Below the Radar Transcript
Episode 214: Reflecting on Brain Surgery — with Dr. Gary Redekop
Speakers: Samantha Walters, Am Johal, Dr. Gary Redekop
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Samantha Walters 0:05
Hello listeners! I’m Sam with Below the Radar, a knowledge democracy podcast. Below the Radar is recorded on the territories of the Musqueam, Squamish, and Tsleil-Waututh peoples.
On this episode of Below the Radar, our host Am Johal is joined by Dr. Gary Redekop, a neurosurgeon and head of the departments of surgery at both the Vancouver General Hospital and the University of British Columbia. Together, they discuss advancements in medicine, the differing perspectives of patients and medical practitioners, and the relationship between neuroplasticity and human resilience. We hope you enjoy the episode!
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Am Johal 0:47
Hello, welcome to Below the Radar. Delighted that you could join us again this week. We have a special guest. We have Dr. Gary Redekop with us. Welcome, Gary.
Gary Redekop 0:57
Thank you, Am.
Am Johal 0:59
Gary, I'm wondering if we can begin with you introducing yourself a little bit?
Gary Redekop 1:03
Sure. Well, my name is Gary Redekop. I'm a neurosurgeon at the Vancouver General Hospital. I've been in practice here for 30 years and enjoy my work. And it always brings something interesting and worthwhile and fulfilling. I have a few other roles related to leadership, headship at the Vancouver General Hospital and in the Department of Surgery at the University of British Columbia.
Am Johal 1:27
Yeah. And you know, Gary, this is a very different line of work than say, I don't know, being a mechanic or something like that. You are going into the heads of people, into their brains. It's very complicated and precise work. I'm wondering if you could maybe share as you were going through medical school yourself, what drew you to the field of neurosurgery?
Gary Redekop 1:51
Well, that's a good question. And I think my experience, like many in medicine, is that I was inspired and drawn towards the specialty that I chose because of people that I met along the way, and mentors who had an impact on my appreciation for the field. And in my case, it happened on the first day of medical school. I do not come from a medical family and didn't really have a lot of awareness of the various different medical specialties. I was interested in medicine in general. And on the first day of medical school, before meeting classmates or having any formal sessions, every medical student was assigned to a preceptor or a physician with whom they would spend a day. And as it turns out, I spent the first day of medical school shadowing a neurosurgeon. And it was really, for me, an amazing experience and I just found it absolutely fascinating.
And it was that sort of first outburst day, first opportunity that got me interested in it. And then, because of the interest that was sparked, I ended up, you know, developing a real kind of student and mentor relationship with that surgeon and others then, and it just really got me really keen on the field. And I think it was because, partly, it's very interesting. And also, he was just so interested in it himself. And I think students are really inspired by physicians and mentors that they see who love what they do, are inspired and really want to share it.
Am Johal 3:22
Gary, since you've had a sort of 30 years sweep doing this work, you're probably somewhere close to having been involved in 10,000 surgeries or something close to it. I'm wondering if you could speak a little bit to, from when you first started as a neurosurgeon, the kind of technology, the science behind what was happening, to, fast forward 30 years, there have been incredible changes in the medical field, the science, the technologies that support surgery, but of course, you can't cover everything. But I'm wondering, what are the things that you remember that have shifted from when you first started to now?
Gary Redekop 3:58
Sure, well, there's been several areas where medical practice has changed very dramatically. And this has involved all aspects of neurosurgery too. And then a few things that are quite specific to neurosurgery. So, the general things that have advanced very much are first of all, imaging, that diagnostic imaging that we have. When I started in medical school, CT scan imaging had been around for a few years, but not long and MRI was in development, but really only became implemented when I was in my neurosurgical residency. So after I graduated from medical school, and even at that time, once that kind of imaging became available, imaging units were not widely distributed and so access to that kind of imaging was initially quite uncommon. And the acquisition times for imaging were quite long. So it wasn't something that was commonly done. And over the years, both the quality of the imaging, the kind of information that we can get from it now, the speed of image acquisition, and the widespread availability of that kind of imaging have really changed the nature of many aspects of medicine and surgery.
And certainly neurosurgery because before that time, the brain imaging was much less detailed, much more invasive, and potentially risky for patients. And if you think back, say 40 or 50 years, the idea of doing surgery on a, say exploratory sort of a basis, was fairly common, whereas now we would never do surgery without knowing exactly what we were getting into. So imaging has had a major impact.
And then there are a number of tools and technologies that have become available in many specialties and including neurosurgery so that we can now do procedures or treat conditions that, in the past would have required a major, open, big operation, can be done in a minimally invasive kind of a way through small approaches, less invasive, with greater safety, less time in the hospital, shorter recovery periods afterwards. So that's been a real change.
