The Gates of Happiness

Wednesday evening I suddenly realized that I was walking with my hands in my pockets. I don’t like walking with my hands in the pockets. It feels like a defense, like you are protecting yourself from something (and a bit lazy)! I then felt that my arm muscles where aching. It then came to me: I spent most of the day with my arms stretched above my head during a long operation. A woman with a giant tumour in the most awkward part of the brain, half of the tumour above the “tent” a tough membrane that separates the cerebellum from the back of the brain or occipital lobe and half of it below the “tent”. The tumour was compressing the brain stem, the clockwork of the brain. The whole area is densely populated with important arteries, deep and superficial veins, crucial nerves. Try this, put you hand at the back of your skull, roughly at the level of the top of your ears, in the middle, and feel a very thick bony spike. This is the thickest part of the skull. Its thick for a reason, because it has to protect the joining point of all veins at the back of the brain, the confluence of sinuses, described by Herophilus, a great Greek anatomist of the fourth century BC. These veins stuck and burred in the skull should be completely exposed; tearing even a small part of them will cause major stroke or death.

To make things even more complex the whole operation should be made with the patient “sitting” while asleep, a nightmare for anesthetists (but not mine very experienced anesthetist) as air can be sucked into the veins and trapped in the heart, causing sudden death. When the surgeon operates in the sitting position he should be looking from below up and his arms are stretched. Try something else now: lift your arms up so that your elbows are at the level of your shoulders and your hands are above your head. And time yourself. How long can you keep it like that? Three minutes? Four minutes? If you can keep it more than five, do let me know! The surgeon should be in this position, on and off for 8-9 hours while walking through a minefield, a wrong small step and a disaster happens. American colleagues usually need double that time, slightly different schools of surgery. Time does not matter. As a matter of fact, when you start difficult operations, time disappears. Nor you feel hungry or thirsty or with a full bladder. Time is irrelavent. Einstein was correct, time contracts! The only thing matters is your determination to remove the tumour, identify and protect all vital strictures buried in the tumour and bring the patient from a risky sleep back to their families.

So yes, my arms were hurting a bit that evening and while walking I felt tired. It was a lovely evening. I saw some steps in a Victorian house, next to the pavement, I sat down. I had some dried mangos in a bag, they were very sweet. I thought again about the operation of that day. All went well. Is this why I wanted to become a neurosurgeon? Is this why people want to become neurosurgeons? The challenge? the nearly impossible? the adrenaline rush? Is this the same reason that physicists study particles (that if Einstein was wrong they shouldn’t reach the surface of the earth) and look at the origins of the universe? Are they trying to see the face of God?

Sunday I took some guests to Hyde Park. No better way to spend a sunny Sunday in London. Start from Marble arch in the speakers corner, where various people make a speech about absolutely everything and everybody else argues with them. Of course its cool to believe what you want and be brave about it but what’s the need to convince others that they are wrong, do you really need to save them? (photo) If you’ve never been to Hyde Park have a look at the triathlon in the July Olympics, it takes place around “the serpentine”. A very specific tree on the hill overlooking the serpentine is my favorite spot in Hyde Park.

“I am right, you are wrong!” “No you are wrong, I am right!”. What a wonderful non-sense.

Talking about arguing, I remember a story I read, when I was at school, on a Greek literature magazine called “Tetarto” (very cool) which is greek for “Quarter”. Here’s the story. Long, long time ago in the far east a very old master and ruler was meditating in his quarters. He was known to the whole country for his fairness and good judgment. His hair and his sparse and long beard were snow white. By his feet a young apprentice was sitting quietly. Suddenly a man enters punting his quarters and starts talking furiously. “My wise master, something terrible happened, my neighbor came to my house, hit my wife and children, killed my animals and burned my house down. I want justice!” “You are right my poor man”, said the ruler, “go back to your family and I will give you justice”. Not long later, another man enters in a bad state and upset says “Please give justice to me and my family my wise ruler”. “My neighbor treated badly my family, let my animals loose and burned my house down”. “I am sorry to hear that” said the master, “you are right, I will give you justice”. When the second man left, the apprentice who was watching quietly, said: “Forgive me wise master but I don’t understand! Two people came and asked for the same but opposing things and you told them they are both right! How is that possible?” The wise master opened his eyes for a brief second and said “My young pupil, you are right too!” and closed again his eyes to continue his meditation.

