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SNI, Surgical Neurology, International, an Internet Eternal, Nancy Epstein as Senator-in-Chief,
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and SNI Digital, a new editorially curated neurosurgery and medical information multimedia platform. With operative videos, expert interviews, podcast, global interactive discussion of
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information, for the next-generational clinicians in 13 languages, with James Houseman as the editor-in-chief. SNI and SNI Digital are pleased to present another in the series of Sub-Saharan
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African International Neurosurgery Grand Rounds, co-sponsored with the Sub-Saharan African Neurosurgeons held in the first Sunday of every month.
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In addition, SNI digital and SNI. supports the Latin American neurosurgical international surgery grand rounds neurosurgery grand rounds in cooperation with the Latin American neurosurgeons held in
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the last Sunday of each month.
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In these Sub-Saharan African International Neurosurgery Grand Rounds, present topics related to global solutions to clinical challenges in neurosurgery. The moderators are Astrada Bernard and James
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Osman, before an international audience. This 20th Sub-Saharan African International Neurosurgery Grand Rounds is a topic of extending neuro-surgical care beyond surgery, building effective
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non-surgical pain pathways.
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And it's to be given by Christopher Gay,
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who is a neurosurgeon in Anchorage, Alaska.
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Christopher Gay, at his training at the University of North Carolina, went to Columbia University for a Presbyterian Hospital for his neurosurgery. He's board-certified in neurosurgery. pain
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management and anesthesiology and works at the Alaska Center for Pain Relief in Anchorage, Alaska. It's contact information as listed below. Well, let's switch gears now. I'll present to
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introduce you to my colleague, Dr. Christopher Gay. He's a pain management specialist and he runs the Alaska Center for Pain in Anchorage, Alaska He and I have collaborated over the years when I
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was in Alaska and we actually continued to do some collaboration on a different plane. But Dr. Gay has
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a successful practice out in Alaska. He trained on the East Coast at Columbia for his pain management journey and practice on the East Coast before moving to Alaska And he's interacted with that with.
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Neurosurgeons in Africa, and I thought it would be good for him to give a perspective on how to build an effective non-surgical pain program geared towards
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neurosurgeons, because as we well know, in a lot of places in Sub-Saharan Africa, there may not be formal pain management program setup. So Dr. Gay, thank you for joining us, and please take it
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away, you may share your screen. All right, thank you for having me, can you hear me okay? Yes. Yes. Great, right, screen's coming up. So, thank you and Dr. Osman for having me on. And I
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look forward to speaking with us, but I first definitely
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appreciate hearing Dr. Bashir's presentation, because that is essentially the embodiment of what we're gonna be talking about, how you set up something in the system that's not there It's not
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letting me share, so can you - cutest slides from your side,
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please, thank you. But yeah, the program that Dr. Bush here described is it was amazing. And I think also it should be highlighted that he said the red carpet was pulled. And he still went and
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did this work in a place where it was not made easy for him anymore.
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So it is certainly inspiring to see that it can be done and then see that it has flourished and that he laid the infrastructure to make it self-sustaining so that a program would not only be dependent
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upon him, has other doctors that can be involved and then bringing in the master trainers and training them to train back into their communities. And so it kind of brings us full circle to where we
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are with this talk, which is extending neurosurgical care beyond neurosurgery and building effective non-surgical pathways. This was, I was, as you mentioned, That was in Ghana for the
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neurosurgical conference at the end of October. And it was really inspiring to hear the stories and see some of the cases that were treated. And the neurosurgeon is there, as they do here, they do
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some remains. But sometimes it's with less resources. And unfortunately, it's with much smaller numbers to do the work. And so it puts a burden on the surgeons to complete what needs to be done.
