noviembre 28, 2021

MASTERS OF NEUROSURGERY

KEKI TUREL

"THE MISSION OF THE FOUNDATION IS TO PROMOTE THE NEUROSURGICAL CAPACITY ACROSS THE LOW AND MIDDLE-INCOME GROUP COUNTRIES (L&MIC)"

Dr. Keki Turel is not only a world-class neurosurgeon internationally recognized due to his vast experience in brain operations for top difficulty cases but also a wonderful person whose charm captivates everybody. 

His devotion and commitment to WFNS educational tasks are out of doubt. Currently is successfully leading one of the most active and attractive WFNS educational initiatives: The WFNS Complications Committee.

 

Dr. Keki Turel

Dr. Turel, your professional CV is impressive, how would you describe yourself?

Thank you for your kind words. Rather tough for me to describe myself. Am a practical clinical Neurosurgeon, who likes to treat the patient as a whole, not just the disease: adopting a holistic approach. 

Am a multifaceted individual with a blend of art and science: on the art front I can draw, paint, sing, compose, play music, have acted on stage, am a lover of nature, and an environmentalist, and am also a pro at photography and a Priest of world’s most ancient Zoroastrian religion. 

As a scientist, the advice and treatment I offer are holistic and practical, considering the socio-economic well-being, at the same time being scientific, utilizing the latest data and technology. 

The qualities of Art and Science blend beautifully in everything I do. On a personal front, I am blessed with qualities of creativity, and innovation, and a sense of intuition which help me both professionally and personally.  

I am also a  sportsman and a protagonist of fitness, physical and mental, which is so essential for overcoming challenging situations, in surgeries, and in life in general. Moreover, if a doctor is not fit how can he inspire good health in his patients?

Chairman of Indian Space Research Organisation (ISRO) integrating 1st ICCN (March 2017)

Many of the behaviors we develop as adults are formed in the early years of our lives. What values did your father teach you?

Our father was our role model. Strong in body and mind, orthodox and religious, hardworking and honest. He had little formal education but had amazing memory and intelligence. 

All this helped him rise from an ordinary salesman in a sewing machine company to monopolize sales and service of all textile mills in Mumbai. He was eventually elected Chairman of a reputed Co-operative Bank for 3 four-year terms. 

We have five siblings who imbibed the qualities of truthfulness, discipline,  hard work, and integrity as he encouraged us to study and pursue our dream, whether it was education, sport, music, scouting. He taught us, not with big words or sermons, but simply by his actions…

Do you always try to be the best in everything?

Absolutely; Want to do my best in everything I attempt, whether it is professional work or hobby, depending generally on my natural instincts and practical skills, and mostly self-trained, by reflecting on and reviewing my own work, and learning from mistakes and Complications. 

Of course, technical training is essential, and with the emergence of newer technologies, one needs to constantly retrain, and reinvent oneself in order to make progress. My child-like curiosity to learn and understand new things persists even at this age.

KET Demonstrating at an Endoscopy Workshop Missouri (Oct 2013)

What would you say is your secret to success?

I try to keep improving every day, competing with myself, and searching for solutions to problem cases. be it finding a novel approach, or designing a new instrument. 

I also like seeing how others tackle complex cases, not only in my speciality but across other surgical specialities, watching their movements, and particularly the instruments and equipment they use which I may be able to utilise, with or without modification in my special field of work. 

Learning does not occur only by observing or discussing with my peers but also by listening to everyone around, residents, anaesthetists or even nurses. Anyone may throw an idea that may prove useful in my work. 

The secret lies in 3 Ds, Discipline, Determination and Dedication, by remaining young in mind and body, and open to change, not allowing your ego to block your growth.

Do you agree on how society prepares itself for leadership?

Society consists of all sorts of people. The ‘haves’ and the ‘have-nots, the educated and the little (or not) educated, the law-abiding and the law-bypassing, the honest and not so, or downright dishonest. Society tends to choose a leader that gives them what suits them personally, not necessarily the larger good (unfortunately). 

It will accept the leadership that agrees with them, and will thus divide itself into the ‘followers’ and the ‘dissenters’. Society does not necessarily prepare itself for the leaders who look at the larger good; rather, it tends to prepare itself with the leadership with the sole purpose of personal benefit.

