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uh, thank you for joining us today. I'd like to welcome you all to another session of back to the future. Um, this week, um, we'll be having Mr Ravindran Vice Agan who will be presenting on neurosurgery this week. He's in ST six at Saint George's Hospital. And, uh, surgical technique that will be going through today is debridement of wound. Before we start off with the video, I would like to say a big thank you, uh, for asset for sponsoring and developing this course along with us. Like to give a big thank you to m d u for sponsoring us. Uh, and another big thank you to medal for giving us a platform to provide you with certificates and to give feedback forms as well. Um, without further ado, do I'll start the surgical video which were on the Brighton of surgical wounds. So I'm just gonna Oh, gosh. Apologize, guys. Just but wounds debride more contaminated wounds require thorough assessment and management. Inadequate weed management can result in subsequent infection and a worse necrotizing fasciitis by not forming adequate deprive mint. Initially, the final wound can be much larger than would otherwise be achieved. Start by inspecting wind and reading obvious foreign bodies with your forceps, make sure to work around the entire wound, clearing debris and make note of any structure that should be avoided. Were handled delicately. Windrell tractors such as Langan backs can improve visualization of the deep components. Be cautious if our painting, as there may be sharp objects in the wound. Once you have removed most of the gross contaminants, irrigate the wound with plenty of water and using swabs. Although be careful not to push foreign material deeper into the wound. Now inspect the wound again, removing any further contaminants. Any dead or devitalized tissue will need to be removed. You can do this with a combination of your four steps and a scalpel. If the tissue is not bleeding, then it suggests that this tissue is unlikely to be viable. You will notice that this Tesco's finest pig leg does not, in fact have an active blood supply so can't really accurately demonstrate this. In general, it is better to remove too much tissue than removing too little bone fragments and devitalized bone should be removed to trying to avoid taking too much periosteum. Make sure to be systematic dividing the wound intersections to ensure that you have cleared all areas of debris and have checked under any over hanging tissues. Further irrigation is required to remove any further dirty and contaminants from the wound before packing the wound and leaving it open. If there are any concerns at all about ongoing infection. Plan to return to theater in 24 to 48 hours. Multiple visits are often required to achieve adequate control. Common pitfalls. Inadequate irrigation Can predispose to infection. If you think you've irrigated enough, just try irrigating it once more when packing a wound. This should be done gently. You're providing a conduit for exhibit and discharge to escape the wound and do not want to ram the packing into the wound. This will block it. And finally, without systematic inspection, removal of foreign bodies material can be left behind in the wound, leaving a site for infection to develop. So that's a video on debridement of a surgical wound. Um, now, without further ado, do it gives me great pleasure to introduce you to introduce to Mr Ravindran BresaGen, who's a neurosurgical registrar ST. Six at Saint George's Hospital in London evening. Everyone thank you for the kind introduction. I'm just going to share my screen catch. Right. So, um, we're gonna have a hopefully a cleaner perspective of surgery. I remember learning my wounded debridement as part of the basic surgical skills course that I'm sure that all of you will be enrolled on at some stage, Neurosurgery is a little bit more refined and hopefully a bit more clean. And I'm here basically to convince you that it is, uh, one of the most popular subspecialties that you should be looking at. Um, we'd like I'd like to keep it interactive. So there's a There's a few kind of business slides that we need to get out of the way. Just talking about structure of training and stuff like that. Just for people who are interested in thinking about neurosurgery. Uh, we'll do a few case based discussion's and I have a video to show you, which is quite close to my heart. Um, so this is the overall, uh, structure of training in the UK for neurosurgery. It's traditionally, since I've applied. Anyway, I got into neurosurgical training in 2015, and it's been it's been what we call a run through training program, which means you don't do a separate S H O program for a couple of years like course surgery and then apply. You tend to you get in at ST one and then it's called Run Through because all the core skills that you need are built into that program. So, as you can see on that diagram, we have what's called core neuroscience training, initial general and then final training and the latter end of training. Uh, and I'll explain. This is more focused towards developing what we call a sub specialty interest. And one of the things that really drew me to the neurosurgery is the diversity. There is literally something for everyone. Um, that link that I have there, the nationally coordinated the Yorkshire hum Burdine ary website. Take a photo of it if you're thinking of applying because it holds the information to the specification and the matrices that we have to enable us to apply. And if you want to target your application and get a head start, that's where I would go. So what's it about? As I said, there is something for everyone. Um, you finished a training towards the end, you get your F. R. C s in surgical neurology and that that that term surgical neurology or surgical neurologist it's probably an outdated term. You