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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