Welcome to Neurosurgeryland

WELCOME TO NEUROSURGERYLAND

I thought our big adventure this year would be our trip to East Africa. Well, that trip was terrific, for sure. But our biggest adventure turned out to be our trip to Neurosurgeryland. Be warned: this is a long post, 6,000 words probably. But I’ll do my best to keep it moving along.

My Life as a Neurosurgical Son

I was the eldest child in a neurosurgical family. I say “neurosurgical family” because when your father is a neurosurgeon, that’s the whole deal right there. Neurosurgeons tend to be Ayn Rand hero-types. That’s what my Dad was.

He got to be a neurosurgeon because of his father, who was a general practitioner (and also billiards champion) of Philadelphia. The story goes that one day in 1932 he blew his nose too hard and the infected phlegm went backwards through his ear, causing a cerebral abscess. With no antibiotics and only rudimentary brain surgery, he soon died. My father was 17. The attending neurologist put my Dad to work as a neuropathology technician, and soon doctors were calling him directly for his reading of the slides.

As my Dad was at the end of medical school the first neurosurgeon in Philadelphia, Francis Grant, came to him and asked him what he was going to be. “A neurologist, I guess,” said my Dad.

“Well, you know,” said Dr. Grant, “if you are a neurologist you will have to do psychiatry, too, to make a living. Why don’t you think about being a neurosurgeon?”

Much to the advantage not only of my father but a myriad of patients who would be seeking psychiatric advice, my father became the third neurosurgeon in Philadelphia.

The next part of the family story is that my father could not stay at Penn although he wanted to. He was Jewish. Dr. Grant said to my Dad, “We did it for Rav (Isidor Ravdin, internist), but we can’t do it for you, Henry.” My Dad stuck to that story, but one time years later he said that it might have been his personality, too.

My Dad wound up as Chief of Neurosurgery at Episcopal Hospital in North Philadelphia and perennial President of the Medical Staff. He has a list of “firsts” he accomplished as a nationally and even internationally known neurosurgeon, but his favorite had to be owning the first CAT scanner in Philadelphia. It operated 24 hours a day, and when they called for an appointment from Penn, my mother would be happy to give them the open 2 AM slot.

I idolized my father, but when I was in medical school he put no pressure on me to become a neurosurgeon, and in fact urged me more toward administrative or academic medicine. He rightly saw that if I chose the neurosurgical path, it would have to come from me. But I chose pediatrics. When my father announced this choice to his hospital lunch table colleagues, there was a silence. Someone spoke up, “But, Henry, those guys work so hard and they hardly make any money at all!” Silence. Then, “Can you talk to him?”

Even though I seem to have a “surgical personality,” pediatrics and administration has been great for me, a real mitzvah. But I remained a neurosurgical son, at home in Neurosurgeryland. When my Dad had a reunion of his residents at a Harvey Cushing Society meeting in San Francisco, I was asked to speak. I told the residents that we were all his sons. They loved him.

My Dad died at age 92 in 2007, his last accomplishment having lived to the age of 92. He was a man of objectives. He told me in his 80’s that he figured that the goal now was to live long, so he reduced his diet and made it to 92. “Made it to 92,” was one of his final statements. He observed many times – many, many times, since he was not one to deny himself the pleasure of reiteration -- that he was born when horses were the general mode of transportation in Philadelphia for God’s sake, and that his generation had seen the most amazing transformation in technology not only that the world had ever seen, but much more than anyone could ever have imagined. Just in his own field, my Dad had gone from relative helplessness with his own father’s illness, through the techniques that my Dad and his generation created, and then beyond. (My own view is that advances in medicine and in space and physics exploration are the quintessential advances of our age, even more important than the securitization of mortgages.)

As if to prove the point, just seven months after Dad died, I got my hip resurfaced (slightly more advanced than the traditional hip replacement.) I had told him I was having some trouble with it, and the kindly (he was kindly with me) neurosurgeon said, “Get it fixed.” Spare parts replacement surgery. If you think about it, wow. Star Trek.