know, we're not just neurologists you can operate. Neurosurgery is a very surgical specialty. I didn't really understand what that meant when people used to tell me that when I was at your stage, Um, it builds on all the general surgical principles. I mean, you know, even wound debridement is really important in cranial trauma, spinal trauma, I think that kind of degree of blast injury or any really see on the battlefield. It's not something you see in, uh, in London so much, but, you know, never say never. Um, it's tertiary. So it takes place in big, busy trauma centers teaching hospitals. There's a heavy inpatient workload you're looking at working on the wards. You have pediatrics. Intensive care is outpatient clinics, and it is truly multidisciplinary. Um, the last case I did on my night shift. Um, I was operating at the same time in the middle of the night with a consultant, ophthalmologist and an EMT fellow, and I was operating on the brain. The ophthalmologist was operating through the orbit just in front of me. Uh, the ent surgeon had to wait patient because obviously the brain is is more important than the nose. Um, it is a diverse specialty. You are literally operating on patient's as young as foetuses. Pre prenatal. So mothers with Children proven to have myelomeningocele is that's where MMSC stands for all the way through to elderly patients who have chronic subdural hematomas. They can get degenerative conditions of the spine. And finally, it's high stakes. It is, um, there's a lot of working under pressure and you need to be quite comfortable with if you're someone. There is a personality I think associated with being driven towards working in high pressure environments, and I think neurosurgery. That's where it's different, I think, to certain more elective surgical self specialties like ophthalmology or E N. T. Um, it's diverse in terms of the surgical approaches. You have open approaches, craniotomy, knees, spinal. We do a lot of spine. Okay, I didn't appreciate this at your stage. So, uh, 60 to 70% of what neurosurgeons do is spinal surgery. We have cameras and fancy toys and tools that we endoscopes and and things that we can use also in cranial and as well as spinal surgery. And now robotics is is becoming increasingly popular. I've seen robots do procedures in functional neurosurgery where you have to be really, really precise to treat things like movement disorders and dystonias. I'm gonna quickly whiz through this, but basically this is again something for everyone you have, vascular. This is your kind of high octane microsurgery. You know, the art of neurosurgery, Beautiful anatomy, vessels of the circle of Willis aneurysms. Very sick Patient's brain tumor's. Okay. People have often accused NeuroOncology, as you know, having poor outcomes. You can't cure brain tumors. But, you know, I would argue that pediatric neuro oncology, if you can with the right histology and you can get in early and you get a good reception, you can cure the patient for life with effective radiotherapy postoperatively skull base surgery for me. I mean, it's one of the best anatomy and really, really special. You were working with other surgeons like I was explaining earlier spinal surgery. Um, the thing I like about spinal surgery and my PhD is a spinal cord injury. Um, is there If you select the right patient and it's all about patient selection, you can have good, functional outcomes and you can return them to a good degree of function. The caveat is, there's a lot of private practice, which is not always a good thing, because you can be biased in your decision making. And there's a lot of sharks out there, so a lot of people get sued. And finally, this is, uh, something that is a bit too clever for me. But this is functional. Neurosurgery tends to attract the really academic, more neurology minded people, in my opinion, who want to cure certain conditions or target specific areas in the brain, which can lead to good outcomes for certain specific neurological conditions. And then, of course, pediatric neurosurgery is a is A is a completely separate entity in itself. We're gonna go straight to a case so hopefully we can try and make this, um, interactive in a way. So first is a vascular case. 40 year old female presents to the ent department. You're the casualty officer or a N E S h o or surgical resection on call transferred to the AM You you probably would be the Medicare set. You're on call. The presenting complaint is that of a sudden onset occipital headache. They've had a transient loss of consciousness and meningism, which constitutes photophobia what we call nuchal rigidity, which is stiffness of the neck. Does anyone want to, uh, volunteer? What might be the most likely diagnosis if you can just type the answers down onto the chat box? So someone has mentioned migraines, migraines, good thought. It's on the differentials. Shh. Subarachnoid hemorrhage. Well done to the person Iona who came out subarachnoid hemorrhage. Meningitis also is, um, I I agree. Now, I I I see why a couple of you're saying meningitis and migrants. All of these are very, very good differentials. Meninges, um, is irritation of the main engines. Okay. And that can be irritated by infection. Like meningitis can also be irritation from blood. Okay, blood is a metagenic. It makes you vomit, but it also causes meningea irritation. Given this is a neurosurgical presentation. Subarachnoid hemorrhage is what we're getting at. Anyone has it to guess why the patient had a loss of consciousness. Why would you lose consciousness with subarachnoid hemorrhage? Very few things that can knock you out. If anyone wants to volunteer a guest in the chat box. No. Okay. Um so what? Physiology is important? And first principle. Also, this is an equation that if you're interested neurosurgery, you should learn cerebral perfusion. Pressure is your mean arterial