Thus a highly educated society prepares itself quite differently than one where real education in life (not just university education) holds importance. In reality, society gets the leader it deserves.

KET Operating in Africa

What would you say to the leaders of the world?

There are 2 types of leaders – those that lead from the front, by example, and the other type who sit back, plan, decide and drive or inspire others to perform. 

I would tell the world leaders to set aside their personal benefits and try to unite various factions in the society and promote peace in the world. With peace comes constructive ideas and progress. Wars drain away all resources human, material, and financial. There are no winners, only losers and sheer destruction. 

Leaders must promote peace – through dialogue (discussion), understanding (analysis), and tolerance. I would expect them to be, ‘The First’ to come forward and help, like most ‘Doctors’, and those with a social conscience would do. 

I would tell them to have empathy, to take ownership of the problem, and solve it as if it affects them personally. Be sensitive to the needs of the population. I would like a leader to surround himself with strong people having the virtues and characteristics like his. A good leader creates good leaders, will continue to be in the company of the bright people whom he will further groom, to become good leaders. 

A leader should also be a good listener and back his followers while espousing the cause of justice and freedom.

You are enthusiastic about education and sharing your knowledge, do you think neurosurgeons are motivated today?

Each generation brings in a different purpose or mindset to life (one should not generalize in today’s Neurosurgeons). 

There are some very senior Neurosurgeons who are quite passionate about teaching, and some who continue to teach and share their wisdom even after retirement. True, they will be enthused if they have an eager bunch of students. 

My concern is surely about today’s PGs & residents in Neurosurgery. Not all of them have the curiosity to learn/know more, to explore new avenues, or have ‘lateral thinking’ – most of them are happy to do mundane duties or are just ‘trigger-happy’ getting into the ORs and doing whatever surgeries they can get their hands to. 

Doing live surgery seems to drive their adrenaline, but they want to get their itchy hands to do some cutting without going through the journey of doing cadaver or animal dissection or lab work or do worthwhile reading or research. I don’t encourage short-cuts and unless they are sound in history-taking, show good clinical knowledge and acumen, writing good notes, and preparing themselves by reading the literature about the cases they are assigned, they are not allowed in the OR. 

On the other hand, it is also the responsibility of the teachers to motivate them, and be an example of what they would like to see in their students… and reward them when they prove themselves.

KET Operating in Russia

The image of the WFNS Foundation corresponds to a solid entity with a solid foundation in its projects and lines of action. What initiatives would you add?

The WFNS Foundation promotes the worldwide development of Neurosurgery, mainly concerning basic Neurosurgical issues and focusing on developing countries. It has active participation in all projects or programmes meant to reduce inequality in the management of Neurosurgical problems worldwide, with equity as the essence of this mission. 

Though much has been done, especially in Africa, as can be seen by the growing numbers of trained neurosurgeons now doing exemplary work despite constraints, especially in Sub-Saharan countries, efforts should continue to realise its mission at par with the rest of the world. 

I would like to suggest the following initiatives:

 1) In view of the solid support provided by way of training and equipment, there should be an audit covering 

   a) The numbers of cases and quality of work done by individual neurosurgeons/departments, and 

   b) To compile statistics, and assess what impact the help given by the Foundation has made. These data should be provided by the Director of the hospital. 

2) Develop Centres of Excellence across the globe. The work done at these centres should be recorded and brought to the attention of big industrialists/philanthropists. 

The Foundation should have a kind of structure that can receive donations to promote the facilities and capacity of such centres. Again WFNS supported trainees can be appointed to man these centres, making a win-win situation for both, the centre as well as the appointed Neurosurgeons. Internationally renowned Neurosurgeons be invited to these centres and give time to train Neurosurgeons of these centres. 

In brief, Foundation must make a structure that will attract the ‘Big Guys’ and donors, and over 10-20 years they can develop into Prodigious Centres of Excellence, which will enhance the capacity, the number of patients treated, level of training and ultimately best patient care. What has happened to erstwhile developing nations like India, can now happen to other less developed nations in and out of Africa. 

3) Develop a culture to recognise great leaders of Neurosurgery, whose career and contributions can be enshrined in its ‘Hall of Fame. This will motivate, both the great Neurosurgeons to continue their contribution, and the Young Neurosurgeons (YNS) to see and emulate them. These centres and Hall of Fame will attract the giants in Neurosurgery to visit and spend time at periodic intervals. 