Ophthalmology

So that was fine, but then last year I started having some trouble seeing. I had always taken pride in my eyes; even here in my late sixties, in strong light I have been able to read the New York Times without glasses. But I thought Father Time was catching up with me. My prescription hadn’t changed and I got checked up each year, but I was having real trouble seeing. I went to the ophthalmologist in December 2010 with pretty severe complaints. I couldn’t see anything on the eye chart with my left eye, and my right one wasn’t so great, either. My ophthalmologist said that my vision hadn’t changed a lot (that was hard to understand), and the small cataracts I had shouldn’t really affect my vision that much. But nonetheless, he didn’t delve further and gave me a packet of information on cataract surgery.

It didn’t make sense to me, but I thought maybe he just wasn’t paying enough attention to helping my vision. I thought I’d try to do that, so I went to the optometrists at UC Berkeley, who used terrific new technology to map my whole eye on each side – fantastic, granular pictures of just every part of my eyes. Star Trek. I wondered with the optometrist, since the cataracts don’t explain the vision loss, if there was something neurological going on, since the exam of all aspects of the eyes was so normal. But it was left at that, a wondering. He asked me to come back to try one or two things more, but I let it go. I got new glasses for reading and that helped some.

My eyes got worse. I had trouble making out a wall menu when the lettering on the wood was in yellow. I thought the type on some of my books was faint. I felt often the way you do when you have looked at brightness and your eyes have yet to accommodate, but they never would accommodate, and I was just left with the glare. Ann and I took a wonderful trip to Africa, and she could see game that I had to look twice or three times to see. We came home and were about to go on a long-planned trip to Hawaii with my brother and sister-in-law, and I said, “I have to go back to the ophthalmologist. My eyes suck.” Maybe it was just age, but I had try again, even if he might just say, get the cataract surgery.

So I did. The house optometrist asked me why my vision was poor (I said, you’re the doctor! To which he took offense), and then why I hadn’t had my cataract operation. They had only done a partial transition from paper to electronic medical records, but he eventually was using both to trace my history. He refracted me (not sure why). Then he looked at my left eye’s progress over the last few years – 20/40 to 20/60 to 20/80 to 20/100. But the size of the cataract hadn’t changed. My ophthalmologist came in and seemed puzzled. I asked him about neurological disease – I’m too old for multiple sclerosis, but something was happening. I told him many of my symptoms. I was emphatic – when I read I can’t use my left eye at all, and I’m scanning with my right eye. Finally, he said he would do further testing. He looked at me as though I had pushed him enough. I could only make out one of the numbers on the Ishihara color discrimination test – but that’s OK, he said, you’re dilated. He asked if his office could set up an appointment with a retina specialist. He asked me to make an appointment to come back for a visual field test.

I went out front and the staff made the retina appointment with the wrong group until I corrected them. I insisted on giving my cell phone number to the front desk person who didn’t seem to know what to do with it on the electronic medical record. I was about to leave when someone came around the corner and said they could do the visual field testing now after all, if I could wait. Of course I could. The tech came and got me for the tests, chin up and one eye looking straight ahead, thumb clicking on device every time I saw a flash of light in various quadrants. The tech excused himself during each test because it was so boring for him to sit there and watch. I left and ate an early Japanese dinner with my step-daughter Sara, a UCSF pediatrician, and 1 1/2 year old Lola. I told Sara I thought I could have a brain tumor of some sort. Then I went home.

The ophthalmologist had left a message on our home answering machine – call him, he didn’t have my cell number, so he is calling here at home. I called and he said, you have both eyes involved, the upper outer fields in both eyes are cut. So there is something going on at the optic chiasm, where the optic nerves cross, right in the middle of the head above the pituitary gland.

“So I need an MRI,” I said.

“Right,” he answered.

“So I’m not going to Hawaii tomorrow morning, “ I said.

“Right,” he answered.

I called my wife who was already there in Hawaii. I explained what was happening. She said, “I think I’m going to cry.”