pressure minus your intracranial pressure. What happens is when you have a subarachnoid hemorrhage or an acute vascular event, your interest, your intracranial pressure spikes, Okay. And if it spikes up to a to a degree, which is high enough, Okay, Higher than, uh, because your mean arterial pressure is derived from from your diastolic in your systolic when you subtract the intracranial pressure, if it is below about 40. If your CPP is below about 40 you you generally tend to lose consciousness because that is the provision pressure needed to maintain consciousness. You always maintain an A B c D approach, so a I will just minimize the chat for a second. I'm not going to read all of this out, but suffice to say that this is all the kind of stuff that you will be documenting in your review. For us, as neurosurgeons were very important, we're very concerned with hemodynamics status. The patient is hypertensive. Interestingly okay. And often you need to generate. Because of that equation, you need to generate higher mean arterial pressures to perfuse the brain. That's why they're That's why the BP is high. The systolic and also they may be in pain. They may have a headache. G. C s is 15. We like to break down the G. C s into the eyes. Verbal and the motor score and papillary response is very important in neurosurgery, its prognostic So an examination, the cranial nerves, they have the right third nerve cranial palsy. Anyone ever think why they might have a right third cranial nerve palsy and a volunteer? The in the chat, Any guesses? It seems that people are feeling a bit shy this evening. Okay, so there could be several possibilities why, that is, and we'll go for it. But other than that, the the neurology was normal investigations. Uh, you always do. Sodium levels. Sodium is very important again in neuro critical care. Your neurosurgery. Some of those just posted something in the chat increased. I C p um, yeah. I mean, you tend to get six. No palsy, actually with increased ICP. So six, no palsy is we call a false localizing sign. Not so much third nerve palsy. Um, chest X ray E c g. What I'm getting at here is problems in the brain affect everywhere, okay? They affect the heart. They affect the lungs, they affect the kidneys. So having a good knowledge of medicine is very important when you're when you're training as a neurosurgery s h o u m, I think it's I mean, I would argue that every surgeon needs to have a good working knowledge of acute medicine, but it's really important in neurosurgery because it has systemic effects. Okay, this is the initial scan, and what we see is that all that white stuff in the star shape is the diffuse subarachnoid hemorrhage. You've also got these, uh, blowing up early, blowing up with the temporal corns, which are the ventricles. All right, it's what we call hydrocephalus. Causes of subarachnoid hemorrhage, saccular berry aneurysms. Okay, that you may have heard of arteriovenous malformations and rarer causes. Okay, so you have dissections, vasculitis, the remit of the neurologists, reversible cerebral vasoconstriction syndrome, being a Sinus thrombosis, cocaine and non aneurysm or subarachnoid hemorrhage in about 10% of cases. That tends to be a venous phenomenon. What? We turn Perry Mason Catholic hemorrhage. So the patient is stable. You've stabilized her. You've picked up the diagnosis, you start IV fluids. You start them on this calcium channel blocker, which helps to prevent something called vasospasm of these cerebral vessels. She then drops her conscious level Had GCS is now eyes, not eyes not opening. Okay, she's making some sounds, Making some small words, Uh, and she's localizing. All right, Your differential tools in this situation include a re bleed from the aneurysm hydrocephalus seizure, drop in sodium level basis spasm. Although at this stage, you wouldn't expect basis spasm when you repeat the scan. This is the initial scan. This is the repeat scan. I I hope you can all appreciate that the frontal horns these structures here are ballooned. We actually call these Mick Mickey Mouse ears. All right. It's a sign that you see all right, it's a sign of a progressive hydrocephalus. Several options here where you can drain, drain off some CSF by a lumbar puncture or an external ventricular drain, which is a procedure under generally under general anesthetic or you pop a drain into the venture. So you speak to me. You refer the patient in an excellent manner, as I've explained, and I accept the patient and I put in a right frontal e v p. Okay, which is an external ventricular drain. What the patient effectively needs is an angiogram to look for an aneurysm. And you can do a non invasive CT angiogram with a dye where they look at the venous arterial phases and a formal digital subtraction angiogram where you give a formal diets done under sedation, and then you take multiple pictures. Okay. Treatment of aneurysms is now modernized in the sense historically was always neurosurgical craniotomy window in the in the skull dissection down the Sylvian fissure down circle of Willis to localize the aneurysm and place this silver titanium clip around the aneurysm head. And you can see this is a ruptured aneurysm. Okay, And this was the what I describe early as the art of neurosurgery, and you were as a resident or a trainee, you were measured by and in those days, the amount of aneurysms you may have clipped. Nowadays, the radiologists have, um, found clever ways to do this minimum with a minimally invasive approach. Small incisions in the groin catheter technology has progressed. They can take the catheter all the way up to the brain and fire these coils, which induces a a sort of thrombotic effect within the aneurysm and the aneurysm thromboses off. Okay. And this there's a big trial called ice it, which basically randomized patient's to these to these treatments and found