Curious about brain surgery? Expert Neurosurgeon Dr Ruth Mitchell reveals all!

In this episode, Benj Faiman talks to Dr Ruth Mitchell about all things Neurosurgery. Dr. Ruth Mitchell is a fellowship-trained neurosurgeon with a strong focus on paediatric neurosurgery, epilpesy surgery, and brain tumour management. She completed her medical degree at Flinders University in 2007 and subsequently undertook neurosurgery training at leading centres across Victoria and New South Wales. Dr. Mitchell is a fellow of the Royal Australasian College of Surgeons, and completed her training in 2020. Dr. Mitchell is also a Fellow of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh. She is a passionate surgical educator, and is the supervisor of neurosurgery training for Prince of Wales Hospital and Sydney Children's Hospital.  Dr. Mitchell completed subspecialty fellowship training in paediatric neurosurgery in Vancouver, Canada, at British Columbia Children's Hospital. She is currently based in New South Wales, practising at Sydney Children’s Hospital and Prince of Wales Hospital.

Transcript

SPEAKER_00 0:00

Welcome to Patient in the Room, our first episode from Australia. Thank you for joining us today. This is uh Dr. Ruth Mitchell, a fellowship-trained neurosurgeon specializing in pediatric neurosurgery, epilepsy surgery, and brain tumor management. Also, it would be remiss of me not to mention that she is a 2017 Nobel Peace Prize winner. First of all, uh Dr. Mitchell, thank you for being here.

SPEAKER_01 0:24

It's wonderful to be here. Thank you for having me, Ben.

SPEAKER_00 0:27

Very exciting times. Um, obviously, today it's all about the work that you do for you know the families that you work with, the children you work with, and and I guess the teams you also work alongside as well. Um I always like to start understanding you. Uh so could you just explain to us a little bit about what a neurosurgeon really is?

SPEAKER_01 0:46

Yeah. Look, I think it's the best job in the world. I get to look after people uh who are having problems with their brain or their spine, and specifically diseases that need surgical management. But not everyone I see does need an operation.

SPEAKER_00 1:01

Okay.

SPEAKER_01 1:01

So um, but we do look after a range of patients, and I'm very fortunate that I do pediatric and adult neurosurgery. So I look after people who are, you know, born yesterday and people in their 80s, and everyone in between.

SPEAKER_00 1:15

So how often are you seeing newborns and and infants?

SPEAKER_01 1:19

It seems like they all come in little groups. So there'll be won't be any for months, and then you'll have three or four babies in the neonatal intensive care unit that you're visiting every day. Uh one of the things that can happen to babies if they're born prematurely, if they come too early, is they can have a bit of a bleed into the fluid spaces in their brain, um, which means that then they get too much pressure inside their head with the fluid. And uh sometimes we have to operate on them when they're, you know, not even at term. So the smallest baby I've ever operated on weighed 800 grams.

SPEAKER_00 1:53

My gosh.

SPEAKER_01 1:54

Yeah. Yeah.

SPEAKER_00 1:56

Wow.

SPEAKER_01 1:56

Not not enough baby.

SPEAKER_00 1:58

Yeah, that's like I can't, it's like I order more chicken from the soup. Exactly.

SPEAKER_01 2:04

It's less than it's less than your milk weighs. Yeah.

SPEAKER_00 2:06

You know? That's wild. When you're dealing with an infant that young, because obviously they're going through this extreme developmental period for their body physiologically, are the risks different in terms of the recovery or does it change?

SPEAKER_01 2:22

So most of the time working with kids, um, we feel like kids are like super resilient and like they bounce back from all sorts of things. Newborn babies are not in that category. They're very vulnerable. And in fact, occasionally a child that small is so unstable that we wouldn't even take them to the operating theater to operate. Occasionally we might even organize to do the operation in the neonatal intensive care unit. Wow. Just so that even just moving them from one place to another can be quite disruptive. Okay. So we're just trying to keep things as calm and as controlled as possible for their very fragile physiology.

SPEAKER_00 3:00

Yeah. Well, that makes sense. I guess taking the root of the safest, the safest route to make sure that there's the least amount of risk in K. Good to know. Um bringing back to sort of, I guess, neurosurgery as a whole. Someone's referred to you as a or referred to a neurosurgeon, does that automatically mean that they're going in for surgery?

SPEAKER_01 3:20

No. So not all the patients we see actually do need an operation. In fact, quite often people come in worried that something that's been found on a scan will need to be operated on, and we have a look at it together and we decide either that they don't need an operation or that they don't need an operation yet. So, for example, we might find a cyst in their brain, and it might look big and dramatic, but it might be something very benign. It might be a normal variant on the anatomy. Um, there's something called arachnoid cysts, which are very common, and people see them and get very worried. Uh, and we almost never operate on those. And so other times we might see something and think that's a very small lesion, it's probably benign. Uh, if we do an MRI in three months and it hasn't changed, then we might not need to do an operation. We might just be able to watch it. Yeah. So it's not always the case that if you have to come and see me, that we're definitely signing you up for a procedure.

SPEAKER_00 4:19

Aaron Powell Okay. I think that's gonna set a lot of people's minds at rest. And you mention it we talk and we have a conversation and we look at things. It seems like it's quite a collaborative approach.

SPEAKER_01 4:29

Aaron Powell I think as much as possible, I want patients to feel like they're in the driver's seat. They feel loss of control when they're having to come and see a specialist and they s feel like they don't know what's gonna happen. And I want to make sure people feel that they have you know all the information that they possibly could have to make decisions about their own healthcare in their own bodies.

SPEAKER_00 4:50

Yeah, it's a really important thing. And I guess that builds confidence in the decisions that are being made. And there's a bit more trust involved. Um, you mentioned that there's lesions that you look at that might be benign. So is that to say that not all uh I guess not all tumors or brain tumors are cancerous?

SPEAKER_01 5:05

Yeah, that's right. So actually there's quite a few brain tumors that aren't cancerous. Uh now, just because it doesn't look cancerous on the scan doesn't mean it it definitely doesn't need to come out. So everybody is so different and every situation is individual. Um, we have to look carefully at the whole picture. And people wonder why you could have a brain tumor that doesn't look like cancer but still needs to come out. And the answer to that is really a bit like real estate. It's all about location, location, location. So if you've got a lump in a bad spot, then if possible, it's good to get that out. Um, and especially if it's something that's decided to grow. Uh but I think that it's really important that patients know that they can have these conversations really frankly with their neurosurgeon and learn what's unique about them and their scan and their circumstances. Yeah. Okay.

SPEAKER_00 5:58

That's good to know. And I guess just on that location, location comment, is there a good area and a bad area?

SPEAKER_01 6:06

Um so an example of an area where we could possibly just watch a benign, uh benign looking, say, for example, there's a tumor called a meningioma, and most of those are benign. If you had one that was small and hanging out far frontal, particularly if it was on the right side and you're a right-handed person, so I know that you're left hemisphere dominant for speech and language, I would say, hey, if it's not bothering you to think about that ha having that in there, that might be something that we could watch as opposed to signing you up for an operation straight away. But even then, patient preference would matter. So sometimes people can't stand the idea of having something in their head. Yeah. And that can help us, that can nudge us towards offering an operation.