And then just the perioperative sort of the non-surgical aspects of patient management, anesthesia, critical care, all those specialties have really advanced and have dramatically improved just the safety of neurosurgical interventions and the care of patients around the time of their surgery.
Am Johal 6:34
And I'm sure over the course of your career, you've seen so many ways in which issues have presented themselves to patients, be it an aneurysm, or an AVM (arteriovenous malformation) or in terms of tumors, and the ways in which you encounter a patient after they've been in the emergency room to the suddenness. And I think with something as complex as brain surgery, there's definitely a kind of trauma that hits the patient as well. And I'm wondering, in the course of your career, as you've encountered patients in those intense settings, what you've seen or reflections that you might have over, you know, there's many routes or areas of the medical profession you could go into, but the brain is a very kind of precise form of surgery, and also the context in which the patients that you encounter.
Gary Redekop 7:25
Sure. You're right, you know, for, I think, for every surgical specialty, but especially those that are seeing neurosurgery, where, you know, the brain is a pretty delicate structure. Cardiac surgery the same, and you know, when, when you're from a patient perspective, you're contemplating having some kind of intervention on what you would consider the sight of the soul or something like that, then that's different from what might be perceived as less threatening or critical or frightening kind of procedures. And yes, it's really important to keep perspective in that, from the surgeons perspective, and the surgical teams perspective.
This is delicate but routine kind of work. And once you've been in practice for awhile, you've had a lot of experience, this is a daily occurrence. But for the patient and for their family, this is something they've never been through before, probably never will be going through again. So it's a once in a lifetime, unfamiliar and very frightening experience. And so that's how I describe it to patients who are having surgery. You know, we come to the hospital, we're going to meet and the common point is this surgical operation, but we come with very different perspectives. And I think it is important for all members of the surgical team to be aware of and sympathetic to the perspective and the feelings of the patient and their family too.
Am Johal 8:49
And for those who are listening to this, Dr. Redekop did brain surgery on me. So this is our connection in that I was a patient with AVM. And it's interesting from a patient perspective, because you're going through something intense. Your memory of how it all unfolds, gets scrambled somewhat. I remember being on the hospital bed, and they give you anesthesia to put you under, but you're still awake for a bit, but the part where they wheel you into, what to me, I remember it was like from woodshop. It's like a thing that your head gets put into to keep it still. But it's probably a more complex piece of machinery. But I just remember, like this thing being jacked up and your head being held. Yeah, what is that machine by the way?
Gary Redekop 9:34
You know, we have a variety of different devices that we use, depending on the kind of surgery but you're exactly right. For microsurgical procedures, we need to have the head held rigidly in position and also something that allows us to have access around the head. If you think of your head being, say, sunk in a comfortable pillow. That might feel nice, but it actually is kind of wobbly in that and it doesn't allow us access to the whole head. So depending on the kind of surgery that we do, we have a selection of different kinds of devices that we can use to hold the head still while we do the operation.
Am Johal 10:08
In the case of craniotomies, for example, it's quite common practice to remove the part where the incision is going to be made, and now to place the skull back on the head. But in previous times when surgery was done, were there metal plates and other kinds of things and how did that technology sort of change over or when the changes in the medical profession happened related to that?
Gary Redekop 10:34
I think there's archeology evidence of openings made in the skull using rough tools where the holes were left in place. But really since the, what you think of as the modern era of neurosurgery beginning around the start of the 20th century, craniotomy has been done with different tools. In essence, it has involved removing a piece of bone, a window of bone, if you will. And I think in general, the practice has been to replace the bone and secure it in position and they kind of fastening the bits that we used to hold the bone in place have evolved over time. But that principle has been part of practice. There have always been situations say in, usually in the setting of trauma, if the bone has been fractured or contaminated as a result of penetrating injury, or if it's comminuted into little fragments, where, yeah, we have different kinds of materials that we can use as a bone replacement. We call that a cranial plasti.
Am Johal 11:29
It's interesting as well, at the time, I remember a number of nurses and doctors describing that, you know, there's actually not that many nerve endings in the skull. So that's not where the pain comes in. It's in other parts. And that's counterintuitive for people who aren't within the medical profession.
Gary Redekop 11:48
Right, well, there's no nerve endings in your bones. So that's, that's actually not the source of discomfort. There are nerve endings, obviously, in your skin, and there's some muscles under the skin, so that can be sore after surgery. But really, the skull and the brain itself don't have sensory nerves. So there's actually no pain involved with the actual manipulation of the surgery. And in the past, awake craniotomy with just infiltrating local anesthetic into the scalp was a relatively common practice. Currently, there's not that many indications for doing awake craniotomy, but it can still be done. And yeah, as long as you can eliminate the pain from the scalp, the rest of the surgery is relatively painless.