I said, “I think it’s going to be OK.” The most common thing for it to be would be a pituitary adenoma, which is operable and non-malignant. I was counting on that. I told her not to take the red eye home, let’s see what happens tomorrow.

She called Sara, who called me and said she wanted to come with me to the MRI. I could handle it alone, but I was grateful and I accepted. My father said that every family should have at least one doctor in each generation.


The MRI

It was Thursday now. The ophthalmologist’s office called at 9 AM. They said they had me scheduled for the MRI on Friday at 7:30 AM. I said, “No.”

She said, “What?”

I said, “I’m getting my MRI today. Who did you call?”

She said, “I called all around.”

I said, “Did you tell them it was for Dr. Budd Shenkin?”

She said, “No, I asked them when they had an opening.”

I said, “Did you call Stuart London’s office?”

She said, “No. I should have thought of that.”

We rang off. At 9:20 she called me back and said, “Dr. London has you scheduled for 12 noon today.” I thanked her. He had bumped somebody less acute, who wasn’t going blind.

I had to get my blood tests to him by noon so I could be injected with contrast. The local blood draw station for Labcorp got stat lab results by the end of the day. I went to my old home hospital, Summit, and they got the super stat labs to Dr. London in an hour.

I went home and did some scanning and shredding – I’m making my home office as paperless as possible, Ann’s too – and Sara and I went down to get the MRI. They did my test while she got a sandwich at Ptomain Heaven, all that is available at 34th and Telegraph in Oakland. When my test was over, Sara and I were escorted back where Stu could review the MRI with us.

Stu looked at me with compassion and professionalism and took us to the computer and said, “You have a macroadenoma of the pituitary. It’s 4 cm by 3.2 cm by 2.8 cm. It has extended first down into the sphenoid sinus and then up to squash the pituitary against the side of the sella turcica (the seat of the pituitary, which has a floor and pillars on each side, so it’s like a throne), and it is putting pressure on your optic nerves. What are your symptoms?”

I told him. Then I asked the obvious question, to which I really knew the answer, but I wanted to reassure both of them, in a way. “Is it operable?”

“Oh, yes, it certainly is,” said Stu.

Ok, then. “Where should be go, Stu?” I asked.

He shrugged, “UCSF. You don’t want to go local with something like this. No disrespect to the local guys.”

Of course. That was my view as well. I knew Charlie Wilson had pioneered the nasal approach to the pituitary years ago right here at UCSF, which was my home institution, and for years I had insisted on PPO insurance so that if something like this happened, I could go there. Charlie Wilson was always my explanation when I signed up for PPO. Not that I planned on it. (See http://www.newyorker.com/archive/1999/08/02/1999_08_02_057_TNY_LIBRY_000018760, for the New Yorker's essay on Charlie Wilson.)

After thanking Stu, Sara and I left with the disk of the MRI and she grabbed my arm above the elbow, in support. I didn’t feel any angst at all. I knew this was doable.

We walked to the car and called Ann on the Bluetooth speaker phone, and told her. She said, “You two aren’t sugar coating it, are you?”

Sara and I looked at each other to make sure. Then we both said, “No, we’re not. It’s really going to be OK.”


Starting with Neurosurgery

I called the ophthalmologist and told him the result. He said that all my vision would return. From his lips to God’s ears, and the ears of his malpractice carrier. I told him that my goal now was to find the best surgeon and be operated on by the middle of the next week. He advised going to UCSF, saying he had had a couple of patients there. I asked him to try to get me an appointment asap, and tell them I’m on the clinical faculty there, etc. But move on it. He agreed.

We checked other sources. Sara pulled up the bio on Sandeep Kunwar, the chief neurosurgeon at the Pituitary Center at UCSF. It said he had the largest series of pituitary adenomas in the country. Another colleague of Sara’s, a neurosurgeon in Sacramento, called her to say there was no reason not to go to Dr. Kunwar. I called other sources, who eventually confirmed the choice. I hoped he was not on vacation.