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And unfortunately, there's a good number of patients that may not be able to be helped because they don't need surgery So this talks about, you know, that very topic, you can operate on one person
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at a time, but with this, we can help a lot. So I was doing a brief story. I don't want to take up too much time with it, but in 1939, it's a film calledThe Wizard of Oz and many of you may have
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seen it, but in the midst of a tornado, the main character, Dorothy, swept away into a new and frightening world. She amasses a few friends and companions along the way, and they all share one
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thought, somewhere, far away, a powerful wizard can solve our problems scarecrow one in the brain, 10 men wanted a heart. and line one encouraged and Dorothy just wanted to go home. They travel
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a long road, difficult road, and they arrive with hope. But when their curtain is pulled back, there is no magic, there is no wizard. There's only a man who ups and realized that the thing they
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really needed was already within them and always within reach. What I heard when I was in Africa and gone at the conference was many patients travel from lots of adversity, lots of difficulty
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getting there to see the surgeon, especially when they're the mission trips and they're doing a focused number of cases in a small amount of time. But unfortunately, all of them, either through
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the screening process or once they got there, they were not surgical candidates and they're often sent home without any solutions. And so what we want to talk about here is when these patients
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arrive looking for hope and surgical solutions, even when surgery's not the answer, what can we do for them? So first we have a math problem. As one neurosurgeon, at least you're a one person,
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And you only have one pair of hands and usually one operating room at a time and a certain number of hours in the day. Again, you can only help a limited number of people one on one. And so this is
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hoping to be able to develop a network like Dr. Beshear has done that offers care to people who may not otherwise have access to it, gives hope to them, gives them their function back, gives them
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their ability to earn for their families and support their families and just contribute to society So many patients you'll see, they never see another specialist of your caliber and this may be their
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only shot to find out what can help them. So even though, as you may have found in, of course this is what's fine and that would stroke, but most patients are not necessarily surgical candidates
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just because they have a spinal condition but it certainly doesn't minimize the disability that they experience from this. And so disability is not a failure of surgery to act or even if it happens
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after surgery, it's not a failure of the surgery It's just a symptom that there is something needs to be done. systemically and in this structure to be able to address these patients better. So
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what I was hoping to lay out, and again, as Dr. Bashir so elegantly pointed out, there is no copy paste. What works here may not work. What works in Alaska may not work in Nevada, what works in
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Nevada may not work in California. Same thing, what works in the United States may not work in any of the countries directly in Africa, but the thoughts and the planning around it can be very
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similar. And so we kind of have three different areas, this is kind of like a stoplight almost, just clear surgical pathology, someone that needs operating room intervention, and those are green
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lights. So they're gonna be highest value use of your time and your evaluations. Second, or potential candidates, people that may be good candidates, but they may need some other stuff done first,
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or there may be some other complimentary therapies that may be available or with this digital age, and I'd love to see that SI is digital and is embracing that with the digital age, we can - employ
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some best practices and reach people. Pretty much any country you go to, a lot of people have cell phones, even in areas where they may not have as much transportation to get into the city where
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specialists are. But if we can reach them through these networks and I've seen some across different countries in Africa as well, and that is a certainly would be a backbone of any program that's
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developed. And then the last is non-surgical pain. They don't need surgery, but they may not feel better without something being done. And these are the ones where we can divide into a training
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and treating pathway with local providers being part of a hub and spoke where the central decisions and protocols come from you or partnered with someone. And that's disseminated out to these other
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training sites where they're learning how do we triage these patients? Who are good patients? What can we do for them before sending them up the pipeline.
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There's just something to think about with any note that we see is, is this person, someone surgical, and if not, what else can be done for them? And if they can start adding that to our clinic
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notes that will help not only us, but anyone else who sees them. And then if we can develop infrastructure that allows these other things that can be done to actually be done, and I think we'll
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start making some more huge differences in people's lives. We'll go to the next slide please. So the basis of that is figuring out the mechanism for figuring out the modality to treat it, right?
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And so we don't really treat pain. We treat mechanisms that cause pain. So we name it. And then based on that, we can make a protocol that allows other providers to implement a lot of these things
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before they end up in your presence considering surgery. But at that time, you know, the other things have been rolled out. And that, you know, if they truly need it, that they will be there.