SPEAKER_00 6:50

Yeah. Okay. That's interesting to hear that, you know, just even if it isn't gonna do anything negative, but the patient says, I actually don't want that there, then that gives you the power to be like, okay, we can perform the surgery.

SPEAKER_01 7:02

It's it's reasonable to do this, it's also reasonable to do this. So g bringing the patient, there's times when you really can bring that the bring it into what's the patient preference. Yeah. There are other times where I see something on the scan and I'm like, this is a bad news conversation. I think that needs to come out. Um, this is my recommendation. Yeah. But there are always other options like doing nothing, uh, doing just a biopsy as opposed to trying to get a whole tumor out. And it's important as well, I think, for patients to know that they can always get a second opinion. Yeah. So if you're not sure that you like the plan you've been handed, or you're not clear that you've understood it well enough, then I think I really encourage patients, if they're having any of those feelings, to feel very free to get a second opinion as well.

SPEAKER_00 7:48

Yeah, this is a very important part of your body. It's the brain at the end of the day. You can't live without it. So I think that's a really good point you're making. Everyone should be able to feel confident in what's going to be happening to them and speaking to the right people to build that confidence and make sure that the right decision is being made is really important. I guess that leads on to the next part is, you know, when in a patient's journey would they come and see you.

SPEAKER_01 8:10

So sometimes I see someone because their GP has investigated them for, like, say, a headache or back pain or leg pain, uh, and they've done some imaging and they found a thing. And so then they're like, oh, I don't know what this thing is, but I know someone who can talk you through this. So often I'll have a referral that way. Sometimes we have a finding on a scan which isn't causing any trouble, but we just found it because, for example, someone was out on the weekend and they fell off their horse or their bicycle and they hit their head, and so now they had a scan, and there's a thing on the scan. So those kinds of things are called incidental findings, where it's like surprise, but not in a good way. And so then often I find myself having conversations with patients who are have just been completely startled by finding they have either an aneurysm or a brain tumor or something else new that they didn't know about.

SPEAKER_00 9:08

It's really interesting because I guess those patients, they're not expecting any of this. Do you find that they're more difficult to have because you're dealing with an element of shock and surprise?

SPEAKER_01 9:17

Yeah, and so the the even more extreme version of that is when I'm meeting someone in the emergency department or or one of my registrars, one of the members of my team has met them in the emergency department because they've come in because they've, you know, they've had an accident or they've had a seizure or something, and this is how we found out that they have a a neurosurgical problem. Um, and so, you know, there's the elements of surprise come in in lots of different ways. Um I I understand that the day you meet me might be one of the most shocking days of your life. And for some of my patients, it's the worst day of their life and of their family's life because they're finding out that there's something on the scan that's going to limit their life, um, that's going to change their life. And certainly change will change next the next few weeks will certainly be very, very different than they than they were going to be. And so dealing with people's uncertainty and frustration and pain and um, you know, there's all the parts of like the the grief cycle come out. So sometimes people want to negotiate, they want to go through a period of denial. Um, it's not uncommon for people to be angry when they find out that there's something wrong. Uh and so you being able to sit with that and buffer that a bit is also part of my job.

SPEAKER_00 10:32

Yeah. On that note of all the different emotions that they're feeling, you know, if you were to give a piece of advice to patients listening today, what's one thing that you want them to know when if they were unfortunate enough to have to have this conversation with yourself or one of your colleagues, what's a piece of advice for them to, I guess, help them in that moment?

SPEAKER_01 10:51

So I think I really would want all of my patients to know that um there's no question that we don't want to hear. So whatever's worrying you the most, like tell tell me, ask me. What's what's the thing that we haven't talked about that you're worried about? And often people are worried about their future, or maybe the future for their child if I'm talking to them about their child, or maybe they're they're worried about their kids because they think, hang on, am I gonna be here to see them grow up? And so being able to have those conversations and make enough space for people to really tell me what they're worried about. If you don't feel like you're being heard by your doctor and you've, you know, asked the questions that you want to ask and you don't think you're getting answers, uh, I think definitely finding someone who will answer those questions for you is really important. I really encourage people to do that.

SPEAKER_00 11:41

Yeah, I think that's a really smart step to make sure that you're with the right person for you. If you were a patient, you know, you're in that position and you haven't been able to get that connection with that doctor. Um this isn't a pitch for Doctify, by the way, but what would you recommend them doing? Like who, what's the next best step for them? Do they speak to that surgeon and be like, look, is there someone that you can recommend me to for a second opinion? Or do you speak to another part of the medical team?

SPEAKER_01 12:05

So I think that um most of my colleagues, I think, would be very happy to uh to make a suggestion about another colleague who they know works in the space in the right way. Um Most of us as neurosurgeons have pretty broad scopes of practice, but we often have special interests or fellowship training, uh an extra training, as well as a body of experience with specific problems. So if you came to me and it, for example, if you came to me and it looked like you needed um actually a spinal fusion, that's not something I spend a lot of time doing. Um, it's not a big part of my practice. So I would have a list of my colleagues who I'd be super happy to recommend to you. And once you've met someone, you can sometimes even do a bit of like personality matching where you're like, I think you get on with this one. And I like that. I like being able to do that. Um and so I think that in the first instance, if you think you'd like a different opinion, it's always reasonable to ask the person that you've already met with. And I would hope that that wouldn't be um met with hostility by any of my colleagues. But in in the case that it does, there's always the option to go back to your your GP or whoever referred you to the surgeon to say, Hey, can you um can you make another referral for me?

SPEAKER_00 13:22

Yeah. I like hearing that, especially the part where you said, you know, the personality matching. You've spoken a lot about the communication and the support and you know the the collaboration that comes together through this experience. So having that ability to connect with that doctor and for the doctor to connect with the patient is a really important thing because it's it's a scary time. And it sounds like you, from what you're describing, are very much there to hold their hand and make sure they feel safe and comfortable and everyone's got their own approach and everyone is a different personality, so that's a really important thing. Um, you also mentioned specialties and areas of expertise. Obviously, for you, pediatric neurosurgery is a big part of what you do. If I'm a parent hearing that my child needs to go in for neurosurgery, the first thing I want to understand is risk. So, how do you talk about risks in pediatric brain surgery to the parents?