He wasn’t. I scanned and shredded some more, ate dinner at Asmara, my favorite Ethiopian restaurant, and called my brother to tell him the change in plans. He would have to figure out whether to go to Maui on his own with Susan, or change plans. I talked to Ann a few times. She would head home the next day. I felt fine, although I still couldn’t see very well.

On Friday morning I got a call from Dr. Kunwar’s office, asking if could I come to his office in Fremont at 12 noon. apologizing for the short notice. I said I thought I could make time in my schedule to be there. I scanned and shredded, did email, and left to be on time. I was taken back to the exam room at 12:20 and they apologized for keeping me waiting. Dr. Kunwar arrived and apologized for keeping me waiting.

Dr. Kunwar introduced himself as Sandeep Kunwar, informally, just the way Mike Ries had introduced himself when I had started seeing him for my hip. While being friendly and informal and very warm, he was brisk and practical, with no time for traditional formalities like listening to my heart or even examining me. He had the MRI and didn’t need anything else. He asked me about my UCSF and UCB connections – he graduated at UCB, and had done all his medical work at UCSF. I asked him if he trained under Charlie Wilson. He said yes, he trained with him, and then took over his practice. “Great,” I said. We are part of the same club.

He told me he would go over things I no doubt knew, and I said, right, treat me like a patient. We nodded understandingly at each other. As he started I interrupted briefly. I said, “I have to tell you, I come from a neurosurgical family, so coming here I actually feel right at home.” He was interested. I told him about my Dad, whom he hadn’t heard of. I said, “I remember coming down in the morning and my Dad wasn’t drinking coffee because he had a brain tumor that morning, and he didn’t want his hands to shake. So here we are.” He shook his head in understanding, right. I had been more worried with my hip than here with my brain. (As Woody Allen said, “Not my brain! That’s my second-favorite organ!”)

He then gave me his personalized rap. The facts of the case were straightforward. He said I had probably had this tumor for eight or ten years. Below 45 years of age they usually produce a hormone, over 45 years they are non-productive. Sometimes they are prolactinomas, but not usually. It had expanded down into the sphenoidal sinuses without noticeable symptoms. It had also flattened out the pituitary and doubtless wiped out several of my hormones. He said the first one to go is Human Growth Hormone, but in adults patients don’t notice anything. (I wanted to say I had noticed a loss of power from the right side of the plate, but restrained myself.) Then thyroid goes, then testosterone, and then cortisol. The thyroid and testosterone are easily replaced by a pill and a gel, but the cortisol is harder.

He asked about my symptoms. I told him I had been on supplementary thyroid because my internist had taken a test just on the basis of ageing and found a little deficiency. My libido had been down for some time, which I found to be a relief. He asked me about general vigor. I’m in very good shape, so I turned my palms out and straightened my arms to say, “Look at me. I’m 69.” He said, “But you could be even better!” Some slow wound healing maybe, but I didn’t mention that. Dry skin. Still, basically unnoticeable except for the vision. He said that once squeezed, the pituitary doesn’t recover significantly but we could replace everything, it looked like.

After the tumor had squeezed the gland and grown downward and obliterated the sphenoidal sinus, it started to go up, meeting the optic chiasm. That’s what had brought me to this exam room.

These tumors can be either spongy or more rigid, in a spectrum from about 20% (spongy) to 80% (rigid). They come either like hard-boiled eggs that can be easily peeled out from the shell, or more like cauliflowers that are harder to resect. Problems with resecting come if they have wormed their way into something that it’s hard to get them away from. The cavernous sinuses would be number one. A nerve can also be a problem. But even in these cases we get most of them. They are slow growing, so if there happens to be some left behind we just follow it with serial MRI’s and then if it gets bigger, we cut it with a gamma knife, just tightly-focused radiation.