Am Johal 12:31
And the hair grows back. There's a tiny bit of pain when the staples are being taken out. But that happens fairly quickly, a week or so, a week to two weeks afterwards. I'm wondering Dr. Redekop, in the various ways that you get called into surgery now, and you're also teaching as well at UBC, what are some changes in the field that you're seeing now that are emergent, or a few years away that you think are really exciting or could be really beneficial or transformational in the field of neurosurgery?
Gary Redekop 13:04
Well, I think that the evolution of less invasive kinds of treatments is still in progress and there are a variety of new approaches that will allow us to accomplish the same kinds of things that have required a big open surgical operation and all of the recovery associated with that. There's more and more things that can be done in a less invasive or potentially even non-invasive kind of a way. So it's really exciting to see that. And the scope of conditions that can be treated, and treated safely, has increased dramatically. You know, I think back a generation or two generations ago, obviously neurosurgery was being done. But there would have been, I think, a decent proportion of situations where a diagnosis might be made or suspected, but really, there wasn't anything that could be safely done about it. And those kinds of situations are less and less frequent these days. And not only is the invasiveness and risk aspect of neurosurgical intervention going down, but the scope of what can be safely accomplished and the range of conditions that can be treated is increasing.
Am Johal 14:23
In my context of having an AVM and a bleed in the brain, and you know, I was lucky that it was in the back part of the brain. So my rehabilitation was fairly quick. I was back at work in six weeks. But of course, depending on the patient and the complexity of what they're dealing with, there's very uneven ways of rehabilitation. I'm wondering if you could speak, I know it's not your area as the neurosurgeon but in terms of advances related to rehabilitation of patients post surgery. And if there are some, you know, new areas of science or things happening in the field that are supportive of patients when they get out the other side of surgery.
Gary Redekop 15:05
Yeah, so the field of what's called physical medicine and rehabilitation, it involves various therapies, speech therapy, occupational therapy, physiotherapy, in some instances, psychological supportive therapy as well. There's aspects of recovery that involve, say, cognition and memory and language, but there's also physical aspects of recovery. And I think in terms of the technological developments, the kind of physical disabilities or limitations that have prevented people from being able to return to say walking or fully independent activity. Those are increasingly subject to developments both in terms of neural implants, things that you can actually do to the brain or spinal cord to facilitate recovery of lost function, but also devices that can connect to the brain and allow the brain to communicate with a physical external device of some kind, so for walking or hand movement. We're in a period of time now where both a potential for interventions that will facilitate actual recovery of central nervous system tissue damage, but also interface between brain and external devices to allow for interaction that can be meaningful with an external tool of some kind.
Am Johal 16:28
Yeah, there's this really interesting academic at SFU, who works in neuroengineering, Faranak Farzan, who's working with technologies around brain stimulation and other things. It's quite interesting what's happening there. I'm wondering if you could speak a little bit to neuroplasticity, because it's a term that maybe not everyone understands fully if they're not in the field, but it's a term that's also making its way into philosophy, in other areas about how the brain has the capacity to rewire itself in a way as a response to various traumas and things. But wondering if you could share your thoughts around neuroplasticity and what it means and our growing understanding of it from a scientific point of view.
Gary Redekop 17:12
So neuroplasticity is broadly applied, as you said, it's the term that we use to describe the ability of the brain to recover function that has been lost due to damage or injury of one part and basically another part of the brain being able to take on that function. And the capacity of the brain to rewire itself, to use the phrase that you used, is actually quite substantial, especially in children and adolescents. So if a very young person has a brain injury that affects one side of the brain, you know, most commonly that would lead to loss of function, like sensory function or movement on the opposite side of the body. If it's the dominant hemisphere, the left hemisphere, usually that's where language function resides and that can be affected too. But people can recover that. And so we call that plasticity.
And that ability to recover function does persist throughout life. It becomes less robust as we age. I think it's a phenomenon that is well recognized, but not really well understood. And it can be really quite dramatic. You know, we see sometimes patients who have injuries or other conditions that lead to very significant disability. And you know, it's interesting for the neurosurgeon perspective, I see patients when they're in the hospital, and then typically, they'll go for rehab, and it might be a few months before I see that person in follow-up again and when they come to the clinic, my anticipation, of course, is kind of thinking along the lines of what they were like when I last saw them and often, the recovery is just dramatic. I really never cease to be amazed at the capacity for human resilience and recovery.