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And those who don't truly need it will hopefully have gotten better through a number of interventions, whether it's medications, whether it's, you know, community. on providers, rehab, but
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there's shortages, not only just neurosurgeons, but also other specialists, shortage of pain physicians, shortage of physical therapists and probably even, I don't know if chiropractic is a thing
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there, but shortage of anyone that can contribute to this pathway. So dividing it early in terms of what type of pain it is, we can make these protocols that will allow our community partners,
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whether there's nurses or advanced practice providers that can implement these other therapies and plans Ridicular pain, and I won't go through all this. This is preaching to the choir. You know
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all the different types of pain. But we have to name it for those who may not be as familiar with it, and then document that as well in the note. The patient's not a surgical candidate, but their
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pain seems to be neuropathic, and they may benefit from treatments with gabapentin or some of the other medications if they're accessible. I did notice several vendors selling gabapentin and perhaps
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tramadol, I believe, were quite common. And so we know there's a pathway medications there, and then just making sure it is affordable and accessible is the other half of that equation. So it's
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one thing to have a great idea, but a second thing to actually be able to implement it as Dr. Osmond said, you can't just come with a problem. We have to have solutions and work on that angle. So
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since this is a wide-angle lens to approach and address pathology and disability together and thoughtfully from the beginning, because we can do an amazing surgery, and if we haven't addressed the
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problems, here's commonly said, you know, we don't operate for pain, because if you operate for pain, you just get pain. And so figuring out what the problem is and figuring out what the main
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pain generator and sometimes injections and diagnostic shots can narrow that down, and their ways of doing these with and without imaging, and ideally with imaging makes it easier, but there have
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been developments of loss of resistance syringes that are kind of automated, so the learning curve drops, and so interlaminar epidurals may become more of a. accessible thing through a training
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program, such as the fellowship that Dr. Bashir mentioned.
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Can we go to the next slide, please?
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Okay. So, you know, what is the evidence support? So there's different layers and levels that we can start. And the base layer is education and expectation setting. Hurt doesn't always equal
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harm, just because you're having pain doesn't mean there's something that needs surgery. But there's other reasons for having pain and ways we can get rid of it in a lot of cases, radio frequency
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ablations, you name it And again, some of it is going to be dependent on your particular area, so it requires, I guess, a self-assessment of what is available, what would be accepted, and what
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is the learning curve for teaching the public and other providers about these modalities, which may not have been as readily available before. And then also embedding it in some of the curricula,
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at least to my knowledge, in the United States, most neurosurgeons don't do a lot of injections, but I understood in Ghana where I was the majority of them were done by the neurosurgeons And so
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making sure that that repertoire is increased and kind of going over the indications and the techniques that can be employed with or without imaging or without, with or without in settings with
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height, access to other infrastructure and settings with low access. So education is gonna be for your community providers, it's gonna be for the patients, it's gonna be telling people some
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reassurance, most low subacute back pain is gonna resolve. You don't need surgery for everything and there may be ways we can help you even without surgery So then structured activation and movement
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is going to hopefully involve physiotherapy or some type of digital offering to provide the exercises that they can do at home and rehab activities that may be a challenge if they live far away and
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can't drive into a city for therapy sessions very frequently. Medications, that's going to again be dependent on what is available on your local formulary, whether it's based on a hospital or just
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kind of what is accessible from a cost perspective.