Tuesday I operated on an adolescent boy in the intraoperative MRI suite. He had quite a few operations earlier by other surgeons. The anatomy was distorted and the main arteries in the left and dominant side of his temporal lobe had fallen into the cavity at unexpected places. I find that no tumour cannot be removed with a Rhoton dissector number 8 and a low setting suction. neurosurgery is not just about what good you can do but also the harm you can cause. Damaging one artery hidden by a wall of tumour could cause this boy to be paralyzed down his left side and loose his speech, for the rest of his life. But this did not happen. Then, a woman who became depressed a few months earlier and her behavior was unusually strange had a scan that showed a very extensive tumour in her brain. I removed most of it on Wednesday.

Thursday was the BMA strike. On Thursdays I have routine outpatients clinics. I felt that I should take a stance. Not for the outcome, that was irrelevant but for the principle. Money are not important. At least that’s how I was raised. Principles are! Principles always weigh much more heavier than outcomes. At least in my mind! So I took part in the strike as a principle. I did go to the hospital as usually, did my rounds, rescheduled my outpatients clinics and got a pay cut for that day! But took an action as opposed to non-action. Somehow my brain is programmed with a bias to action, one of the reasons I became a surgeon!

Trying a new ultrasound based neuronavigation (gold star on the right) in addition to standard navigation (blue star on the left) on Friday 22 June 2012.

Friday two more operations. A young man had a fit at the airport just after security check. He was known to have a low grade astrocytoma but the scan showed intense enhancement, usual indicators of higher grade and hence more aggressive tumours. There were quite a few cystic components, so perfect indication to try a new equipment called SonoWand, an ultrasound-based neuronavigation (photo). It proved to be much more useful than I expected (sorry for my doubts Robin!). Robin is the rep who corners me in every conference and meeting and tries to give me 30 mins presentations in 10 mins coffee breaks. But you are right, it is useful! My second patient was an elderly man with a tumour in the left side of his cerebellum, close to what is called cerebelopontine angle, a space between the cerebellum and the pons, part of the clockwork of the brain. Then ward round, dictating replies to letters, answering emails. It was Friday late night, the weekend had landed!

It was time for blue skies and sandy beaches, time for a few days off. Quite a few friends were bragging about Sicily, how “its like Greek Islands!”. OK then, Sicily it is! We arrived Wednesday evening in Palermo. In the main arrival hall a massive (theatre-like) poster with “Mafia” as a main title (photo). We had no idea what what it was advertising, so we maid up a few translations :-) “Sicilian Mafia welcomes you in Palermo!” or “If anybody mess with you in Palermo, call little Tony, competitive prices!” or “No job is too small or too big for us! call Pepe on this number” :-)

“Sicilian mafia welcomes you to Palermo”

They often say that the Sicilian “Godfather” is the greatest movies of all times. I never saw the movie more than once, so I have my doubts! Talking about Sicilians in movies, there is a scene in Tarantino’s movie “True Romance” where Denis Hoper cornered by mafia in his trailer, tries to talk himself out of being shot and saving his son who messed up with Walker’s “business” and is hiding somewhere. Walken instantly figures out that Hopper is lying and tells him how “sicilians are the best liars; I am Sicilian! you cannot lie to a Sicilian!”. Then Hopper goes on to tell the most magnificent story (and an obviously blatant lie!) and while having a last drag of his Chesterfield cigarette, knowing that he will be shot seconds later, says completely cool! to the “Sicilian” Walken: “Now tell me! am I lying?!” Astonishing performances! What a fine moment in cinema!

Christopher Walken as Vincenzo Coccotti “I am Sicilian!” Magnificent cinema!

Palermo is full of little streets, buzzing Italians, street markets in very! narrow streets (photo). People walk densely the market streets, there is hardy any space to walk. Then out of the blue a scooter tries to go through these streets, starting and stoping, and trying not to run over any pedestrians. How bizarre!, you think. Until you see two scooters coming from opposing directions in the tiny crowed market street. And then three scooters! This can’t be happening! Then a Fiat Pundo!, oh my God you think, they will kill someone. Everyone acts normally though, just moving their feet the last second so the car can squeeze through. And then, can’t believe our eyes! a Van! That’s it, time to get out of here, before a bus appears! Off to Porta Felice, we had no idea what exactly meant but we made something up, again: “The Gates of Happiness”.

Street market in Palermo. No, not for pedestrians only! Look out for scotters, cars, vans and… buses!