different outcomes. But they found that the coiling was in some ways had a had a more favorable risk pro well, compared to the, uh, clipping, but also the rebleed, um, rates were slightly higher in the, uh, the coiling up. This is an example done by one of my former bosses at King's and Mr Kalai Vasan. Uh, and what you can see is this is what it looks like in real life. All right, so this is a microscopic view of the internal, uh, cerebral, very internal carotid artery. Just, uh, just here. Okay, This is a very difficult aneurysm to tree. It's what we call a blister aneurysm. And what you have to do is put a clip on the side and he's done a very clever, um, fenestrated clip, which is just going around the blistery aneurysm here. All right. And these are some reconstructed, uh, images from the CT A. So another, another case. Again, I'd like to keep an interactive if possible. As I said, 60 to 70% of what we do is spinal cord stuff. And obviously, I'm quite passionate about this because this is what my PhD s are. So you've got an 18 year old man presents with left arm numbers. I want you all just to try and think a bit like a neurologists. What do neurologists always ask? They asked to localize the knee. Jha. He's also had a non specific headache, which is worse on coughing. It's difficulty feeling objects, pens, pencils, buttons with his left arm. Left hand. Sorry. On examination, you've noticed the left hand sensation. Left arm sensations decreased in pinprick and it crosses the sense of the sensory deficit. Crosses across the left upper chest to involve the right shoulder pin. Prick is normal in the lower half of the body rest. Rest of the examination is normal. No motor deficit. Vibratory sense joint position. Sense normal. Now, I I really do hope that you all know this diagram in the top. Right? So this is very important. You would have learned it in your second year of medical school. Hopefully for the first or second basic neuroscience classes. All the localization spinal cord attracts. Okay, because if you know that you can work out what the problem is and what's going on. So, um, if you if you if you need to localize this lesion, there's very few things that cause this classic distribution of sensory loss. Okay. And I've given you a clue here, but this is where the problem is. So this is where you've localized problem. So this is a more of a high level question. Does anyone want to guess where the or what the problem might be? 18 year old male. What by might be causing a lesion here. Any possibilities? Differential diagnosis. Just type your answers in the chat. Is he an athlete? Okay, um, to be honest, uh, no, he's not an athlete, but I'd be interested to know why Cata CRE asked that question. Spondylolisthesis spondylolisthesis is slippage of vegetable body on another now. It wouldn't typically cause a central problem okay, but good thought so. No for spondylolisthesis. Any other guesses? Tumor? Yeah. Tumor is always a possibility. Um, it's quite a slow, progressive history. So I will accept tumor, particularly interim medullary tumor focusing on there. But it's not the classic kind of thing there is. There is a path economic. Uh, this this sign is pathognomic of a particular type of condition that we see in the spinal cord. Okay, Anyone know what this is called? The distribution of the sensory loss. Everyone know what it's called. Sort of particular term. They always ask it in your medical exams and your finals. So it's worth knowing this term. It's called a cape. Like, uh, yeah, sure, Yeah. Not. Not bad. It's a It's a cape. Like distribution. Yeah, sure, Like I suppose. But cape like distribution. Um, and it is a dissociated sensory loss. Okay, so I will show you. Um, this is what the patient had the MRI. It's a sagittal view of the MRI, and you've got a large white signal in the within the spinal cord itself a survivor cord. That is what we sometimes term as shrinks or dilated and central canal. So yeah, So people who said Tumor excellent. Well done. But the shrinks or the string go, Malia, uh, is what's favored. And for the Gold Star, he had headaches. And that's because he's got what we call cerebellar tonsil descent. So every time he coughs, his pressure goes up and you get a bit of impaction of these tonsils, and it causes causes further headache. All right, so this is what we call a chiari malformation, and they're associated with these string go. My allergic conditions surgical option include a frame and magnum decompression where we take off the back of the frame, and Magnum, which is just bridging here. And we can also put a shunt into the strengths itself and redirect it into different cavities like, for example, the pleural space. And that's one of the things I have. To be honest, I really like about neurosurgery. You're not just operating purely on the brain or the spine. We operate on the neck. We sometimes have to operate in the chest. We sometimes even have to go into the heart to put shunt catheters in. Okay, the tummy to do shunts. Um, lumber, spine, anterior lumber approaches. You literally really need to know all your anatomy. It's not just brain and spine. Um, this case is close to me because it's what probably inspired me to do neurosurgery. Pursue it as a career. I was a third year medical student, I thought wander down to the neurosurgery department at King's College Hospital, where I saw Mr Chris Chandler performing a pediatric endoscopic. Third, ventriculostomy surgery is full of all these kind of long words, but ultimately, when you break them down, you can understand it. Endoscopic because it involves an endoscope. Third ventricle. I assume you you would have all heard of. That's one of the central CSF spaces in the brain. Stuff me. It's like a stoma. In general surgery, it means to create an opening stoma like you see in the in the leaves. Okay, Why do I like it? I like