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work very well. Sometimes oral steroids can work well, you know, acetaminophen or peracetamol or whatever the is available there. And then other medications such as muscle relaxants, we hope not
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to focus on opioids because that has been shown not to solve anything and creates more problems of its own. And I believe right now the US uses like 90 of the world's hydrocodone. So clearly it's
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something where the rest of the world has figured out how to get along without opioids and so we would not recommend that for long-term pain management there either. And then we get into the
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targeting injections when they're indicated and this is part of the training process where we again help the community providers identify the candidates and then those that are you know appropriate
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and can be would like to be trained teach them how to do some of the more basic injections that can be done with or without imaging you know for set joints or ideally done under imaging but some
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things are becoming even with portable ultrasound units that can be handheld to do a lot of these different types of injections. And so developing a list of protocols and develop a list of providers
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who can enact these recommendations is gonna be key. So it comes down to the structure and infrastructure. And so one thing that you could look at is picking one area that you wanna focus on in
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terms of the different pathways for treating pain, whether it's some medications or injections or the type of pain that you're focusing on and you're gonna assign that to a committed provider and
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kind of do a pilot and say, when you get this type of patient, do this, this and this and you can attract that. So can we go to the next slide and I think it kind of breaks that down a little bit
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more. So again, you can't be everywhere at all times, but your judgment can be through protocols and training to make sure things are done just like a franchise. If you go to a restaurant in one
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country, seen in another menu may vary a little but generally they're doing things the same way. And so it sounds like Dr. Bashir just is doing that with the stroke interventions throughout
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Pakistan. And here he could do the same thing with neurosurgical and pain, which do go hand in hand, a lot of the conditions, whether not just spinal conditions, but other conditions in the head
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can cause pain syndromes and various nerve blocks and things of that nature can also be used to address those again without having a lot of additional infrastructure or without having to allocate a
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lot of time from resources such as fluoroscopy or things that may be in high demand for other specialties as well. So this kind of, this one kind of starts at the tier three, you can have the
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community health workers reinforcing the education, monitoring activity adherence, looking for red flags so they can escalate when needed. And then the next line is the people who are actually kind
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of intervening. So the physiotherapist who are actually carrying out the plan, And again, that could be something digital. and design based on the community needs. And I got to screen for other
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things that are not urgent, but they need to be on your radar a little sooner. And then medications could also be managed at this stage as well. And then last is the neurosurgeon and pain
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specialist is going to diagnose classified mechanism, design that protocol, train the trainer, and then handle any escalations that come up through this pathway. Next slide, please.
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So what would this intentional training look like? Just, this was almost a paint by numbers, and I love hearing Dr. Bashir's description because he said he identified about two providers from the
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various hospitals, and they'd come, and they'd learn, you know, the protocol, they'd come and they'd be trained, and they'd go back and they'd become trainers in their community, and so it was
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kind of becoming a multiplying effect, you know, and you're doing the same work, the same effort, but your efforts are being duplicated and expanded exponentially over time, And so you see their
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cases were. lower at the beginning, but then they would start to increase. They did just as many in six months as they did in a whole year. So the same thing here where you start to develop not
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just a model that's built on one person, but a model that becomes self-sustaining where eventually you're going to have people in not every community, but a lot of the communities that can handle
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this. And so once the public feels better, you know, in terms of objects, that's a great thing. Because if you're responsible for bringing this to an area, certainly from the political
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standpoint that you talked about, that's going to be a political win, that my people feel better. And when people feel better, they're going to think more positive of them. And so that hopefully
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will help integrate this into being something in society that is, you know, desired. And of course, you know, politics, if you help some family members of politicians, because pain has no
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respect of person or position, it hurts everybody. And so they will certainly have pain conditions. And once you have some wins with that, then they will hopefully see There's a benefit to this
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and then people that don't have the same resources to travel often and some people can travel out of the country to get these types of treatments, but we want to empower each country to have their
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own. So I don't want to
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assume I know all the details of any of the countries that you may be from, but from the interactions I had, it seems that neurosurgeons are in high demand and pain is even less common in many of
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the countries there. So again, we want to identify some community providers, teach them the mechanism in the framework, give them a protocol that can be executed without having them having to call
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you, kind of like standing orders, and I'm sorry for the typo there, and then build a feedback loop. We're going to have a kind of a case review and meet and review, you know, what patients did
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we see, and you got to get these objects and metrics. Who got better? You know, what gaps emerged? What can we improve? And so you're going to document the wins and then address any of the
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losses and non-wins. And then again That's a great slide. It tells you how you start almost anything.