4) The leaders of the Foundation should actively engage with Health Ministry officials of individual states to initiate and promote Neurosciences, and Neurosurgery in particular. Our field is generally considered, even today in many parts of the world, as esoteric and even a luxury, not realising that at least 10% of all hospital admissions are directly related to Neurological diseases. 

Our speciality needs visionary leadership and to propagate awareness amongst laypeople, Health officials and bureaucrats, and even general doctors.

Operating in Russia

How do you value the help of the WFNS Foundation for Neurosurgery in Africa?

WFNS Foundation is the brainchild of my mentor Prof. Dr. Madjid Samii (MS) and Prof. Gerardo Martin Rodriguez (GMR). In 2000 when the former assumed Presidentship of WFNS, he had a strong desire to do something for the Lower Income Group (LIC) Countries. 

He asked for reports of WFNS activities from the second Vice-Presidents across the globe. Dr. Abdesalam Khamlichi obtained reports from the African continent. The abysmal disproportion between the African population and the available number of Neurosurgeons shocked him and he and GMR decided to start a Foundation with an initial personal contribution of USD Ten Thousand by each of them. 

The mission of the Foundation is to promote the Neurosurgical capacity across the Low and Middle Income Group countries (L&MIC). Africa was the first target, especially Sub-Saharan Africa. Morocco, Egypt, and South Africa were having reasonably good services, hence they mooted WFNS accredited training programs in these countries which will serve to train Neurosurgeons from other African countries. The focus was on Sub-Saharan countries. They also evaluated Kenya where Dr. Mohammed Qureshi (MQ) et al were already providing basic Neurosurgical services. 

The COSECS program was accredited whose responsibility rested on MQ. Thus Kenya became the newly accredited site. These training sites provided 1) Full Neurosurgical Training and 2) Super Speciality Fellowships. (viz. Endoscopy). WFNS offered a fellowship stipend of 430 USD per month to each trainee, which was later increased to 500 USD. Dr. Andrew in Kenya did this course and started Neurosurgery in his town. Having been fully trained he now needed specialized equipment. 

MS used his good offices with leading surgical companies obtaining basic and Micro-instruments from Aesculap, basic Microscope from Zeiss, and Endoscope from Storz at highly subsidized rates (30% of original cost). 

Any fully-trained Neurosurgeon working in a deprived or a L&MIC was eligible to apply and receive these specialized tools at an amazingly discounted rate, namely Hi-Speed Drill for USD 500, Zeiss Microscope for USD 10,000.  The Foundation purchased some of these items, from their kitty and distributed them to Neurosurgeons qualifying from various other countries and working in resource-hit locations. Dr. Yoko Kato exhibited amazing philanthropy and donated large sums from her Yoko Kato Foundation (YKF) to WFNS Foundation without even whispering the kind of help she was providing. The Foundation now works all around the world providing training, education, and basic equipment and instruments, to several groups in L&MICs.

African Neurosurgery has evolved significantly since the activities of the Foundation. Referring to the survey conducted in 1998 the population of Africa was 800 million of which 615m were in Sub-Saharan Africa, 140m in North Africa, and 45m in South Africa. There were 565 Neurosurgeons, most of them (400 or 1 in 0.38 million) in North Africa and least (79  or  1 in 7.78m) in Sub-Saharan Africa. 

The WHO recommended rate was 1 in 0.1 million. Post Foundation the survey conducted in 2016 showed the African population rising to 1120 million with again the greatest rise in Sub-Saharan Africa (884 million) and in North Africa (181 Million) but simultaneously there is now a great proliferation of Neurosurgeons in Sub-Saharan Africa, from 79 to 369, as also in North Africa from 400 to 1187m, and in South Africa from 86 to 171m. 

The ratios show a great increase in the availability of Neurosurgeons in Sub-Saharan Africa (1 in 2.4 million) and in North Africa (1 in 0.13 million) Clearly, the Foundation has made a huge impact in a short span of a decade and a half.

Teaching Son Mazda to Perform Microvascular Anastomosis

Tell us about the surgical algorithms and operations that bear your name.

i) Congenital Atlantoaxial Dislocation (CAAD) is a commonly seen disease in India, and elsewhere. The Government Hospital where I was trained as a leading referral center in the last millennium. The cases were generally classified as Reducible and Irreducible. 