the anatomy. I mean, it's it's literally like your I think I remember the first time I saw it was almost like you're moving through space. Okay. When you go out in the big screen, we'll have a look at video shortly. How do you do it? You go through the right frontal. Uh, whole generally. So the patient's asleep there, supine. They're on a horseshoe. You make a small hole in the skull and you introduce an endoscope. And then you create a stone in the floor of the third ventricle, and that's basically the principle. Okay, so you can see the camera going in there. This is the trajectory, and I like endoscopes. You get a really nice view with illumination, and you can aim the endoscopes in different trajectories. And your target tumor's here at the back Pioneer Region Aqueduct, etcetera. It's completely different to open neurosurgery, endoscopic skills. Ent surgeons are very good at them. They're very used to going up the nose and doing different things. So we don't really get introduced to an endoscope so early in our training. But, um, it's really nice. The view is really nice. Take take my word for it if you haven't seen one, and I'll show you a video shortly. Bleeding is a is a real problem. If you get bleeding under the endoscope can be very, very difficult to control. Your, uh um I don't think this is gonna work last time. So what I will do is show you. Yeah, Okay. I hope you can all see this. So we're looking at we've done the endoscopic approach. We're into the right frame and of Monroe. Okay. And this is the fella most riot vein, and you've got the anteroseptal vein as well. Um, that's one of our landmarks that we use. Okay, so this is Yeah, the anteroseptal vein. The thalamus. Try a vein framing of Monroe Chorioplexus you're in. You're literally within the lateral ventricle the endoscope is going through. Okay, so you're now going and you're sitting literally within the third ventricle. Get you to the juicy bits. So these are the mammillary bodies. Okay, so the forests, these are not not far behind. And you can create memory problems if you damage that. So what? What they're doing is they're basically creating an opening here, and the indication for this operation is hydrocephalus. So it's a good operation in in pediatrics, for example, when the patient hasn't had being more infection and they're above a certain age using it, using an endoscope to create this opening, Um, use a balloon catheter to dilate the stoma, and what you'll see is you'll get a further really, really nice view as we go down here and you're restoring normal CSF flow. And actually, you're looking at the basilar artery, the posterior cerebral arteries. Either side, um, and it's it's just a I mean to me. I mean, this is beautiful. Okay? Yeah. And if you get if you take the end, if you dare take a scope really, really place, you can zoom in and get some really, really neat pictures of the It's got a real Okay. So to conclude, um, I For me, the brain is the most complex thing in the universe. Okay, there's more neurons and synaptic connections than there are stars in the universe. And that, to me, is just an astounding, astounding piece of relativity that helps you put into context that you are literally working with a really complex machine. It is, as I and I quote from one of my I was lucky enough to be taught by the great Henry Marsh, who is a retired consultant from Saint George's Hospital. I urge you all to read if you're interested to read, do no harm, which is one of those books. And you know when when you operate on a brain tumor. You're, you know, patient's really do put a whole great deal of trust in you, and you are literally, literally about to operate the thing that generates their thoughts, emotions, their fears and their hopes. Okay, so they're putting an immense amount of trust in you, and your scalpel is cutting through that. Yeah, So it's something to bear in mind. It's It's a lot of responsibility. You're helping people of all ages. I'll give you a piece of advice. Decide early on. Doesn't matter if you want to do in your schedule or not decide early on. If you want to do surgery, decide if you want to be a surgeon who's more interested in pathology? Pathology driven. Okay, so you may like tumor's. You might. You might like vascular stuff, and then you end up doing this stuff or, if you're patient driven. So whether you like dealing with oncology patient's because you like taking them on the journey from diagnosis to treatment, to seeing them in the clinic after you've taken out the tumor and having that MDT approach, I think it's it is a useful distinction, pathology driven versus patient driven. So think about that The good thing about neurosurgery is there's lots. It's well, the good and bad thing you need. Economically speaking, it's very labor and financially, um, driven. Okay, so there's lots of technology companies and spinal instrumentation companies and stuff that are involved in it. So that means it's always going to be driven forward by technology. There's lots of research. I mean, you know, as I said, the brain is so complex neuroscience, it lends naturally into the research. So if you like neuroscience, if you like research you like toys and technology. I think it could be for you. Um, you, I would say if I was sitting and I've done some interviews as well and been on the panel, Um, if you need to if you want to do neurosurgery, I think you have to be. You have to be obsessed with the brain because otherwise you're not really gonna see yourself through the end of it. There's so many challenges along the way, and it's big. You know, it's a career that is very demanding, lots of sacrifices along the way as well. So I think you really need to love the craft. You have to love the brain have to love the surgery and, you know, the outcomes can be very bad were often accused of having very poor outcomes. And yes, I