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Yeah, and that's what, like I said, with Dr. Bashir hearing, his was like this topic, but it's already done. And so I think it's proof that this type of approach is very beneficial and can work.
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And his program is sort of improved for that. And I think, again, it's kind of a plug and play. Like you said, many conditions can come here, come into the same framework and be successful. And
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it just has to be done with intentionality. What
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Khashim did is he did exactly this, but they just expanded it and it also took on a life of its own and they directed it appropriately. But this is the nuts and bolts of how you get it started.
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That's exactly right. Indeed, I was thinking of that when you said to bring solutions and not just problems. Next slide, please. All right, so what can we do this week? So, you know, I'd like
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to leave some action items and not just tell you these are things that can be done, but these are things that can be done here and now. When you see a patient, you can add this line surgical,
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optimized, non-surgical, and you start documenting that. And then, maybe for the next five patients, document what non-operative treatments you would like to see happen to them. And then kind of
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keep a, I guess, a list of what the most common things, I guess, issues that come up and the treatments that could address these. And then, again, if you're interested in trying to develop
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something like this, I'm happy to talk with anybody about what your particular details are for where you practice. And then, again, you'd start thinking about community partners that could work
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well with you. Maybe you get referrals from a certain place or maybe you work through the government and they can have that streamline. And then, otherwise, it's also just the screeners, the
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questionnaires and things that making them accessible. I don't know if the literacy rates are the same as what we heard earlier, but knowing what are patients gonna be able to read and respond to
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and what is the best way to reach them. Maybe it's through pictures, maybe it's through some other modality, easy for them to come in and lowering any barriers to care is part of building that
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structured protocol and then training the team and hopefully developing some interventional skills for providers that are already in the community. So just like Dorothy and the lion and the 10 man
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went to the Emerald City and they found out it was always within you. We have resources that are within our cities and within our ecosystems that we can train, tap and extend and help to reach more
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patients Next slide, please. OK, and that's it. You train for years to change one page of life at a time, but now you can change thousands. That's a QR code that'll take you to any of my contact
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information if you wish to talk further. And I'm happy to answer any questions anyone may have right
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I think that's terrific. Would you send a, you don't have my email address, send a strata, your contact information, email and
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stuff. We'll put that in the video so they can talk to you. Sure, absolutely. Thank
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you. Anybody have any thoughts about this? Fred Todd, your colleagues with Jay and Strata and so forth. Any comments you have about this?
24:33
I really appreciate the presentations today both for Dr.
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Bashir as well as Dr. Day here. I've been in private practice here in Texas here for 30 years and
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I've sort of been intentional in applying some of these principles that's already been expressed by both of our presenters here and
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it works. I
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think that future is
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definitely, you know, challenging here to, in this day and age, particularly in the environment that we end, but
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as already been stated here, we have to be intentional in our efforts and our purposes in order to improve the quality of healthcare for our patients soon. And it's, we should become more versatile
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as, as neurosurgeons, you know, just not as surgeons, but also just taking care of the whole, whole patient. It would be more holistic in our approach. So appreciate the
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efforts that the two presenters have actually presented. So great. Thanks for your comments, Fred. Chris, that was excellent. Sorry, I was a a little slow on getting unmuted, but. very
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thoughtful.
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You mentioned
26:04
that you noticed that most of the epidural steroid injections when you talk to the neurosurgeons you met in Ghana were being done by neurosurgeons. Any thoughts about how neurosurgeons who are
26:19
already doing that sort of thing, doing epidural steroid injections can expand their repertoire in short procedures that they offer for pain management. And what might be the low-lying fruit? Yeah,
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I think
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we'll start. I'll say it with other types of epidurals. So even the ones that are doing the epidurals are saying like the majority use the caudal approach.