SPEAKER_01 14:16

So I think it's important to put things into like a big picture about what are the risks and the benefits of doing a procedure, but also the risks and the benefits of not doing it. And so when I go through a consult with a patient or um patient's parents, I normally start with what are the indications? So what are the goals of the operation and what are the um upsides of doing it? We're gonna get a diagnosis, we're hopefully gonna get the whole thing out, that sort of thing. Um and once we've so it's almost like this two-step process. The first is I try and talk you into the operation. Here are the good things about the operation, this is why it's better than doing nothing or uh, you know, an alternative procedure. And then once I've convinced you that this is worth pursuing, now I'm gonna try and talk you out of it, which is where I bring out all the risks and say, there are some things that can go wrong. We aim very much to bring our risks for this kind of procedure down to zero, but we never get to zero with the risks that exist. And then I try and group things for people so they can kind of get their head around them. And I know it's a really overwhelming conversation, so I'd like to sort of slow down and check if they're kind of tracking it. Sometimes people get very overwhelmed when you talk about risk and they get anxious. And I've had patients get, you know, quite emotional. And so then just, you know, just stop and let everyone catch their breath, um, and find out what it is, what is it that they're particularly worried about. And that's often when you find out that like someone in the family's had a really bad surgical outcome, for example, or something like that's happened, which is informing their experience with what you're talking about. And if you don't get the elephant in the room addressed, then you can't get back to talking about this operation for you or for your child uh on the in this instance. And it's not gonna be the same as what happened to your aunt, it's not gonna be the same as what happened to someone from the kids' school. It's gonna be different, and here are the specific risks here.

SPEAKER_00 16:22

Yeah.

SPEAKER_01 16:22

And so letting people know what are the common expected outcomes as well. So you, you know, your kid's definitely gonna be a bit grumpy after the operation. There'll be a convers combination of sleepy and grumpy, and they might be a little bit off their food, letting them know things like when we do operations uh around the front of the head, you know, they might have quite a swollen forehead, they might even have swollen eyes. Their eyes could swell shut. Let them know that. Let them know it won't last forever. So give them the sense of what to expect. What's actually the expected postoperative experience? How long are you going to be in hospital? And then once all that kind of what's definitely going to happen is in place, then what could also happen? It could happen that you have a stroke, it could happen that there's significant bleeding. Then you find out if they're willing to have a blood transfusion, if that was indicated. Really important to have that conversation before you need a blood transfusion, because if someone has religious reasons why they would not want one, it changes how we plan for an operation. And we really need to know that early. So finding out finding out about the patient as you discuss risks is really important.

SPEAKER_00 17:28

Yeah, sounds like it's also an opportunity for patients to really open up to you and share their their thoughts and their feelings around things. Do you find that there's ever a difficult barrier to breakthrough with parents? Or do they normally, because it is their child, they're pretty relaxed and saying, look, here is everything. I I don't want to hold back any knowledge?

SPEAKER_01 17:51

Every family's different. And often the the probably the most um the families I feel for the most are the ones where there's already been another child who's had um ill health and has been in and out of hospital. Often families and and kids pick up kind of hospital-related trauma and healthcare-related trauma from those experiences. Uh, if you've got kids who have complex syndromes and have spent a lot of time in hospital already, you're dealing with all that backdrop. So you really have to be respectful of that and try and pay attention to what they are responding to. Are they responding to something that I just said, or is it because it reminded them of something that happened to this patient's brother or this patient when they were younger? Um, and I think being able to get that kind of information out is really helpful. Because when we're having a conversation about an operation for your child, I'm building a bridge for the whole encounter. So we really need to have a strong connection that we're building now. So no matter what happens, we're gonna be in it together.

unknown 18:58

Yeah.

SPEAKER_01 18:58

And I think that's the the kind of the vision I have is like we're we're building a connection, which is unlike any other connection, really, the relationship between doctors and patients. And lots of people want to commodify that. They want to use sort of marketplace language around it. But I think the doctor-patient relationship is really special. And we have to uh invest in it and we have to fight to preserve it.

SPEAKER_00 19:22

Yeah. And that I think that fight comes from both sides. You know, patients they want to trust, but you mentioned, you know, past experiences. So working through those fears, being open with the doctor and making sure that their fears are being heard and met and understood so they can do the best thing for their child. Because at the end of the day, it's not about them, it's about their child, and you're there to give them every piece of advice to guide them in the right direction that they feel is for their kids.

SPEAKER_01 19:47

And sometimes it's not just advice, sometimes it's resources. Um, occasionally there'll be a a patient, a a parent who's, you know, just found out their kid has like um like a big diagnosis of like a syndrome where there'll be multiple different teams involved in looking after them throughout their life. And fortunately for some of those conditions, which aren't very common, there are support groups. And so sometimes we can also be part of connecting them. Uh, and that can be very empowering and very reassuring. So people understand that their their experience isn't unique and that, well, it's unique, but it they're not alone. And that they have that there are communities of of people who are, you know, in very much the same boat.

SPEAKER_00 20:33

Yeah, I think that's a really awesome, awesome thing to hear that you guys give more than just the medical side, you're understanding the community that's required to to deal with things, you know. The old saying is it takes a a village to raise a to raise a child. And we're always going to be children, someone's child, so we're always gonna need our community to help raise us and keep us moving forward as well.

SPEAKER_01 20:56

Absolutely. And the villages that are needed to raise a child with um significant disability, um, or one of these more complex diagnoses is is really uh such an important part of their well-being. So when I see myself as a surgeon, I'm just one part of that big tapestry, one part of that village. Um people often think the surgeries are like the most important thing that happens, but that's not the case. There's a place that that has in the overall care of a child that, you know, has to be understood.

SPEAKER_00 21:29

Yeah. Um just moving on to, I guess, the surgery aspect of things. Um, you know, one very practical question that pay uh parents ask for their kids, and you kind of touched on it before about setting expectations, but how much pain typically is there for a child after brain surgery and and how do you manage that?

SPEAKER_01 21:47

So it depends very much what the operation has been. Um if we do an operation where we are, you know, doing a craniotomy, so we're opening up the head, we're taking out Window of bone for the duration of the operation, opening up the lining of the brain, and then doing something inside, whether it's taking out a brain tumor or another or a cyst or something like that, or taking out a focus that might be causing epilepsy, then I find that there's a certain amount of pain postoperatively, but that that's pretty well managed with our current kind of pain protocols. And one of the things I want nursing staff or want patients' parents to know is that nursing staff who work in pediatric settings are really good at picking up when kids are in pain. Even if they're really little and they're not really verbal yet, they don't have a big vocab to tell us that they're sore. There's behaviors that kids have when they're in pain. Their heart rates go up. Sometimes the blood pressure goes up. And so the trained nurses that will be looking after your child after the operation, they're really good at picking up on that and they can help with that. Sometimes, for example, if I do operations for a condition called uh chiari malformation, um, which is an operation where we're making a bit more space at the at the back of the brain, at the back of the head, where the head meets the neck. And with that operation, we have to dissect uh through quite a lot of neck muscle. So that's really sore afterwards. So then we tailor our post-operative pain relief to that and try to make sure that we stay on top of that as best as possible. Um, so each operation has a bit of a different strategy for managing post-operative pain, and part of that starts before we even do the operation. So thinking about where to put the local anesthetic, how much, uh, and also speaking to my niece, the test, about what medication to give during and after the operation.

SPEAKER_00 23:43

Yeah, it sounds like the reassurance that patients might need to hear that each individual is treated as an individual, and the staff know how to read signals that we might all be missing, even as parents. Exactly. And I think that's the confidence that people need to hear so that they know that my kid's in good hands. There's a lot of people looking at them to make sure that they're comfortable in that, in that recovery.