think the the losses are huge. But when you do have winds and victories, they are massive. You can, As I said, if you can cure a pediatric brain tumor, you're literally giving that patient, uh, an entire productive life. And I think surgeons stereotypically are, you know, painted in this picture that we don't have a human side psychopaths, blah, blah, blah. What I would say is that maybe there have been characters like that in the past, but your surgery particularly you really do need a human touch. You need to be empathetic. This is why it is critically examined that the interview phase, Um, as I said, You are lit piece Patient's are literally coming to you at the most vulnerable point in their lives, and you need to be able to understand what it means to them. For you, it's just another operation. For them. It is a life changing event. Brain injuries, spinal injuries, brain tuners, etcetera are life changing events. It's not just a risk fracture and you're a team player and you have to be a team player. There is no one man show here longer on other days of the neurosurgeon. Is he or she is the captain of the ship. Okay, it's a proper team, sport. There's no way around this finally, to sit to conclude you, you have to cope well, and I I use this expression thrive under pressure. It's not just about cope. You have to be someone who pressure brings the best out of you. I hope that makes sense, and people throw around this word for better or for worse. Resilience is such a big word these days. You know, being resilient, the NHS, right? I don't particularly like that word because, you know, for various reasons. But what I will say is that because of the demands of the Korea and the sacrifices you make along the way, training is long. Um, there's long hours. If you want to learn, you have to stick around. You have to. You have to show commitment. You have to be involved. You have to do electives before, etcetera, etcetera. So if you are someone who so I'll end on this note if you're somebody loves the brain, Uh, you like the idea of working really complex anatomy pathology and also vulnerable patient's. And you think you you you have the leadership and teamwork qualities. I honestly think it will be a very rewarding career. I'm not saying it's going to be an easy career, but I would like to hope it will be a very rewarding career for you. So on that note, thank you very much for listening and thank you also for being very interactive during the case. Discussion's, um, the last time I did this, I it was I had some amazing questions asked from the from the audience. So I think that's actually probably one of the most useful things, actually from the whole talk. So I I'd be happy to take any questions at all if anyone's thinking about doing your surgery. Even if you're not thinking about neurosurgery, Um, now is your time. If you if you want to ask any questions at all stunned into silence. Any questions, guys? Uh huh. Okay. Thank thank you, Michel, for starting the starting. The question. So the longest procedure, I think the longest procedure I ever took part that I ask is two parts one was during my elective in America, and I would say that you have to do an elective in neurosurgery to show commitment to introduce before you even apply was a 16 hour repair of a break. Your plexus, Um, injury A vulgar. So the brachial plexus We all learn it for our medical school exams and then later, or MRCS, and we still have to learn it for F. R. C s actually, So they keep asking about it. So we literally have to stitch the nerves of the break of plexus. And that's a branch called peripheral nerve surgery that we don't really do in the UK It's actually orthopods and the plastics to do that here, some neurosurgeons do it in stand more. In my training, there was something like a 30 hour plus procedure. I was scrubbed fel. Now I was not scrubbed for 30 hours nonstop because that's crazy. Uh, we operated for for a certain amount for about half of it. On one day, we described we sent the patient to intensive care, brought them back the following morning and then operated, and that was a vascular case. It was a arteriovenous malformation. Now an arteriovenous malformation when people talk about diffusing bombs, right. Aneurysms are kind of like diffusing bombs. But imagine like a bomb without multiple little bombs on it. OK, that's what an arteriovenous malformation is. Okay, if you if you start cutting veins and things like that, the whole thing can swell and explode in your face, and I've seen it happen. So that is scary. And it's proper microsurgery under the microscope. Really? Careful dissection. So, yeah, to answer your question, the longest 16 hours as a medical student in 32 hours, I think it was as a as a tricky the biggest piece of advice to any medical student once in neurosurgery. Um, it's never too early to start building your CV. That is, keep a portfolio. Um, put all your certificates, any courses you attend to start doing it. Now just shove it into an A for binder. I wish I did it. So I'm telling you guys now because it will save you a lot of time later. Uh, show commitment to specialty. Turn up. It doesn't matter where you were. There's no excuses. Doesn't matter if you're not your current hospital attachment. I don't So I don't know how many of your medical students how many of F one's and two's, but there's no excuse. Like find your nearest neurosurgical department. Drop them an email. If you're affiliated to that hospital, just turn up. Turn up to handover. Turn up early. Introduce yourself. You have a right to be there. OK, I I remember being at your stage and just thinking, you know, you're constantly in the way in theater and no, everyone's too busy for you. There will always be at least one person who has some time for you to explain things and teach you something. Okay? And that's what I would say. Show