In my evaluation, I found that there was a hitherto undescribed entity of ‘Partially Reducible’ variety. It was an observation that skeletal traction (A popular method of reducing the AAD then) helped in reducing AAD that could not be reduced by simple extension, and after a few days of continuous traction, most of them were reducible with good clinical improvement, after which a posterior fusion using a metallic loop (Hartshill) and H bone graft was fixed to retain the fusion. 

I prepared a new surgery-oriented algorithm on the subject and was invited as an International Faculty to present this topic at the Annual International Meeting of JCNS in Tokyo in 1990. A 20-minute video film, illustrating a variety of AAD cases was projected. 

This was a novel subject for the Japanese Neurosurgeons then, and paved the way for me for several future invitations to their beautiful country.

ii) The other original contribution was a description of and diagnosis of cervical canal stenosis by simple plain X-rays without using any scales or measurements in the pre-scan era. 

This was based on just one glance at the lateral view of the plain x-ray and observing the position of 3 vertical lines 1) The posterior border of the vertebral body 2) the Facet joint line, and 3) spinolaminar line. Normally these 3 lines are clearly and independently visualized. If lines 2 & 3 overlaps it is a sure sign of spinal canal stenosis.

iii) I have also described a reliable plain X-ray sign of lumbar canal stenosis (unpublished). During my early years of training and practice lumbar spine surgery invariably involved doing long and wide laminectomies, often at multiple levels. 

Gaining experience and maturity, I realized that we could achieve excellent results by miniaturizing the procedure by decompression of the precise root(s) that was/were causing symptoms. Having gained increasing familiarity and experience with the use of microscope and hi-speed drill, I tailored my operations for lumbar stenosis to just decompression of the relevant root without unwarranted and excessive bone destruction, granting early mobilization and resumption of work. 

I named this operation, ‘Microsurgical Internal Decompression of Spinal Stenosis (MIDSS)’.

KET with Miguel Arraez and Armando Basso (Tucuman -Argentina 2014)

As someone who pioneered microsurgery in India in the late 1970s, what advice would you give to those starting out?

My tryst with Microneurosurgery got initiated as a consequence to improve upon the results of standard Neurosurgical procedures. 

Today Microsurgery is not a special aspect of Neurosurgery as it was when I started, but, in fact, a basic standard requirement of Neurosurgery. It requires an understanding of Microsurgical anatomy, development of skills (hand-eye coordination), lab training on animals and cadavers, before venturing to even assist at Neurosurgical operations. 

This includes techniques of drilling, dissection, use of key-hole suction, micro coagulation, and micro suturing on a flat surface as well as in deep pockets. “Practice makes a man perfect” and this attitude and effort should continue even when one is fully mature. 

The Young Neurosurgeon (YNS) must also know the anatomy (components) of the microscope, controls, and all its functions. Mental composure and ergonomic physical postures are also important ingredients as he proceeds to navigate through delicate tissues inside the head and spine. Knowledge and selection of a mere handful of correct Micro instruments from a vast array of those laid on nurses’ trolleys will also develop with experience and able assistance from an experienced nurse, who also is an asset, especially to a YNS. 

It is essential that he positions the patient himself, does navigation (as is now customary for almost every case), and be responsible for the operation skin to skin, from the moment of the incision until the final stitch is taken and dressing was given. 

Ideally, the microscope should have an HD camera and recording system to document the procedures that he does, so that he can (and should) review later in the day when he can critically assess his performance, write notes, draw diagrams and learn from his mistakes. 

This habit is not just at the beginning but should continue until he is fully accomplished and beyond. In short, the requirements are Solid Training, Careful Planning, Meticulous Execution, and Constant Review of work done, including post-op imaging, clinical follow up and learning from Complications.  

This is not theoretical advice, this is what I diligently follow even today.

Enterprise Dubai Award

You have performed some of the longest surgical operations lasting from 24 to 27 hours at a time and you have credit for removing two of the largest brain tumors in the world. It takes a lot of strength and courage to do that, how do you feel about these accomplishments?

Some of the longest operations I did last for 24 hrs. or more was during an era when facilities were less and our personal efforts prolonged to enable radical removal of tumors in a safe manner. Microsurgery was still in its phase of development and being one of the pioneers I had to set a benchmark of safety. 

