Sobel and Prof Stummer among others. Look at the view at the back: Big Ben, House of Parliament, and the wheel. Which other place can offer these views?

Views from the Milbank tower window...

Dusk on a hot Saturday evening as seen from the Milbank tower window…

The feedback was amazing. Delegates said that this “wasn’t the best course we’ve ever been, it was the event we’ve ever been” or “we didn’t want to miss a minute!”. By Sunday night, 14 July it was all over, we went for a last drink with Mitch at St Pancras and made plans for the future. Monday morning, 15 July back to work, seeing my patients, teaching my trainees, planning operations… From my trip to Athens to the end of my course in London, that’s what happened during those two weeks (well, some of it…) Tuesday afternoon, 16 July I was off to my afternoon oncology clinic to the UCLH Cancer institute. I normally walk, its about ten minutes walk from Queen Square across the University Campus. While walking past Russell Square I saw dozens of people sunbathing and lounging under the sun in the park. Was I jealous and temped to do the same? Work and play are both needed, but lying on a park will give you only temporary comfort and fuzz, which its okay if that’s what you are looking for… but some people are looking for the adrenaline rush… that severe challenge… and then another one…and another… and somehow… I know exactly why!…

Russell Square park on a Tuesday afternoon

In the heart of central London, Russell Square park on a hot Tuesday afternoon

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