commitment. Get organized. Get on that website, the Yorkshire Humber Dina re website. And i'll, uh I'll put it up here so you can see it. Um, yeah, this one. It's the Yorkshire Hamburg scenery website. Put in the chat, actually want to do that? Um, yeah. So that's my biggest piece of advice. Covid makes it hard to. Yeah, I know. I do feel for you guys. I was just chatting to some of the faculty Martha and Gentlemen, about how Covid has affected things. And, um, still, virtually you can drop emails turn up to outpatient clinics. It's not just about theater. I would say Don't fixate yourself in theater. You need to be someone who enjoys theater and, like it's called theater because it's dramatic. Yeah, there's lots going on. There's lots of fashion. Sometimes tempers can be flaring, and it's ultimately I like to think it's for the goal of the patient. Okay, everyone is very patient centered. Um, don't worry about attending theater at this stage, because that's not really going to get you into neurosurgery. It will inspire you. And you can watch so many videos Now on YouTube. The neurosurgical Atmos by Aaron Cohen Godel uh, Google It is an excellent resource. It's a free app. You can sign up to and watch countless videos on neurosurgical operations so you don't have to be in theater to observe neurosurgery, but reach out to your nearest your nearest neurosurgery department. Make contact. Um, introduce yourself. Tell them you're keen. Tell them you want to do neurosurgery. Now is the time. It's never too early, and it's never too late. That's what I would say. Um Yeah. Any other? Any other questions? Would you please write or repeat the name of the application? Sure. Uh, sorry I didn't actually paste it, did I? So it's the Yorkshire and Humber Adina re basically coordinate recruitment. Okay, So when I wrote this presentation, this was the just put in the chat for you guys, but this was the link where you can go and have a look, but these guys is We'll have a contact where they will share some information about the application process, what's kind of expected. And generally you have kind of desirable criteria, essential criteria. And so on. Any more questions. Guys, I think one thing I would ask is, uh, so my brother has done neurosurgery, and he's kind of gone. He's thinking about during surgery. But he said, Would you need papers and someone before application to get up spot on your surgery? It's always changing. Um, it's always changing. But when I applied, you did need papers, but case report counted. Okay, now, that was a while ago. Now I understand that case reports don't count. You don't need to be published in nature. All right? What? One advice I could give you is to identify people, neurosurgeons or even neuroscientists. Even neurologists. Okay, Who are publishing? Literally. You can go on pub Med pub, med their name. See? See who is publishing in your local departments. Approach them. And I guarantee you there will be at least one project that you will be able to get involved in. The question is about timing now, papers are not easy. If you want to write a good paper, it's not something you can just splash out in a couple of weeks. Yeah, from the moment you start writing reviews and everyone has to approve, you know, we're talking minimum six months, sometimes even a year, so get involved early. Um, I would say that yes, papers are now requirement. I don't think you know they need to be neurosurgical necessarily. But obviously it looks better. The outpatient clinic Is this required for ST Portfolio? No, it's not required for ST Portfolio. But, um, if you go to outpatient clinics, you actually see the types of patient's and you understand what neurosurgical patient's are? Some of them have long term chronic conditions. Some of them have more acute conditions. You see how they look like after an operation. Sometimes how disfiguring. Sometimes you know, craniotomies and surgeries can be all right. And I think it's giving you guys and building a picture in your mind about what these patient's look like taking histories and examining them for neurological side. And these are These are important skills for any doctor, any medical shoot, so outpatient clinics don't underestimate them. It's not boring. It's not, You know, the kind of sexy surgery all the time. You also it's about the patient. And you will only really understand what neurosurgery is like in the outpatient clinic. And that is some advice that I never took. Uh, to be honest, I I Well, I've seen some outpatients in my elective, but I didn't go as a student or an f y doctor. But at my during my elective, I really enjoyed the outpatient clinics, so I cannot recommend it enough. But as far as I know, But please check the website. It is not required for ST training. No problem. Uh, what's been your hardest case? Surgically, an emotion. Um, I will answer that. So, uh, it's pediatrics. Um, Okay, so pediatrics is always the one because It's not just what. It's not just one patient. You're generally treating three patient's and I'm talking about the parents. Yeah, there was a case where I was on call at King's as the Reg. I'll keep this short because I'm worried there's other questions and time and stuff. But it was a baby that was referred with a very large tune, and they were becoming very drowsy. Um, it was that time in the morning where you just kind of waking up? It was around 99, 30 10. Um, I immediately know, you know, obviously realize the severity of it spoke to Everyone brought the child across, and obviously the parents is their first child. Yeah, the young parents distraught, right? They don't they have no idea. There, you know, to the layperson, it's frightening when you have a condition of the CNS, and especially when it's your first child, right? And they're putting even more trust in you than than I was saying about the trust that patient's