SPEAKER_01 24:05

And I think the other thing to mention is like it's very much managing pain postoperatively is a very multidisciplinary thing. So we actually have a pain service at Sydney Children's Hospital where I do my pediatric uh cases. And so we can ask them to specifically drop by and see our patients whilst they're recovering to make sure we're not missing anything and just make sure that's really been optimized.

SPEAKER_00 24:27

So it's a team sport. It really is. It really is. Moving into that, I guess, recovery uh aspect. Is there an average period for you know recovery from brain from brain surgery? Is it days, weeks, months?

SPEAKER_01 24:39

So there's different stages of recovery. Um, you know, kids recover fantastically well in general, and often will be going home something like day three, four, or five after an operation. Sometimes it's longer, it depends what the case was. Um but for elective cases, that's often the expectation. For uh other um other cases, they might be in a bit longer. Things that happen because someone's had an accident or they've it's been an emergency case, often there's more things to be sorted out, so they often are in hospital much longer. And so the hospital phase is obviously the acute phase of recovery.

SPEAKER_00 25:15

Yeah.

SPEAKER_01 25:16

And if you're a grown-up who's had brain surgery, who lives by them by themselves, then we have to make sure that you can do everything for yourself before we let you go home. But if you're three, I mean, you're not doing your own groceries and laundry and you're not preparing your own food, and you're getting help with toileting and bathing. So the threshold for letting you go home safely is very different. And so we can often get kids home earlier in the journey than we would a grown adult. Partly because, you know, past a certain threshold, kids get better faster at home, you know, with their familiar environment, their routines. And sometimes in hospital there'll just be one of their parents there. They might have two parents at home, they might have siblings, pets, things that make, you know, things in people that make them feel like themselves. So they often recover faster getting home. So I do try to get my pediatric patients home as soon as it's safe.

SPEAKER_00 26:09

Yeah, that's good to hear. But obviously, you know, it is a pediatric part of the hospital. Do they make changes to help create a nicer environment for the kids while they're there, like potentially dimming lights, having different sounds, reducing the streets?

SPEAKER_01 26:21

Oh my goodness, there's so much good stuff about kids' hospitals. Like they're fabulous places. And um, you know, there's things that the kids love about being in hospital. Um, so it reframes the hospital experience. There's icy poles going around all the time, you know. There's a fair bit of ice cream. Uh there's something called the Starlight Lounge, where they can go and like play games and there's competitions and they can win stuff. And often they come back up to the ward, like once they're well enough to go down to the starlight, they can they've got face paint on, their siblings have got face paint on. Uh, so you know, there's there's a play therapy is a big part of the hospital experience. And there's a lot of uh ways that joy is introduced into the setting. So I think, you know, one of the sad things about COVID was a lot of those things had to kind of stop. And so in some places they haven't all been rebuilt yet. Uh if you're an adult patient, uh you don't have quite the same volume of celebrities coming through the hospital to say hello uh as you do when you're in a pediatric setting. Um I remember one ward round as a registrar, I was working on Good Friday, uh, actually at the Royal Children's Hospital in Melbourne, and I I almost had to slide tackle the Easter Bunny because the Easter Bunny had come around uh as part of the Good Friday appeal and was going to give my patient some chocolate. And my patient was fasting for theater. Like they weren't meant to have anything to eat. Um, they were just on like sips of water, and this massive Easter bunny was about to be in their face, and so I nearly was violent to the Cadbury crew. Blessed them. They were very gracious about it when I explained that even just leaving it in the room was gonna be mean for a kid who really cannot eat. Yeah. Cannot eat until after their operation, and I don't know when the operation is gonna be. Yeah. So um there's a lot of a lot of fun that happens in children's hospitals that is is very different than what happens in in adult hospitals.

SPEAKER_00 28:26

Yeah, I guess to wrap up this pediatric point of of the discussion, I know you mentioned that it's really important and a big thing to come out of this would be for parents to ask every question and help uh deal with any sort of nervousness or any concerns. Is there any other thing that you want them to walk away from this conversation with?

SPEAKER_01 28:45

I think letting people know that all their feelings are valid, like whatever you might be feeling about this is legit. Uh people shouldn't, you know be beat up on themselves if they're feeling, you know, sad or um or anxious. That's legitimate. It's uh all your feelings are legit. And the I think the other thing I would say is when you're the person who's in a support role for someone going through uh, you know, a significant healthcare encounter, you have to look after yourself too. Yeah. So, you know, you need treats, you need sleep, and many of the conditions that I manage, it's gonna be a marathon, not a sprint. So you really want to be helping people to see ways they can look after themselves, even while they're wanting to look after their kid or their family member who's in hospital.

SPEAKER_00 29:32

Yeah, I think that's incredible advice. Thanks for sharing that. Moving into epilepsy, this is one of your special areas uh as well. Um this is an area that feels a little less visible, uh, but it's obviously very impactful. Um if I'm someone living with epilepsy, at what point does surgery become part of the conversation, if ever?