Time was of least importance and fortunately I’ve been blessed with a good amount of physical and mental strength. Long surgeries are a mind game and when you are fully absorbed, all other faculties, desires, and needs are overtaken by the challenge and passion of surgery. 

The two 27 hour-long operations were for extensive skull base meningiomas. On yet another occasion we performed 26 hours’ surgery, but it was not one operation. I had 5 major cases on my regular list, which got over well past midnight but during the same evening 3 emergency cases were admitted, one with acute aneurysm rupture, and another with bilateral extra-dural hematoma. 

All of these cases were taken in tow, and we ended up at 10 the next morning. Then, from 11 am I had my regular out-patients which lasted through the whole day until 10 pm. Fortunately, all this was possible due to good teamwork and support (and my strong mind and body!). Two of the world’s largest brain tumors were again meningioma in young males aged 18 (1981) and 16 (1996) respectively. 

I was fortunate to have the opportunity to operate on such enormous tumors; however, they were not as challenging and demanding as the other skull base meningiomas. It is interesting that the first of these 2 patients was filmed on a conventional 16mm movie camera and was the first-ever brain tumor film to be made in India. These accomplishments only increase your self-belief and set up a personal milestone to perform better. 

One can’t rest on one’s past laurels, else you will plateau and eventually decline.

Dr Keki Turel is a person with a great sense of spirituality

You became the first surgeon in India to operate on patients with AIDS in 1987 and you have won many, many awards, such as the Best Citizen of India award. What are your thoughts about these achievements?

The first case of AIDS in India was a 17-year-old sex worker, who developed an advanced stage of AIDS and post TB meningitic hydrocephalus. 

She was ‘skin and bone’ and about to die. All she needed was an emergency VP shunt, but the hospital was not truly ready with the precautions prescribed for staff by WHO for performing surgery on an AIDS patient. 

Somehow we managed to collect articles as per the protocol and accomplished the operation at the end of the day, least realising this was the 1st ever case of AIDS to be operated in India when at that time most people dreaded to even stand close to such a patient. There was resistance from Hospital staff, and even my spouse was apprehensive about possible contamination. 

Anyway, true medical professionals do not get intimidated but overcome such hazards. It was gratifying to see this young lady patient not only just recover but blossom into a beautiful woman. It is also interesting to note that for a whole year no further AIDS cases were operated in the entire country and even the second-ever case was also done by me. 

He was a young boy who got infected by a blood transfusion and the resistance I faced this time was even greater, with even the Dean of the Institute questioning me if all these efforts and risks were worth taking, especially with an unwilling and unsupportive staff. Well, we again had to overcome this impedance/reluctance for the successful removal of his multi-loculated brain abscess. 

Guided by the Hippocratic Oath we take, my single argument was, that what looks like an incurable disease today, may find a cure in the future, and providing them life-saving surgery at that time may help them survive and see the light of the day, when such drugs that cure are made available, and time has shown that.

Speaking about awards, they are the byproducts of the persistent work and not the AIM, and whilst they are an acknowledgement of your meritorious activity, they should only encourage you to strive harder. It is good to honour an individual when he is active and dynamic and in his prime. 

In my opinion, awards are also an obligation to justify the honour bestowed on you by making further progress.

KET Scrubbing

Do you have any spare time left for your personal life, what do you spend it on?

Everyone knows that a busy doctor usually has little or no time, I always say, “it’s only the busy who can do a lot of things, and that’s why they are busy.” So, even the so-called free time that I may have, is gainfully utilized by a variety of my activities and hobbies. 

Since I am creative, I enjoy playing with my brain, creating some literature, playing music, doing photography, editing videos, etc… Of course, I also do Yoga, meditation, and gym training every day. 

Lately, ever since we started working on a hitherto less-traveled trail of ‘Complications in Neurosurgery’, a considerable amount of time goes in connecting Neurosurgeons and Neurosurgical Societies worldwide, through  International Conferences (ICCN) which we organized in Mumbai in 2017 and 2019, and later created our unique Virtual platform, ‘NeuroComplications’, on which we have introduced some key functionalities, and continuing to enhance its capabilities. 