26:45
And that is good, but if the closer you can get to the pathology, the better response you may have, right? So optimizing for interlaminar epidurals, which are ideally done with fluoro, but you
26:56
don't have to have fluoro for that. And then again, like I said, the, probably one of the learning, the biggest learning curve for the interlaminers is the loss resistance method. So getting the
27:05
feel without getting, you know, a dual puncture. And so there's some very interesting devices that are on the market right now. And, and if you want to hear more about them, I'm sure they might
27:16
be willing to, you know, send over a sample or two or maybe sponsor some time to talk with you. But since, so, so those, those syringes that with the, the altered resistance modality that those
27:32
can be a replacement for the need for fluoroscopy. Is that, is that what you're suggesting? They, well, it takes, it standardizes them. So that's what you want with like any type of protocol or
27:44
program. You want to be standardized. Like I said, if you go to McDonald's, you want to get the same burger here and there. So this takes away the, I've only done three of these, you know,
27:53
effect versus I've done 300. It really is an amazing, you know, tool where you can. you get the lost resistance without having that variability. You know, not having the fluoro, it won't
28:02
necessarily make that part easy, but it's one less thing to think about. If you can feel the landmarks and if the patients, you know, aren't too big in their girth, then you can usually fill with
28:12
interlaminar spaces or you can usually get into there. So it will give you confidence for the neurosurgeons who might just be starting over, will give them confidence in the consistency of being in
28:21
the right place. Indeed. And then one of the, I was pregnant with the CEO of the company that makes one of them is called the Episact device. And he said, that was his goal when he developed it.
28:33
And he said, he'd love to come over, you know, on a mission trip or something as well. But his goal was to be able to utilize his device in places that don't always have fluoro and don't have all
28:42
those other resources consistently. And so that was, you know, in their actual planning and mission. It's like, we don't want this to only be done in an order to fluoro, but being able to have
28:52
something that can be used to go out to places where there are less resources and I still hope. good results are at least better, more accurate results. And so, yeah, it's pretty neat. I can
29:02
send over a video if anybody's interested. I think I have a video of me using one of them, which is pretty impressive. I was a little skeptical as I don't really need that, but then they brought
29:13
it. And as you know, I had a shoulder injury issue recently and so reaching to do the loss of resistance wasn't working. So I used a device and I could do it with my one hand and it was amazing So
29:24
it helps those who are skilled and those who are unskilled and kind of equalizes the skill set so that you can deliver a reliable response. But SI joint injections can also be done. And again, with
29:37
ultrasound, you can see some of these joint entry spaces. It's kind of a harder joint to find the entry spot to without some type of imaging. But handheld point of care ultrasound, which those
29:46
aren't nearly as expensive as a full device and they're portable. So you can take them around if you go to different hospitals And then for set, joint, medial branch blocks, radio frequencies,
29:55
those things. would require more, you know, imaging, but they also go a long way. If you do a radio frequency ablation on the media branches, you're usually looking at about six months or more
30:07
of relief for a patient of 70, 80 reduction in their pain. And so their, you know, quality of life goes up significantly and it can be the difference between someone working and not working and
30:17
supporting their family and kind of going into poverty because they can't basically make a gain for the gainful employment
30:26
Yeah, me, everything you have come, but we're getting your closing time here. Any comments you want to make? Yes, I want to make a, first of would I, all like to thank Dr. Gay for a great
30:37
presentation. My comment is sort of like, give you the aspect of pain management in my country. So this is done by anesthesiologists. So
30:53
it's interesting because,
30:57
as neuroscience scenario, you know, we haven't penetrated because they stand by our sociologists. So all the aspects of pain management, they're the ones who handle it. And they are taught under
31:12
graduate, postgraduate, and because I think probably because of the shortage of specialists, they end up taking that area of pain management, even management of cancer pain and all that is done by
31:30
our sociologists Now, we still
31:35
teach it at an undergraduate level. I teach it to medical students, but I hardly manage it actively, you know, sort of like in our practice And I highly doubt if any of our neurosagans in my
31:53
country. really is involved in paying management. It's mainly done by anesthesiologist. So that's the concept I wanted to give. And basically, I'm giving that concept to highlight how
32:07
things change between different countries. What is done in the US, then you come to find in Kenya, it's very different, because the circumstances are different. So that's how it is in my country
32:22
Thank you. I think that's wonderful that you have the resource. And so, you know, as Dr. Bashir said, it's not a copy base. Every country is different. And in the US, actually,
32:31
anesthesiology is primarily dispensed with is that handles pain management here as well. And I think some some countries, though, it just becomes, you know, there's no one that's doing it and
32:42
having someone, there's no one that's trained to do it. And I think those are the ones that would benefit from something like this program. But I'm glad that you do have those resources available.