The approach used be under the lip with Charlie Wilson, and is now through the nose. You break through the sphenoidal sinus, which we won’t have to do here because the tumor has already destroyed it. Then you follow it in, debulk it from the inside, then go carefully with each surface of it and pick it out. Then put some fat he would get from my abdomen into the sella, which the tumor had enlarged, like the foam we use to take up the extra space in packages. He told me he had done over 2,000 of these operations now, and the risks are down to under 1%. That’s a good number. He said I would regain the vision I had lost in the last 3-6 months, but that the endocrine function lost would not likely return, but could be replaced.

He said he operated at both Washington Hospital and UCSF. He went into private practice and operates in Fremont because he has a technology and he wants to do more with it, go different places in the body, and you can do more off-campus. It’s funny, he said, you would think you could innovate more on-campus. But in fact UCSF is great for the science, but off-campus is best for technology. I could choose where I wanted to be operated on, it didn’t matter to him, each has its own strengths and weaknesses. I didn’t ask more about that, I just wanted the earliest date available. That date turned out to be Wednesday, August 3 in Fremont. It would be less than one week from ophthalmology appointment to operation, which was my goal, so long as I got the best neurosurgeon, which it seemed like I did. As I left the front desk to get my blood tests, he left the opposite way, waved and said, “See you Wednesday.” I responded, “Be there or be square.” We smiled at each other.

I got my blood tests, collected my paper work and drove home. It was set. I had my man and I had my op date. I was very comfortable to be back in Neurosurgeryland.

The Operation

I picked up Ann at the airport that night to the relief of both of us and filled her in. Over the weekend I worked out, did some work (scanned and shredded), notified near and dear, decided with this risk level that son Allie didn’t have to come from his home in Panama to stand by, decided to let leadership at Bayside know the prospect but to wait until post-op to let everyone else there know – why worry them? - took grand-daughter Lola to the merry-go-round and the little farm in Tilden Park on Sunday, got the pre-ops on Monday, did more work on Tuesday, scrubbed hard in showers Tuesday night and Wednesday morning and slept in freshly washed sheets and pajamas to minimize infection risk, loaded up my pill boxes for two weeks, got packed up with slippers and pajamas by Ann, and we drove down together on Wednesday morning, all ready.

The anesthesiologist came and we talked. He was a Stanford guy, which was reassuring. I remembered Reagan’s aplomb as he was wheeled into surgery after the assassination attempt, “ Any of you guys Democrats?” So I confessed we were Cal people. He recalled gifts of cases of wine he had received from former patients. Stanford guys…. He shot me some Versed. I said, “I like Versed.” He said, “Who doesn’t?” That’s the last thing I remember before waking up in the recovery room – no ICU, even – and Peter and Ann thought I looked ten years older. I got morphine and was fine.

First thing I did when I woke up was look around and check my vision on signs. My left eye was working fine, already. My right was better, too. It had already worked.

At nine PM Dr. Kanwar came by. I asked him what else he had done during the day. He said, two other cases, a spine and something else, the clinic, and then a gamma knife conference. He’s 44 years old and full of energy – the perfect age, and the perfect intensity. He told me my tumor had come out completely – it was hard-boiled egg, not cauliflower. My tumor was the size of a small tomato, almost as big as they get, and very rigid, almost like cartilage, maybe 90% on the spectrum. It had probably been there for 8-10 years. He said that since it was so fibrous, there were only a handful of surgeons in the country who could have handled it – he wasn’t bragging, he’s not a braggart, it was just fact. Good choice of surgeon. Wow. And here I was just conversing with him after his being in the middle of the brain just a few hours ago. As Ann said, it was scary that he was in the middle of my brain, both literally and figuratively. Ann’s a funny person.

I told him, “I don’t know how much you make, but whatever it is, you deserve a lot more.”

Recovery

The first night was morphine, the second night was hydrocodone, then it was home on Friday. Ann sat with me and 27 year old son Pete did, too. Ann ministered to me as she knows how to do – second major surgery in three years. Over and out, hopefully. She told me not to be abstemious with the hydrocodone, which I tend to be, to keep ahead of the pain.

I told Pete, “I feel fine!”

Pete laughed and said, “Dad, of course you do, you’re on hydrocodone!”