Am Johal 18:55
When I came in the first time to the hospital, and a couple months later, when I had my surgery, I was actually supposed to be in Chicago for a conference, but I didn't end up going. But I think had I had to have that surgery in the States, you know, I will probably would have had insurance in some kind of way. But it probably would have been into the millions of dollars, a 14 day stay at the hospital, all these kinds of things. There's some great benefits to the public health care system in Canada. The only bill I got for extensive stay was, I think, $180 because I took the ambulance the second time, but other than that, it was what I consider to be fabulous, excellent care at every step of the way. I'm wondering if you could, you know, over your 30 year or so career in terms of the benefits of working inside of a public system, but also, what else could be done in terms of investments from government to enhance the quality of care in the neurosurgery area?
Gary Redekop 19:53
That's a complex question, but I gotta say, you know, we are proud of the work that we do. And I think in terms of facilities and people that we can confidently say that we provide care and have the equipment to provide care that's on par with the best that is done anywhere. There are limits in terms of capacity. I think one area that is often overlooked by policymakers or not given enough attention is rather than focusing on the hospital based care and capacity and having more ICU beds and more of this and that, is actually injury prevention. So you know, there are some conditions that we deal with that are independent of what you would call the social determinants of health, but many are and, you know, I think that rather than having more operating rooms and more ICU beds to deal with patients who'd had head injuries or other conditions that really are definitely related to social determinants of health, really investing in primary care, in prevention, in all of the kinds of aspects of public and social activity that would reduce, say, traumatic injuries arising or conditions arising from addiction, mental health problems. These are big problems and much harder to solve after something happens, I think, then to reduce their occurrence by addressing the root cause.
Am Johal 21:20
Gary, you teach as well, at UBC, as you mentioned, I'm wondering if you could speak to aspects of seeing this new generation of neurosurgeons coming through the system and about to enter the system. I'm wondering if you could just share some thoughts around that, what you get out of teaching and also advice you'd give to young neurosurgeons entering into the field?
Gary Redekop 21:43
Sure. Well, I think, you know, the teaching that I do involves two sorts of levels of relationship to neurosurgery. So I'm a professor at the University of British Columbia and the department of surgery and we're involved with teaching medical students in general. And on average, about one out of every two or 300 medical students goes into neurosurgery but many will become family physicians or emergency physicians or others who deal with the kind of symptoms that patients who have neurosurgical conditions present with. And so there's an aspect of my teaching that involves not so much the neurosurgical techniques, but helping students to appreciate the kind of conditions that may come to their attention as patients present with various kinds of symptoms. So I think that's really important. Because like you said, I've been in practice for many years, I've never had a patient ring my office and say, Dr. Redekop, I think I have a brain aneurysm, you know, they go to the emergency department, or they go to their family doctor.
And then yes, as far as the neurosurgery training goes, I think like many surgical specialties, apart from the technological development of this specialty, there has been a real demographic change. So when I graduated from medical school, which is now well over 35 years ago, the demographic shift in medicine was underway. And there was a significant proportion of women in medicine, even at that time, in the mid eighties, but very, very few went into surgery. Surgery was still a man's specialty. And when I was a resident, there were very few women residents along the way. And just the if you were to look at the manpower, if you want to think of it that way of the specialty through a diversity lens, it really wasn't. And over the course of time, surgery has benefited greatly from a much more diverse range of practitioners and, you know, women have become welcomed and now make up a large proportion of surgeons in many specialties. I would say that cardiac surgery and neurosurgery have been sort of the last specialties that have really attracted women. But that has changed too. And in our neurosurgery residency program here at UBC. We take one resident into our training program every year, and for the last two consecutive years, they both been women. And we've had several women graduates in the last few years. So the nature of the workforce is changing and the demographics are changing. And that's been a really interesting development too. I think it has benefited our profession and benefited our patients.
Am Johal 24:26
Okay, I'm wondering if there's anything you'd like to add?
Gary Redekop 24:30
I don't know that there's much to add in terms of telling you about neurosurgery. But I would say that I have been very fortunate, and I'm very thankful that I met people along the way who inspired me, and that started me on a path to a career that I have found and continue to find really interesting and challenging. There are certainly times of discouragement, but overall it's been a real journey of enjoyment and fascination and hopefully contribution. And I have had the opportunity to work with many great students, residents, and colleagues over the years. So I'm one of those people who's been very fortunate to have a career that I think both contributes to make the world a better place but also has given me a lot of satisfaction.
Am Johal 25:18
Gary, well, I've certainly benefited from your work, so to speak. So thank you so much for joining us on Below the Radar.
Gary Redekop 25:26
Thank you for the opportunity.
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Samantha Walters 25:31
Below the Radar is a knowledge democracy podcast created by SFU’s Vancity Office of Community Engagement. This has been our conversation with Dr. Gary Redekop. Head to the show notes to read up on some of the resources mentioned in this episode. Don’t forget to subscribe to Below the Radar on your podcast listening app of choice. Thanks for listening, and we’ll catch you next time on Below the Radar.
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