32:50
And, you know, I realize every country is different and even within a country. every city may be different. And so any place where this may be applicable, I think it's a worthy to look at. Thank
33:03
you. Yeah, yeah, yeah, great comments. I think it's also a matter of a vacuum
33:10
being filled if it's not being utilized. When I trained at Duke, Blaine Nashold was the neurosurgeon who had interest in pain And at that time, neurosurgeons, Blaine did a lot of the neurosurgeons
33:26
were putting in, at the time, they were called dorsal column stimulators. And so that was the
33:35
domain of neurosurgeons, but neurosurgeons were not involved as much. And so anesthesiologists became the ones that filled that void and became most prominent in putting in spinal cord stimulators
33:51
now but so it's a matter of of where that void is and where it's filled. And if you don't have people who are filling that void, then it creates opportunities for others. Indeed. Said has been,
34:07
it's from Persia, which is now being resurrected as the Iran of it should be. And he's trained in France, and he's at works in the United States. What have we had to presentations today? What are
34:21
your thoughts about all this? First of all, it was a great, great presentation, but both of the speakers really, I enjoyed it. I had the possibility working with Dr. Ronald Young, who passed
34:33
away a few weeks ago. He was a pain neurosurgeon. He taught me a lot when I was working with him at UCLA.
34:42
Brilliant pain management neurosurgeon that really is reminds me of him, and also to mention my first mentor medical school. Dr. Momma Chafi, he was originally from Pakistan. He was trained in
34:58
neuro - New Zealand. And amazingly, he put so much time to teach me, encourage me for neurosurgery. I never forget him and his kindness. He had a degree in neuroscience, which was equivalent to
35:14
PhD from New Zealand. I really, it goes back to the, for what Dr. Nimrod said that, it goes back to their teaching the young people, encourage them and train them to go to the pathway they wanna
35:31
go. I really appreciate both talks. I learned a lot and I congratulate both of them. Thank you very much. Let me make a few comments and we'll close up, Australia, you know, first of all of us,
35:46
Kasim was just an outstanding presentation You guys have done a fantastic job. and that goes for your brother also and who we should have in the future. You mentioned, I think what Chris said about
35:59
the story of the Wizard of Oz is absolutely true. There is no utopia. You have to make it. Isn't that right, Chris? Absolutely, absolutely. And unfortunately, that's what communism is trying
36:12
to sell people today. It's utopia, it doesn't exist, and it exists in each individual to do the very best they can to achieve what they can. And because then when you mentioned everybody was very
36:26
happy to have you come back, and when you got there on the ground, it was a little different. All of a sudden, everybody disappeared. And this is just basic human characteristics, human jealousy,
36:37
human failings, and you persisted. You did what I said with the Dean. Come to me with a solution, you had a solution, and you showed the results, and you had to be aware. of what the optics,
36:52
the political implications were 'cause they were making the decision. And this is too complicated actually for these people to do that. There's another phrase I used to use all the time in when we
37:06
would talk to the residents. I'd say, I want you to do this. Well, they can be all the reasons why it can't be done. And I told them, I know all the reasons it can't be done. Now, find a way
37:16
to do it
37:19
And that's it, it's not no, no, no, no, no. We gotta find an answer. If you don't find an answer, that patient's gonna die. So you find an answer. And I think that's good. And another thing
37:31
is, you showed us, 'cause then that it can be done. You got to a place that had nothing. And now you have a pun job, which is 130 million people who had no stroke care And now you got to the,
37:47
and they were going to the cardiologist now you've got. a place where you've got your stroke system in every hospital, you've got ambulances, you've got people wanting to contribute money to you
37:58
and ask you and your brother this once before, is how you're gonna make sure that you're able to sustain it and keep the government out of your business. And
38:10
that's not easy, but you have to do that. Otherwise it's gonna get, like you said, with the money initially, it'll never get there. And so you're right And I'd like to also say there's a great
38:21
movie, which I read a lot of courses on motivation and so forth. There's a great movie out calledPatton. I don't know how many of
38:32
you have seen it. It's an excellent movie like
38:39
Christopher was talking about. And it talks about leadership. The movie is all about leadership It was written at a time when the - when the army wasn't popular and the people were against it.