The pandemic has pushed us all into a virtual world and we are using this platform to organize webinars on a variety of themes concerning Complications in Neurosurgery every two months. These webinars have grown significantly in stature and popularity, with the worldwide appeal from Neurosurgeons of all generations, and that leaves me and my team with no spare time. I’m also editing two books on ‘Complications in Neurosurgery.’ Now tell me, do you think I really have free time? If I get some more time, I would like to sleep a little more.

KET With Prof. Madjid Samii & Prof. M G Yasargil

Dr. Turel, what is your ultimate goal in Neurosurgery and in life?

The Ultimate goal in Neurosurgery, and also, the aim of my life is to establish an International Centre for Neurosciences that will cater to all aspects of Neurological Sciences, including Education, Training, Research and Rehabilitation, and creating awareness by disseminating knowledge to not only the medical professionals but also to the laypeople. 

It’s my dream project and a green project that will be developed on a sizeable plot, uniquely devised and designed, capable of housing hundreds of patients and thousands of staff on its campus.  

Considering my country’s population of over a billion, which has only one dedicated Institute of this kind, our Institute with its ambitions futuristic plan will go a long way in not only taking care of Indian patients but also serve as an International Centre of Medical Tourism. 

Thanks to my Internationally located friends and colleagues, there will be a collaboration with other reputed Neuroscience Centres and an exchange of Faculties and Trainees across the world.

My other goal is to make Neuroscience available, affordable and achievable to all corners, by developing satellite centres affiliated with our main Institute in Mumbai. 

This will be a huge collaborative effort that will keep one engaged for the rest of one’s life and future generations as well, reinventing new ideas as we progress. 

For the past several years I have also nurtured the dream of scaling Mt.Everest in Nepal, the highest peak in the world. I am maintaining my physical fitness to enable me to achieve this feat but will have to take a few months off from my medical life, which is becoming increasingly difficult now.

KET with the World Renowned Guru Ravi Shankar, Founder of ART OF LIVING

Dr. Turel, what is your ultimate goal in Neurosurgery and in life?

The Ultimate goal in Neurosurgery, and also, the aim of my life is to establish an International Centre for Neurosciences that will cater to all aspects of Neurological Sciences, including Education, Training, Research and Rehabilitation, and creating awareness by disseminating knowledge to not only the medical professionals but also to the laypeople. 

It’s my dream project and a green project that will be developed on a sizeable plot, uniquely devised and designed, capable of housing hundreds of patients and thousands of staff on its campus.  

Considering my country’s population of over a billion, which has only one dedicated Institute of this kind, our Institute with its ambitions futuristic plan will go a long way in not only taking care of Indian patients but also serve as an International Centre of Medical Tourism. 

Thanks to my Internationally located friends and colleagues, there will be a collaboration with other reputed Neuroscience Centres and an exchange of Faculties and Trainees across the world.

My other goal is to make Neuroscience available, affordable and achievable to all corners, by developing satellite centres affiliated with our main Institute in Mumbai. 

This will be a huge collaborative effort that will keep one engaged for the rest of one’s life and future generations as well, reinventing new ideas as we progress. 

For the past several years I have also nurtured the dream of scaling Mt.Everest in Nepal, the highest peak in the world. I am maintaining my physical fitness to enable me to achieve this feat but will have to take a few months off from my medical life, which is becoming increasingly difficult now.

With Dr Qureshi in OT in Mombasa

The WFNS Foundation

The WFNS Foundation, an initiative by my mentor Prof. Dr. Madjid Samii was established 2 decades ago with the aim to promote the development of basic Neurosurgery worldwide, with a special focus on developing nations, and in particular, the African Continent, WFNS Foundation is already doing an exemplary job. 

Significant progress has been made in terms of imparting training and education, especially in Africa, where at one time, the number of Neurosurgeons could be counted on fingers of one hand, we have well fully trained professionals serving their nations. 

True, they need more facilities and equipment, and trained manpower as the population they are dealing with is way disproportionate to the resources available, but this can only happen if we, seniors of WFNS prevail upon the health authorities and politicians to realize that Neurosurgery is not a luxury but a serious necessity. Most of their health-related resources are spent on communicable and infectious diseases and overcoming malnutrition. 

Nearly 10% of all hospital admission are attributed to Neurological conditions. Amongst Neurosurgery.

«My ultimate goal in Neurosurgery, is to establish an International Centre for Neurosciences that will take care of all aspects of Neurological Sciences»