Pete urged me to name the tumor. Didn’t want to do it then. Subsequently settled on “The Tomato.”

The ophthalmologist’s office called to find out what happened, so I called back and told them. We let Bayside know I was fine and they could let out the word. We let near and dear know.

It’s good for a doctor to experience the other side of health care. It makes us better doctors. I noticed the hospital. The room was good size and private; the TV was flat screen with a pretty good cable range of shows, including Giants games. The nursing was attentive, each nurse with his or her own personality. Kim fought playfully with me about how we were going to keep me un-constipated while taking pain meds. Roy said his charge nurse wouldn’t let him leave Mylanta by the bedside because it was a drug, and he hoped I would understand because he didn’t want to get written up. I had my blood drawn at 4:30 AM each day. The default channel on the TV was constantly rotating nursing conferences about their quality efforts, very earnest. The charts on the walls as I took my walks were about steps toward quality. That’s good. Think of how hard it is nationally to get hospitals to take action for quality – very difficult. Large groups of people like American hospitals are, by definition, average. Yet national imperatives have filtered down to hospitals well, and progress is evident to a patient like me.

The night before discharge Sandeep’s PA Joe repeated the rules of recovery again: Two weeks of no work, no lifting, lots of reading, some walking, and no blowing the nose. Then two weeks of limited work. Then done. Expect sinus headaches for a couple of weeks. Use Ocean Spray. Things in my head were rearranged and we needed some time for it all to sclerose in and become settled.


At Home

When I got home Ann brought me meals in bed. I followed her advice on meds and rest. I appreciated her ministrations and other secondary gains. I had thought about cautioning others that I didn’t want a fuss made. Then I thought, what’s wrong with a little fuss? Forget the Mr. Cool. Emails, flowers, cards, books. Food. On Saturday Stu Lovett came by with blueberry pie, and we visited. He said he saw my car out front so he figured I was OK. Ione with a stew. Marjorie and Michael with a great salmon dish. And as with the hip, a sandwich from Andronico’s tasted like no other sandwich ever tasted – last time tuna, this time ham and cheese. Cards from people and group cards from some Bayside offices. I choose to believe that these are real expressions of person to person concern and affection. I’ll take it.

I followed Bobby and Susan’s Maui adventure each day, they came back for two days here, used some Giants tickets and loved the stadium, visited for an hour in the sun with old and very dear friend Bob, and as Hemingway would have said, it was good.

I started feeling better, but then Peter sat me down and lectured me: “Dad! You’re not following the orders! You have to take it easy! I saw you picking Lola up!” He was impassioned, frightened for me, and he was right. I thanked him and pledged to be a better patient. I appreciated his concern and his love

And then there is my vision. I kept checking it out. Would it get better still? I walked around the block with Sara and Lola and I thought everything looked more colorful, and the air was clearer. There was no glare. I can see my cards in Freecell more clearly; I can read the numbers on the squares clearly in the New York Times crossword – still can’t do the puzzle all that well, but at least it’s not because of my eyes. I can read real books. I decreased the font size on my Kindle so I can read it faster. What a gift!

I saw my friend Joel the urologist, and we talked again about our OB friend Hank, who died in May of malignant melanoma. He had told Joel that he felt like he was in a speeding car and couldn’t get out. What an image; I understood it. I wish Hank could have gotten out, but even if he couldn’t, I was thankful that I could. Joel said, retire, man! He recounted those who worked too long. But we love our work. The trick is to keep it in its place, I said. Yes, he said, keep it in its place.

After a week I drove into the Oakland office so they could see for themselves. I was home free.

Endocrine Follow Up

The following week Ann and I drove to UCSF to see my endocrinologist, Lewis Blevins. He told me I looked so young, and we would wait six weeks and take hormone levels and see what needed to be replaced. He said that he has been at three different institutions with different neurosurgeons, and Sandeep is the best. He used to say to patients that post op, 1/3 will have worse endocrine function, 1/3 the same, and 1/3 better. With Sandeep he says 5% will have worse, 10% the same, and 85% better. Neurosurgeons are not fungible.