SPEAKER_01 29:53

So not everyone with epilepsy um gets discussed at a comprehensive epilepsy team level, but I think a lot more patients with epilepsy should be discussed because often when we put the pieces together, we start to see that there might be a role for surgery. So many people with epilepsy, there won't be anything a surgeon can do. But there are times when someone's been living with epilepsy for a long time, and finally they get to a neurologist who thinks, hey, maybe we should just have another look at this. And they're able to find a way in which surgery might be helpful. So to tell you a little bit more about the kind of comprehensive epilepsy teams that that I get to work with. So there's two: there's one in the kids and one in the adults that I'm a part of, and I I love that. Um the the real workhorse are the epilepsy neurologists who also sometimes get called epileptologists. And so this is someone who's done their training in either pediatric or adult neurology. And then on top of that, they've done extra fellowship training on epilepsy and everything to do with seizures. So they're absolute wizards, for example, at reading EEGs, which are like what I like to call to patients the sticky dot test, when they put all those sticky dots and glue all those leads onto someone's head, and then either have them walk around with a beanie on in the community, getting recordings of what's happening to their brainwaves, or they might be in hospital, in a hospital bed, being videoed as well, so that we can see if they have a seizure, what that looks like in like in terms of what's happening to their body, but also what's happening to their brainwaves. And so once they've had this really good workup, um, the EEG techs, the neurologists, uh, myself as a neurosurgeon, neuropsychologists, uh sit down, and together we try to put together a picture, and we often bring a radiologist along as well, because in addition to having just like a normal MRI, there might be some advanced sequences that we get. And there's often some additional tests that patients would have if they're having one of these comprehensive epilepsy workups. Uh, spectr scans, PET scans, and they all need interpretation and correlation. So it's a long, detailed conversation to come out to the other end of that with a conclusion, which will be look, there isn't an a specific area that this seizure is coming from that we think we could do a specific operation for. Or actually, yes, there's something we could do. So broadly, there's kind of two groups of operations we do for people with with seizures. One is where we're actually trying to get rid of the seizure focus and hopefully get someone to a point where they don't have a, like they don't get those seizures anymore. Um and so the most common one of those that I do is taking out a significant portion of the temporal lobe, so a temporal lobectomy. The temporal lobe is often the naughty part of the brain in seizure. So there's a specific, specific pattern to the kind of seizures that people get if it's the temporal lobe that's kicking off. And so we would go into that operation having a strong sense that this is what's driving this patient's epilepsy, and then go through quite a detailed consent process about what could go, what what function could be affected, and uh what is the likelihood of cure for other epilepsy and all these sorts of things. And then we take out a significant portion of the temporal lobe. And and people are a little bit sore after this because I have to cut through the temporalis muscle, which actually helps you chew. It's one of the accessory chewing muscles. So I try and put loads of local in there and give them, you know, just the right meds afterwards, but that can often be a bit sore. Um afterwards, we give them all that information. And if they think, yep, it's worth it, let's give it a go, then that's what we do. So less commonly we find there's another part of the brain where it's very active and there might be something that looks obviously unusual on the scan. Sometimes there's nothing quite as unusual on the scan as you'd want to see it. Often a really good look at a scan shows us something that we think, oh, actually, that might be a low-grade tumor that's causing this. And so then we might take that out with the goal of not just taking out the tumor, but also dealing with the epilepsy. So there's that kind of operation we're actually trying to fix the problem completely. And then there's a group of operations that we do where we're trying to modify the disease. So those procedures have been described as palliative in the past because it's like you're modifying the disease, but you're not getting rid of it. So they're still going to have epilepsy, but they might have less dramatic seizures. So I do two operations that I would say fall in that category. One is called a corpus callosotomy, where basically we just disconnect the corpus callosum, which is the connection between the right and the left hemispheres. So almost completely. So I normally do four four-fifths of that from front to back gets disconnected, you know, using a microscope. Uh, and then the other operation I the other operation I do that's in this kind of category is putting in something called a vagal nerve stimulator. So it's not even brain surgery bench. You're operating on the neck and in front of the pecs. Yeah. So you put uh a little lead around the vagus nerve as it goes uh down the neck or up the neck. Uh, and then you take um a little battery pack, a little generator. So it's got a little computer in it and a battery, and you put that in where a pacemaker would go. And then you connect the two with a lead, and it's all under the skin. And so for some patients, that helps to uh modify their seizures and brings them to a place where their seizures are either less frequent or less intense. Uh, very occasionally it gets rid of them altogether, but we certainly don't, you know, advertise that that's the likely outcome. That's an unlikely outcome.

SPEAKER_00 35:41

Yeah.

SPEAKER_01 35:41

So there's a whole range of good stuff we get to do. And I'm really passionate about this, as you might be able to tell. These are wonderful operations to get to do, and they can be completely life-changing. Epilepsy is a devastating disease, and it limits people's lives, it limits their present and their future, it has profound impacts on their relationships, um, on what they can be employed to do. And when you're a child with severe epilepsy, often you'll be on a whole bunch of medications trying to modify that. And at some point, you can be on so many meds and having so many seizures that it's affecting your development. So you're not meeting developmental milestones, you're not growing the way that you should be in terms of cognition and in other tasks. And so kids often won't be making progress in school, or they might not even be getting to school. So being able to interrupt that process as early as possible is really rewarding. And, you know, the best case scenario is we get to give someone their life back. Um, so I feel passionately about this, and I think that probably not enough patients get referred to complex epilepsy centers and to like comprehensive epilepsy uh centers. So if there are any um, you know, people with epile epilepsy listening to this or general practitioners with patients with epilepsy, you know, make sure they've seen a neurologist recently at um at one of the centers where we do epilepsy surgery. Because often it's really late in life that it gets picked up that something could have been done.

SPEAKER_00 37:10

Yeah.

SPEAKER_01 37:10

And it, you know, unless you're so uh if if you there is a there's an age group where we'd say, you know, probably not appropriate for elective cranial cranial surgery. But, you know, people in the 50s, 60s, 70s, we would consider doing something if we think it's going to make your life better.

SPEAKER_00 37:27

Yeah. You've answered a lot of my additional questions in that. I think that was really well, you really showed your enthusiasm for this because it's obviously something that does impact so many people's lives in so many different ways. And you mentioned the relationships and the work aspect, but also that development side. Um, you know, you did mention a couple of points where you're talking about, you know, removing parts of the brain. Um, but you also highlighted that it doesn't always have to be that. So I guess what are some of the other options for patients with epilepsy who, you know, let's say they're not a candidate for brain surgery and, you know, they can't get that device that you were talking about, which sounds really, really awesome. Um, you know, what are some of the other options for patients with epilepsy?

SPEAKER_01 38:13

So I think if someone's um the the real key is to have a good epilepsy neurologist who's, you know, a big part of your team, uh, because there are always new medications um becoming available. Um and there are also, you know, things that would would have seemed like kind of crazy a couple decades ago that are now we're getting more and more evidence about how they help, like cannabis products, for example, getting that prescribed properly by an epilepsy doctor who knows what they're doing. There's also um some patients who benefit from being on a keto diet. So there's a real range of things that can be helpful and um and can be part of the solution for patients with epilepsy. And having an you know a proper epileptologist driving that program for you is really important for for epilepsy patients. They really deserve that.

SPEAKER_00 39:10

Okay. It's good to hear.

SPEAKER_01 39:11

And and I mean the way I'm talking about them, you can tell that I really appreciate my neurologists. I appreciate them enormously. You know, most of the operations and the the care that I enjoy providing the most is the stuff we do as a team. And and epilepsy surgery is a particularly good example of a team sport.

SPEAKER_00 39:30

Yeah. On on that surgery of epilepsy patients, sometimes it is removing part of the brain. So what is recovery from a surgery like that look like?

SPEAKER_01 39:40

So for most people, it'll be, you know, needing to get through that postoperative period of feeling a bit sore and sorry for yourself. Sometimes people have a few seizures after the operation, um, just because we've been in there and we've stirred things up. And so if people are having uh bad seizures around the time of the operation, that might slow them down. They might end up being in hospital a little longer because of that. I normally tell people they'll be in hospital on average, somewhere between like three and seven days after an operation like that, but with the caveat that some of these procedures people do seem to take a little longer. Also want people to know that sometimes you need some rehab after you've had epilepsy surgery. And it may be because there's been some function that, you know, isn't as it was when you came into hospital and you just benefit from a little bit of finishing school before you actually get back into the community.

SPEAKER_00 40:30

What might be an example of that change in function?

SPEAKER_01 40:33

So if someone's got um a bit of trouble finding words, for example, often we find that can be a thing that happens after someone's had a dominant hemisphere temporal lobectomy. Uh they can find, you know, just a little bit, little bit of um extra challenge with that. So giving them a bit more time with speech pathologists and also occupational therapists to kind of come up with some strategies around that. That can be important.

