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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