He said that he didn’t see why neurosurgeons don’t refer all pituitary tumors to UCSF. There aren’t enough of either pituitary tumors or neurosurgeons to make a financial difference. Maybe it’s the neurosurgical personality, the ego. I agreed with him. There are two current theories for organizing health care. One is vertical integration, or integrated networks, like Kaiser. The other, as suggested by the book “Redefining Health Care” by Porter and Teisberg, is centers of excellence, where a primary care doctor or a patient him or herself, could choose among competing centers for quality, cost, and accessibility, for each individual affliction. I’m in the centers of excellence camp. Made sense for my hip, made sense for my pituitary. I found the centers where problems from other docs were referred to for repair, and I just went there straight away. Makes sense to me. Surgeons and centers of excellence are not fungible.

What I Make of All This

So what do I make of all this?

First of all, I’m on Medicare and a Medicare supplement – so notice, not once have I said anything about a network, calls to insurance companies, or cost. I paid only $50 for the refraction done at the ophthalmologists. Medicare has great problems, but they sure aren’t on the patient side. For patients, this is just the way it should be.

But I reflect back to my Dad. This case is such a triumph of modern medicine! In my Dad’s day, he would have had to do a pneumoencephalogram, probably, an excruciatingly painful Xray procedure where the neurosurgeon injected air through a lumbar puncture, the body was tilted this way and that, and the lesion outlined against air in the ventricles of the brain. Instead, we have an MRI with about half an hour of lying on my back, and exquisitely detailed pictures of every aspect of the brain, with millimeters of definition. Tell me that’s not Star Trek.

Then there is the surgery itself. Minimally invasive to the middle of the skull? The pituitary gland is like a pit in the middle of the cranium with the brain curled around it. Go in through the nose and operate on it with fiber optics and microscopic controls with a TV set enlarged to guide the instruments? Are you kidding me??? My Dad would have sawed off half my skull, I guess, looking for the pit. This has to be Star Trek, not earth in the 21st century. Except that it is.

So, as I say, modern medicine, space exploration, the Hubble, cosmology, string theory, not to mention securitization. I mean, think about it.

But beyond that, I take it personally. Look at what everyone had to do to be able to have Sandeep do this for me and in me. Look at what Mary Lasker and Lister Hill did when they started the NIH. Look at what Charlie Wilson did as a pioneer and as a trainer of others. Look what Sandeep has done to prepare himself to help me. Look at the time he took just with me. They did it all through the years so that they could do this for me, and for others like me. It is a person to person service. They did it for me.

Not that I particularly deserved it. I was lucky. I was the recipient of the favors of strangers – except for my father, who was not a stranger, and who also made his contribution.

And look at the people around me and the much-appreciated secondary gains. Succor and attention. Family around me and caring, friends, associates. I have to look at it all and be grateful.

I know the tendency for public health and preventive medicine to take a back seat to spectacular curative medicine, and that the greatest advances in health have been clean water, hygiene, and immunizations. But still, I’m hardly making the same contribution that these giants, including my doctors Mike Ries with my hip and Sandeep Kunwar with my tomato, have made and are making, not only in Neurosurgeryland and Orthopedicsland, but also in Cardiologyland, Oncologyland, and other Medicallands. It’s hard for me to think I’m making enough contributions. But I’ll just do what I can.

There was a study of righteous gentiles who helped the Jews during the Holocaust. Many of them had some experience in their lives earlier where someone had done something for them, more or less without obligation, just to do a good deed out of compassion. They knew how it had felt, and they could do the same in turn with some of these poor oppressed Jews. I think I feel the same way.

I am so grateful.

And finally, finally – it’s great to have personal relationships, and to feel individualized, but I am also part of a group. So, I don’t want to be just a name, I want to be a number! I want to be Kunwar pituitary adenoma patient #2,134! Come on, give me my place in the starry kingdom of Neurosurgeryland! I want my number!

Budd Shenkin