SPEAKER_00 40:56

I think it's crazy that, you know, your dominant side, because like for me, when I associate dominant side, it's basically the main thing is how I write or play sports. But you're saying it also influences things like epilepsy. I just find that's such an incredible concept that there is a difference because I'm a left-handed, you know, that I have would it be my left hemisphere or my right hand?

SPEAKER_01 41:17

No, no. So so actually left-handed people, so almost all right-handed people are left hemisphere dominant for language, but not all left-handed people are right hemisphere dominant for language. In fact, it's much closer to like half and half. Wow. So if you needed, God forbid, Benji, you should need neurosurgery. Touching would I would be keen to get a functional MRI for you where you get, you basically go into the MRI scanner, but you get to do homework while you're in there. So you have tasks, like they might show you a picture of a dog. And then they when you say, you know, when they ask you what that is, and you say that it's a dog, um, they see which side of your brain lights up. Where is there more activity? And that would tell us, you know, for for making words, this is the part of Benja's brain that does this. But we know that if we show you a picture of a dog, you'd just be like light up with happiness, right? So that might be a bad example.

SPEAKER_00 42:09

Yeah, that that would be something that would happen for me personally. Yeah, yeah. We do love dogs here. Um you mentioned a few times that, you know, post-surgically they might have a couple of seizures. And it sounds like brain surgery might not necessarily be a cure. Um but I think it's important to talk about, you know, it is a whole life, it's someone's entire person. Can we talk about the benefits of having a procedure that really improves the quality of life and you know how that might be a fearful option because it doesn't solve the problem, but it really can change someone's world?

SPEAKER_01 42:45

So uh the corpus callosotomy is a great example uh of an operation where we're not curing your epilepsy, but hopefully we'll change a particular aspect of it. So, specifically with that operation, what we're trying to do is stop what would be like basically like a regional storm in one part of your brain from being a problem in the whole brain. So once it crosses the midline and it affects the structures on both sides, then what we can have is seizure activity, you know, in both arms, both legs. And the real problem with that is that if you lose tone in your legs, then you fall over. And so by the time I'm doing a corpus callisotomy on someone, they've often broken their nose a number of times because they've had so many drop attacks, they've had so many falls. Their family might describe times where they had near misses, where they, you know, almost fell down the stairs. Uh, those sorts of really like life-threatening type accidents can happen. And people who have epilepsy have a higher risk of dying. This is partly why we take this so seriously, is because you know, if we can, if we can lighten the tune the burden of the of the seizures, we can we can change the likelihood of them getting to live to old age. So with a corpus callisotomy, I don't think I'm gonna get you seizures. You're free, but I'd like you to stop landing on your face, you know, falling downstairs, doing that sort of thing. So I've certainly had a couple of patients where it's really given, not just given the patient their life back, but it's given their family their life back because they don't have to be around 24-7. So if you can imagine being a teenage boy where your seizures are so severe that either your mom or your dad has to be with you all of the time, I mean, what kind of life is that? That's that's really challenging. You're going through all these changes and developmental stages, but you're there's a whole bunch of life activities you're not participating in because mom's always there. Uh and I think that that's a strain on everyone.

SPEAKER_00 44:40

I was gonna say, yeah, you're talking about that patient experience, obviously, as a teenage boy, if my mum was, you know, over my shoulder every year.

SPEAKER_01 44:47

Holding your hand every time you're out in public, holding your hand every time you walk down the street. Like, can you imagine?

SPEAKER_00 44:52

Yeah, but then from the the parents' perspective, you know, being able to let them go off because you've you know that they've had something that gives them a bit of their life back, and you get to give them this life that you'd probably grown up imagining that you'd be able to give to your kids. So it really takes that that uh I guess weight off the the people involved's shoulder shoulders and gives them a bit of their life back as well. Because at the end of the day, you know, parents and family members who are worried about their family members, they're always going to be there. But being able to give them some of their life back is also really important. Huge.

SPEAKER_01 45:23

And it affects the whole family, you know. And that's the thing is one of the things I like about pediatric neurosurgery is that everyone remembers that people belong in their families. And so everyone remembers that what affects the child affects everybody. And sometimes we forget that in adult medicine. We forget that no, this person like lives in a in a context and what happens to them does affect the people around them. And, you know, it might be affecting their partner, their kids, uh, the rest of their family, you know, it might have an impact on their pets, on their it certainly has an impact on work. So remembering that this isn't just yeah, and friends, absolutely. Like people hate to see their friends suffer. Of course. And, you know, there may be activities you just can't take a certain friend along for because they're not safe for someone with seizures. Um, people who have bad epilepsy, they can't just go swimming. Because if they have a seizure out there, they're gonna drown. You know, there are people who can't have a bath because that could be something where, you know, if they're having a bath and they have a seizure and no one's there, it could be fatal. So you think about all the ways in which freeing someone up improves not just their life but their whole their whole world. It's it's pretty fantastic.

SPEAKER_00 46:43

Yeah. You're pretty much giving them their life that they always wanted, which is incredible. Thank you for doing that for them.

SPEAKER_01 46:51

I wish we I wish we could do it more. I wish we could do it for more people, and I wish we could and um and I think we're always looking for ways to do it better.

SPEAKER_00 46:58

Yeah. Yeah. Of course, of course. Yeah. We've got a couple more things that we want to talk about. You we we touched on the fact that, you know, not all brain tumors are cancerous. Um, but let's say someone were to hear the words, you know, brain tumor. What are the th the key things that they should understand first to help them comprehend that?

SPEAKER_01 47:17

So I think it's useful for patients to have a look at their scan, and then they can physically see what is it that we're looking at? And where is it relative to other things like their nose and their eyes and their ears, like which side is it on? Or is it right in the middle? Um, how big is it? People like to know how big things are. So I just I'm like, what does it that fine? They want to know, okay, so now I just like get out the calipers on the computer and measure it up for them if it hasn't already been measured so they can see, oh, okay, that's the size of a grape, or that's the size of a, you know, it's always fruit for some reason, or a golf ball, or you know, some kind of sporting thing. Uh, and and I think that that helps people to try and get their head around it. And you you're watching them cope in real time, you know, they're watching them cope with what's going on in real time. So giving them as much meaningful information as possible. People want to know what the future holds. And I don't have a crystal ball, but I do have a set of expectations about what their journey is going to look like based on everyone else who's come through with a similar-looking thing. So letting them know that. The other thing is sometimes people come to me and they've already been given a set of information by a well-meaning non-brain tumor expert. So sometimes we have to find out what they already think. And it may be something that they've figured out, like either the pediatrician or the GP or the emergency doctor has said something, and they might have said something correct, but they've misinterpreted it, or they might have said something that's like maybe just a tiny bit misleading for them. So it's always really useful uh to make sure that they're what they've already laid down as like the facts of the case are accurate and are relevant to them.

SPEAKER_00 48:57

So it's almost like starting the conversation of what do you know so far?