put in you, right? They're giving you their baby. And then, obviously this is very, very consultant Led. Uh, You know, I I didn't do any heroics by myself. or anything like that. But me and the consultant, we saw the patient together. We took the patient together that day. Um, and, uh, we did a partial tumorous section, um, and did as much as possible that was needed at that time to temporize, then took the child back and did a more elaborate, uh, tumor, uh, tumor resection as well. And I think for me, different cases stand out for different reasons. And it was a long journey that we went on with the child and the parents. But to summarize, I think the moment for me where it was there was like, you feel that human connection and your research is very human specialty. I would say that is when the mother, just as as they were leaving, she just gave me this look because I had literally been with the child from the moment right to to the end of his stay. And, uh, i'll never forget that look, because it's like no words can be spoken at that time. Uh, there are no, uh, you know, people talk about being speechless. It's not really about that, But we both just understood each other, and I think for me. I'll never forget that kids. But there are other cases, you know, Patient's have died and things like that, which are moving for different reasons and not necessarily good reasons. But I try and remember the positive things. Thank you for that question. Hannah, Hannah, Marie, Uh, in terms of omelets. Question. How did I go? But I was very lucky. I trained at King's, and when I was a med student there, we had a twin link program where it was twinned with different institutions. So they they had some spaces, and what we needed to do was do a competitive interview and and show of CV and things like that. And I was lucky enough to to get the place, and it was very intense. I mean, the US they started for 4. 30 AM Um, you know, all of my friends on medical electives were, you know, on a beach somewhere. And, you know, they thought I was crazy for wanting to do and kind of kill myself. Doing 44 AM starts and stuff. But the reality is that if you want to do it, it's, uh, that's what I would say little sacrifices. Yeah, it's the soft you do back then. That adds up later and then takes you further. All these little little things that you do early in your career is what then propels you forward. And that's one general advice I will give you so us electives. A long waiting lists apply early. You may not be lucky enough to have a twin links thing that I did, but just email them just literally like, you know, don't just email one place, email them all like you know, you email 100 people. I guarantee you, at least five or six of them will get back to you and and and hopefully show some show some interest, um, to Iona. When would you think the current lack of John's and neurosurgery start to resolve itself? Yeah, very good question. And I know clearly has an insight into the current workforce issues. Now what they've done is they've given us too many, Uh, well, they've appointed in a way, too many trainees, and there's not enough consultant jobs at the moment. I don't know when it will start to resolve itself. They are already addressing things so they're reducing, which is not so great news for you guys, but they're reducing the number of entry points and jobs at ST one to try and address the imbalance of the bottleneck that we're facing at the end. Um, I kind of for better or for worse, I decided to do a PhD. I'm not an academic, um, sort of pretending to be a scientist at the moment, but I fell upon a really great opportunity with an amazing lab, Amazing supervisors. So I just thought it was too good an opportunity to turn down. My point is, I think it's not just about doing training. I think these days not not just, you know, just doing training is not enough. You almost have to do something extra. So teaching you could be a really good clinical teacher and do a teaching qualification. Or you could do a science to re like an MD or a PhD like I'm doing. Or you can go into management and, you know, people even think about doing things like M. B. A S and stuff like that. So, um, open your minds. It's not just about surgery is not just about medicine. There are lots of other transferable skills you can get from other spheres that you can bring, and that makes you unique. And that makes you a stronger candidate for hopefully for consultant positions. I'm hoping I wanna to answer your question that it will resolve itself within the next 5 to 10 years. I'm hoping that's optimistic. No worries. These are great questions, guys. Thank you very much. So, yeah, I think it's probably the more useful part of the talk. You know, I can talk at you all day, but this is the most useful. But I think any more questions, guys just pop in. Um, I think that's I think, uh, anyone no one else has. Um I got some questions, but I'd like to thank you. Mr Vice again, uh, for giving us an amazing talk on neurosurgery. Um, I've only had a few weeks, uh, of placements during my medical years. I've not had much exposure to neurosurgery myself, but it's it was a very interesting talk that you've given us, especially this question. A Q and A session just now has given us a lot of insight into neurosurgery itself. So thank you for, um, you know, presenting today. I really enjoyed it myself. And I hope everyone else enjoyed it as well. Um, guys, it's important for Mr just again if you get these feedback for and signed, Uh, and you can also get your certificates and thank you very much for turning up today. Actually, Uh, thank you, Mr Facade, for a lovely talk today. You're very welcome. I wish everyone the best. And, uh, you're ever down ST George's way. Then do come and say hi. We'll be happy to Happy to have you here. All right. Perfect. Thank you. Thanks. Bye bye.