38:52
That's not what the movie's about. The movie's about how you be a good leader, trying to get people together who may not be united to do it and how he gets it done. And it's a wonderful movie to
39:05
say if you can get that. The lesson I think a name would say this is true is patience. It isn't, Americans are very impatient people. If I can't get it done today, I am not interested in the
39:22
answer is you have to have patience. The Oriental people are very patient. You've got to be patient. You've got to, it takes time and time and time to work it through. But you'll get it. And
39:34
what you've shown is that you can do that. So I think through that Sam Rojas was in here. He could have told us about what happens in the Middle East. And I think what we found in what Jay Morgan
39:46
said is that, your problems are not unique. What Christopher said, yes, is you have to have a solution for every place and every circumstance because it depends upon your environment and
40:01
circumstances. I don't care if you've got all the best things in the world. You can own a Rolls Royce. That won't get you to work faster than it does if you have a Volkswagen or maybe a little
40:13
faster than a bicycle, but it still gets it done And so you don't need all the fancy stuff. And a lot of those things, all of us have learned along the way, you don't need it. There's a person
40:25
where we're going to have it on a series called Dr. DuFaux, a huge DeFaux in France who operates on gliomas. He doesn't need the imaging. He doesn't need any of these things. He has longer
40:29
survival than anybody else does because he has awake surgery, interoperative monitoring, goes into neuropsychology testing which people don't even think about or use.
40:49
and actually operates on what is a functioning brain. So it doesn't really matter that you have the most advanced equipment. I think Nim would agree with that also. He's practiced for 35, 40 years
41:04
and seen everything and done everything you do the best you can. So I'm sorry to take the time, but I think it was a terrific presentation. So there's a lot of wisdom here And I think I hope that's
41:18
beneficial to people. Thank you, Australia. Yeah, well, thanks, thanks, Jim. And thanks to both of our presenters very, very, very, very practical information. Any other, any other
41:30
questions or comments before we close out?
41:37
Just to say, I'll see you in about 10 minutes or so. Okay, Sam is another leader where people need to know, Well, what you guys have done and what do you overcome? Chris, it looks like you had
41:49
a comment, go ahead. On this thing, I put a document in the chat. It's got a little handout. If anyone's interested in it, it kind of summarizes the things that we talked about. And then - Send
41:57
that to us also, 'cause so we can put it in the video. Okay, can you do that? Absolutely, thank you. Okay, thanks. I'll send it to you, Jim. Okay, terrific. Okay, thank you, everybody.
42:09
Okay, thanks. Thank you. Let's try it for our next email list. Thank you. Okay. Thank you so much. Mm-hmm. All right These are the references for this talk. Take screenshots for your use and
42:23
reference.
42:27
This is the
42:32
first of Dr. Gay's summaries on extended neurosurgical care beyond surgery. Take a screenshot
42:38
of this slide.
42:41
Take a screenshot of this second slide on
42:45
the steps of classifying pain.
42:51
Take a screenshot of this third slide,
42:56
and this is the last slide on a glossary of key pain terms.
43:04
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43:12
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