In Palermo (and most Italian cities for that matter) most people drive tiny cars so they can park everywhere, and I mean everywhere (photo) but (sorry Italian friends!) they are sloppy drivers (photo). Most cars have dents! (Perhaps not as sloppy as Moroccan, where you think if you stand on the street for five minutes you will! witness a couple of spectacular crashes! That said after 4 days days in Marackesh and no car crash to witness I thought something was terribly wrong about my views on driving until on the way to the airport a crash finally restored the order of the world. Nothing serious, except from the drivers arguing in very loud arabic).

No space to park? No problem! That’s what pavements are for! Life should be that simple!

Saturday night in Via Roma. The result of some fine Italian driving. Italians gathered around the scene in seconds!

Back to Italians, who also love driving scooters. Thursday afternoon two big! dudes in their fifties, riding massive scooters, some short of local “rebellious” easy riders, stopped in the middle of a small street one next to the other, all macho and ready to have a chat about kicking someone’s… backside (we thought!) but instead they …kissed on the cheek! :-) That didn’t go as we imagined! By the way, Italians kiss once (not just overweight dudes on bikes, but everyone), French twice except Parisians (three times), Dutch also three times, Greeks twice, Brits…variable (you have to take the lead!). No need to know exact kissing etiquette, just improvise and as long as you act natural you will pull it off.

Looking at the sea from a Sicilian beach

There are few good beaches in Sicily, Mondelo and Cefalu for the locals, S Veto (Sicilians say its the best beach in Italy) and Taormina, quite far from Palermo. Blue waters, clear skies (photo); small shops, with Sicilian souvenirs “made in China”; simple restaurants looking at the waters (photo). You feel the hot air hitting your face; sweet smell of sunblock on the skin; North Africans selling cloths, umbrellas, toys (and whatever you can imagine!) on the beech; takeaway pizza, slim base, tomato sauce, cheese.

You ask for directions, “where is piazza Marina?” for example and locals start to argue between them which is the shortest way (as far as we understand by the hand movements), with the fingertips of both hands like five-finger pinch, forth and back and shouting in Italian. We haven’t got a clue what they are saying. Then they shout “Antonio!, English”. From within the crowd, suddenly Antonio emerges, cool, riding his… stationary scooter with the engine off, full of importance. People are making space for Antonio’s scooter pushed by his feet. We were psyched up that Antonio will be super fluent. That’s it we’ll get our directions! After a pause Antonio begins: “me, English no good!”. “Go…erhh… bread… store, Guiseppe parlare English!”. Top marks for the effort (and the drama!) to Antonio!

The view from the veranda of a simple garden restaurant. Do you feel the hot air hitting your face?

I had three books with me, for light summer reading and to hold some sand grains trapped between pages like unique souvenirs: Frayn’s “Skios”, Asimov’s “The end of eternity” and Dalh’s “George’s Marvelous medicine” that my registrar Victoria gave me as a Christmas present when i took my team out for a Christmas lunch last December. Skios was a comedy of errors and mishaps, mistaken identities between a professor and a charming (and “harmless”) impostor, American, Russians and of course Greeks, as the whole plot tales place in the imaginary island of Skios. (In case that the island does exist! and you live in it! please do let me know). It was like reading the script of a comedy, I am sure someone will turn it into a summery movie.

“The end of eternity” one of (genius) Asimov’s masterpieces revolves around Andrew Harlan, a “Technician”, very powerful member of an exclusive organization that can travel through past and future centuries and alter cause-effects relationships. At the beginning Harlan was moving towards the 2456th century! Whoa! Can you imagine how life will be not in two and half thousand years from now but in two and a half thousand centuries!!! I am still reading it on the plane (had to stop to write this blog), but it looks like Harlan meets Noys. What do you know, in 2456th century love still exists! I did not have chance to read “George’s marvelous medicine” (sorry Victoria!) but its now at the top of list for my next break.

Out the plane’s window the afternoon sun glows on the Adriatic sea. It must be summer!

Wednesday was the take off, Sunday touching down in Heathrow, that is three days in the beach plus two days on the road and air (also fun). So was it like the Greek Islands? No way!!! So my dear blog readers (you are now nearly 10,000) go for the real thing! The most spectacular day light on the planet, the most seductive blue you’ll ever see! I will report live from there before the summer ends (and finally read Victoria’s book!).

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