SPEAKER_01 49:00

So what do you know? What what what's your understanding of this? Like, is what would you like, you know, what questions are already on your mind? We'll cover everything, but also sometimes they do have that burning question right up front. So knowing what, like kind of try to get them to set the agenda a little bit is can be really helpful.

SPEAKER_00 49:16

Aaron Powell We've spoken about recovery a lot and that it's very different and it's an individual experience. Um, what are some of the factors that can, you know, influence how someone recovers?

SPEAKER_01 49:27

I think that the patients I've had who've recovered like really well, some of the things they seem to have in common are being children. Children recover, generally speaking, much better than adults. Um, everything still works. You know, they don't get sore knees when they get out of bed in the morning, all this sort of thing. But I think if you have a patient who has kept themselves in pretty good shape, is actually taking care of their body and like exercises regularly, then that patient's gonna have an easier time after most operations than someone who hasn't prioritized that. And so it's been a lesson to me in my own personal life that looking after yourself is partly an investment in your life now, but it's partly an investment in your future because it would be foolish to think that I'm never gonna be a hospital patient. And one day I'll need an operation for something. And that will go better if I've made an effort to make sure that I'm have certain amounts of flexibility and cardiovascular fitness as well as strength going in there. So there are some procedures for which uh patients actually would go through like prehab. Normally, when I'm seeing patients, it's for cranial conditions, where there's not really necessarily heaps of time to wait and, you know, like take months to get ready. Um, but I think it would be lovely if everyone had an opportunity to kind of almost do a physio or an exercise physiology type program before they came into hospital, because for almost everyone that would make their hospital journey better. So at the same time as saying that, I know that uh, you know, I never want to blame a patient for how they're doing postoperatively. What happens, happens. Um, and as long as someone's committed to participating in whether it's physiotherapy or occupational therapy to help them get home, uh, I think that the motivation can make a big difference as well. And one of the other factors is I, you know, I certainly really feel for people who don't have supportive friends or family around them. I think their journey of recovery is is much harder. So one of the challenges all of us have, I suppose, is asking for help. But being able to ask for help if you are going into hospital and call on your friends or neighbors to provide you with a little bit of extra support can make a real difference.

unknown 51:56

Yeah.

SPEAKER_00 51:57

Lean on the people around you.

SPEAKER_01 51:58

Yeah. This is the time. Yeah. I like hearing that. Why save the fine China? Now's the time. Yeah. Cash in all those favors, you know? Absolutely. Yeah.

SPEAKER_00 52:06

Um, this next one might be a bit uncomfortable to ask, but I think it is definitely important. Can things go wrong in brain surgery? And how do you talk about the risk with the patients?

SPEAKER_01 52:15

So I think we talk about risks as part of the consent process and for every operation. And we let people know that even though something's unlikely, it's possible. And we try to paint a picture of what that would look like if those complications occur. I think that having those conversations candidly equips you for when something does go wrong. And sooner or later something will go wrong. And so if someone wakes up from an operation and they have a new weakness, for example, that they didn't have before, being able to be very honest is the key. And so open disclosure is absolutely imperative. Letting them know this is what's happened and this is where we are now, and this is what I expect the future will look like. And making yourself available for any questions that they might have is really key. And it's super uncomfortable if you know that someone has had a complication from an operation that you have done. Even though we know that that's part of the journey of surgery, and as hard as we try, we can't get the complication rates for you know big operations down to zero. We still always want that for our patients. We wish for that. And I care deeply about my patients, so I find myself feeling, you know, very upset if this is something that happens. But being really honest and open and making yourself available for the patient and their family and checking in on them frequently while they're recovering is really important to this. And I think the kind of thing that goes through my mind and the thing that I say out loud at times like this is, you know, we're in this together, you're not alone. And then you have to prove that and show that with your actions.

SPEAKER_00 54:01

Yeah, it sounds like it's very much uh a nice thing to hear that it's not something where you relinquish your responsibilities, you're very much a part of this experience with the family, with the patient, with everyone involved. And from what it sounds like, a key thing for patients to take away is that the people that are a part of the medical team are very much there to do everything that they can. And it's it's it's you're you're asking them to use you as much as they can because you will provide all the support that's needed. And if it's not you, it's you know who to give them. That's right.

SPEAKER_01 54:33

And we know what the team looks like, and we know that drawing on that team will will improve their their next steps in in lic literally and figuratively.

SPEAKER_00 54:42

Yeah. Yeah. Beautiful. We're gonna move into some myth busting uh quickfire questions. Um there are some you know, questions and common misconceptions. This one is a favorite of mine because I've seen lots of shows. Do I have to be awake to have my to have surgery on my brain?

SPEAKER_01 54:58

No, I think that there are a small group of patients who need who who benefit from having awake surgery. I've done a few awake craniotomies for patients that had something near an eloquent area of brain. So some people would benefit from that, but not not everyone. And the vast majority of surgery that we're doing, you're fast asleep.

SPEAKER_00 55:19

Count back to 10, never made it past three.

SPEAKER_01 55:22

Exactly. There you go.

SPEAKER_00 55:23

Um, can brain surgery change my personality?

SPEAKER_01 55:26

That's a great question. I think it's very unlikely. Uh, there are instances of uh of times when it has made a real difference to how someone thinks or feels. Um my hope is that you're still you at the end of the operation, um, even if you feel a bit groggy. Um, but it's certainly a possibility. There's a wonderful book I like called When the Air Hits Your Brain. And it was written by uh an American neurosurgeon called Frank Fratosic. And the name of the book uh refers to a phrase which is one of the rules of neurosurgery he's exposed to very early on in his career. And the first rule of neurosurgery is you ain't never the same once the air hits your brain. So it is, you know, big stakes operating on people's brains, and things can change.

SPEAKER_00 56:17

Okay. I think that's a good way to put it. Um how dangerous really is brain surgery?

SPEAKER_01 56:22

It's as safe as we can possibly make it. But it is a high-stakes game, and so so many of the things we do around the time of surgery are made to improve the safety profile of surgery. And we have benefited in surgery from using insights from other industries, like the aviation industry, to improve safety profiles in theater. And so one of the things I'm most enthusiastic and evangelical about is a surgical timeout. So before we do your brain surgery, we're all going to stop doing what we're doing. We're all going to be quiet and pay attention, and we're going to go through a checklist. It starts with introducing every member of the team who's in the operating theater, checking who the patient is, checking if they have allergies, and then making sure we're doing the correct operation on the correct part of the body. Making sure we've got the right imaging available, that there are no pressure area concerns, that they've had antibiotics, that they've had all the other medications that we might want them to have, and that everything has been optimized for a safe operation. And anyone can speak up at any point in that and go, actually, guys, I'm just, I think we've just lost this drip. Okay, we're gonna let you do that. We'll get let you sort that out before we get started. Um making sure that we haven't, oh, they they are allergic to that. Oh, I'll have to use a different prep, like that kind of stuff. Just making sure there's no area where we haven't gamed ourselves for success in every way, and that we have a shared mental model. So it's a bit like a cockpit, right? That's what I was imagining. We want to get it right. So, yes, there are risks, but the entire enterprise is geared at reducing them. Aaron Powell Yeah.

SPEAKER_00 58:01

And I think for anyone who's looking for a zero-risk surgery in any part of surgery, might be looking for a very long time. Aaron Powell Correct. Um Another quick one will I lose my memory after brain surgery?

SPEAKER_01 58:13

Aaron Powell I hope not, but it is certainly possible, particularly some of the epilepsy surgery that we do. If we're operating in the temporal lobe and in the mesial temporal structures, we can um things like the hippocampus, we can affect memory. And so often we do a pretty uh extensive workup ahead of time with a neuropsychologist to try and figure out exactly what this person's working memory is like to start with, so that we can appreciate what uh what deficit they might have at the end if we go forward with what we're planning.

SPEAKER_00 58:44

Yeah. Nice. Does having brain surgery mean I won't be able to live independently afterwards?

SPEAKER_01 58:50

I sure hope not. If someone's living independently when they go in for brain surgery, I would very much hope that it wouldn't change that. There are times when things happen and that is not the outcome. Um, but and the other thing to say is that sometimes you're dealing with a patient who's, when you meet them, already deteriorating. So someone who's come into hospital with a big malignant brain tumor, for example. They might have been living independently on Tuesday, and Wednesday they're in the emergency department finding out something bad has happened. On Thursday or Friday, they're having a big operation. And then by next week, it becomes apparent that they're not going back home on their own because everything has changed. And it's not just the brain surgery that's different, it's the brain tumor and the effect it's already had on their brain. Uh, and it's sort of like everything catching up to what's happened to them.

SPEAKER_00 59:36

Yeah. Completely understand. Um can seizures get worse before they get better after epilepsy surgery?

SPEAKER_01 59:43

Oh, absolutely. And in fact, uh it's an important thing that people should know. Um, it's certainly not predictive what happens in like the 48 hours after an operation. You know, we've just been in there, we've been stirring things up. It's what happens in the medium to long term that's most predictive.

SPEAKER_00 59:58

Yeah. Yeah. Okay. Is brain surgery more risky in children?

SPEAKER_01 1:00:04

I think that unless it's very small children, uh, it's probably less risky than in some of our older adults. There are different risk profiles. The one thing that very small children and babies are vulnerable to is any blood loss because they've got there's so little baby. They have, you know, like sometimes they've got like basically a cup of tea amount of blood in them. So you can imagine, like every drop you lose, you, you know, you've really got to aim for trying to do as bloodless an operation as you can. And for those patients, we sometimes have cross-matched blood already ready in the operating theater or right next to the operating theater, so we could start transfusing early. Um, so the risks are different. The bleeding risk is probably the biggest one where not very much, not very many mils of blood need to be lost before we have a problem with blood pressure and heart rate in in little children. But in most ways, I find kids recover better than adults, and uh they seem to be less prone to get postoperative infections of various kinds. And uh certainly their hearts and lungs in most cases are much more suited to the task of going through a general anesthetic than some of our older adults, or certainly adults with other um health conditions.

SPEAKER_00 1:01:18

Cool. Yeah. Nice. Um, this is a big one. Will brain surgery affect my child's development and learning?

SPEAKER_01 1:01:25

So we normally would only do brain surgery if we thought that it was either going to uh help that or um have no effect on that. Particularly with epilepsy surgery, if we're able to reduce the amount of seizures that a kid is having, or best case scenario, stop them, then over time they might be able to come off of all those really strong anti-seizure medicines that they've been on. And often it's a combination of the seizures and the anti-seizure medicines that have been kind of holding a kid back. So once their their sort of medical burden lightens, they can actually uh often be seen to have like big strides, big improvements developmentally. And that's exciting. Now, some kids don't ever like quite catch up to their peers, but they actually start to, you know, lay down new memories, put on weight, you know, improve with their language, start moving around more any number of things. Yeah, they start to actually, you know, tick some milestones off.

SPEAKER_00 1:02:20

And I think it's also important that like it's their kids' milestones, it's individual milestones. Milestones don't don't have to be the same for everyone.

SPEAKER_01 1:02:27

Yeah, and everybody's different anyway. Um most people don't benefit from terribly tight scrutiny, you know, there's always something to find. And when you have a kid who's kind of been medicalized and has a condition, then everyone's just like watching like a hawk. And so no matter where your kid is up to with development or disability or seizures or tumors or anything, I think one of the things I really like to emphasize is make sure you take time to enjoy your kid. You know, you have a wonderful, beautiful child. Make sure you get time to enjoy them and really just do the fun things that you can do with them. Um make sure that's not always about the the you know medicine and the the badness.

SPEAKER_00 1:03:10

Yeah. I like that. I like hearing that. So we are getting closer to the end. So a couple of final thoughts. This is obviously sorry. This is obviously called the patient in the room. So when I'm sitting in the room as a patient, what do you wish I felt more comfortable asking?

SPEAKER_01 1:03:27

I I really hope my patients feel comfortable asking me what their like deepest fears are, like what they're really worried about. And actually you've touched on a lot of things I think people worry about. Things like memory loss, personality change, postoperative pain. Um people often are really worried. They want to know, am I gonna die? You know, and I I I hope that my patients that I make enough space for them to ask those questions, that they can ask the thing that's worrying them the most, so that we can really get to the bottom of that.

SPEAKER_00 1:03:58

Yeah. I think having the the scariest thoughts given the space that they deserve, because you are set you are walking into a position where as a patient you're handing over everything and it is a common thought in and it again, I I don't think this is just for neurosurgery, but it's a big question asking, am I gonna die? Yeah. And it's a safe question, it's a safe space to ask that question, and it's a very valid question. I think that goes back to you saying all your thoughts and fears and feelings are valid. Everything's valid. Everything.

SPEAKER_01 1:04:28

There's got to be room for it.

SPEAKER_00 1:04:29

100%.

SPEAKER_01 1:04:30

Yeah.

SPEAKER_00 1:04:31

And if someone's listening, um, if someone listening one day might need neurosurgery as an adult or for their child, what's the most important thing you want them to know going into that experience?

SPEAKER_01 1:04:43

So I think I want all of my patients and possible future patients to know like we're human beings too. Um, and we have, you know, ups and downs as well. And none of us are perfect. But what we really want to do is be in partnership with you, with you, with your kid, um, with your family, um, as you go through what could potentially be one of the, you know, most difficult parts of your journey, but which hopefully will be something where you always feel that your humanity is upheld and respected and that your wishes are really at the forefront.

SPEAKER_00 1:05:20

Amazing. That's really beautiful to hear. Thank you so much for joining us.

SPEAKER_01 1:05:25

Thank you for having me.

SPEAKER_00 1:05:26

You've provided a lot of clarity around a lot of things people question and might not feel they can ask or don't know who to ask if they're living with, whether it be epilepsy or a family member or friend who's got a family member or friend with any of these conditions that we've spoken about. So, really, thank you for sharing your knowledge and highlighting the impact that you and lots of others are having on lots of different families. This has been Patient in the Room. Thank you all for listening.