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Neurosurgery in China

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- Colleagues and friends, thank you for joining us for another session of the virtual OR. This is another session by Dr. Juha Hernesniemi, reviewing his technical pearls and experience. 50 years in neurosurgery. Juha, thank you again, very much looking forward to learning from you. Please go ahead.

- Okay, colleagues, I'm Juha Hernesniemi. I speak about 50 years in neurosurgery and especially about how I have been teaching my techniques to the world. More than 3,000 people came from Helsinki and the last four years I was in China, I will tell also about this experience. I was just born in a small village, less than 100 people. And then ending up in the largest country of the world, China with 1,410 million people. So this is a good stop here, but I'll show how that life was in China. Okay, so we saw how it runs in the second biggest hospital in the world. The biggest hospital in the world is in Zhengzhou also, with more than 10,000 beds. And heavy competition between these two hospitals in Henan. Henan is the biggest province in China. So I was born here in Finland, here. With the 100 people village and then I went to high school here in Finland. And with 18 years, I tried to come inside medical faculty. Helsinki didn't come inside and then I left to and this was the biggest happening for me. So then I came back as a medical doctor. I came to begin my residency in Helsinki, '66, '73, '79. And then I went to Kuopio, this is Eastern Finland, what was called my residency, Western Siberia. Very small city and very difficult to get papers published, because no one knew the name of Kuopio, but we learned, right also besides operating on it. Then against all the advices, I could come back 17 years later to be Chairman in Helsinki. So, and this since our life, 2001, Professor came to Helsinki and this was my chairman in Neuro Institute, Professor Marco Caste, who was more proficient than anyone else, he was fighting so heavily to get resources from the researcher, so he could fight with the administration. He was speaking and speaking and speaking. They had to give up. This was his strength. He was speaking so much that the administration was giving up. And this is one of the most important pictures here to see. The one who is following my search, is Professor Yasakil. This of course very special moments for me. I operated 2001 in front of him. First, a young lady with carotid bifurcation aneurysm. And this lady was an older lady has ruptured basila bifurcation aneurysm. Professor Yasakil said to me, he is like my shadow, he will not say anything, but in five minutes, he was giving advice all the time. But I didn't care. I didn't care. I closed my ears, because it was my patient. I was doing that. And what happened in 45 minutes after the skin incision, I had clipped and from there, I could make big eyes. Then he went around the world and said, then he was advertising to see how aneurysm can be clipped in 45 minutes, like Turkish people usually do. They decrease the time. It was 40 minutes, 35 minutes, finally half an hour from skin incision basilatic aneurysm was clipped. So, but you understand the big pressure I had, I didn't care. I was experienced, I did well. So and then this Professor Yasakil teaching in Helsinki life course, this is my connection to China. Dr. Hu Shen who wrote me a letter, "I will come to Helsinki," and then he wrote the second letter, "Pick me up from airport." He was here with Professor Yasakil, he was great artist. He didn't speak so much English, 40 words, but I noted that he's excellent neurosurgeon and he's, Professor Yasakil doing his gymnastic at the age of 78 years, fighting for the patient and the many other famous neurosurgeon were coming, also operating in Helsinki. This is Dr. Kava watching him in the life course. So we had to always create stars around the world to operate on and at the best 150 visitors during the 10, 20 years. This is Professor Spenik, my good friend. Unfortunately, he was visiting me in China. Unfortunately, he died last year before his third trip to China. And this once we were eating scorpions in China. They are very delicious, even if it looks very weird. In China, we can get all kinds of things to eat, everything that moves and also that doesn't move. So this is in Taiwan. Taiwan. This is neurosurgeon student of Alikrist. This is me, Kawashima from Tokyo, from Indonesia. And this is Taiwan. Taiwan is independent country. They don't belong to China. This is what they say. So.. I'm speaking about my presence and future. This is a lecture I was giving in China and I'll tell in the same time, I'll tell principles how I was teaching the Chinese this. Zhengzhou, this is in the middle of China, the most popular, biggest province in China, 110 million. And it was the second largest hospital in the world with 6,500 beds with the university hospital in the same city, Zhengzhou was the bigger one, with more than 10,000 beds. And always just this situation I could see Professor Xu Bin in Huashan Hospital. Professor Xu Bin has done more than 10,000 bypasses personally. And this is a number no one else in the world can do, because he's a young man. And this is Hu Shen, who I met before I left China, he was Chairman in this hospital, and he was going to retire now so this, I could meet them in China, but in China traveling was forbidden during the COVID time, so it was not so good. So we went many times to China to operate on, this is Harbin. Harbin has tigers. For some reasons they were thinking my team, we are tired, not to see the tigers. I was extremely interested to see the tigers but they don't, they cannot go because we are too tired. But the pandas, I have seen pandas. I have seen, this is from the hospital, our hospital, Henan Provincial People's Hospital. You see that the families are always coming to the hospital. These are poor people. They have no money to come inside the room, but they are there, sleeping in the corridors, steps, and they are all the time there. Why? Because they take care of the patient. They bring food to the patient. So you cannot get food in the hospital. This is Nepal, this is Arian and this is Salona. His wife, wonderful family. Two daughters, we had, we were one year in Nepal, very good time. Very poor country, but we had good time. So that was excellent neurosurgical department in an old, old rotten hospital. Like, Dr. was saying that neurosurgical department was like diamond in a shit. This was birthday, this was our team, team in Janakpur, Nepal. And then I went to Chinese Congress in Shanghai and with my good friend Xu Bin was there, contacted 2017. And I promised to come to China after one year in Nepal, because I had promised to go for one year into Nepal. And then I began my work in Henan Province People's Hospital Own Center with 60 or 65 beds. This was the time I met the administration of Henan Province People's Hospital. This professor Lee is a chairman of the 650 beds in the center. And like in China, so it was very festival. So this is President Gu, president of the whole hospital. So we made a, signed an agreement for three years in, China flag, Finland flag, and then many important people there. And then we were coming to China. This is my good friend. He was first my student, came to Helsinki, then he began to do his own surgeries and he's now the most famous Chinese neurosurgeon in the world. He's doing, what, 1,500 operations a year. And this record to doing bypasses in 17 cases in one day with his beautiful team. I have seen that myself. So it's not, when the China ones opens, go to him. Go to HuaShan Hospital is now the biggest neurosurgical center in the world. 850 beds and 20,000 operations a year. This was my hospital, Henan Provincial People's Hospital, the second largest hospital in the world. And always patients, many patients there. Over 650 beds for neurosurgery, neurology, and cerebrovascular diseases. There were 15 different subunits with senior leaders and I told already about this size of the Henan province, big population all the time increasing, and Zhengzhou, 11 or 12 million medium-sized city in China. And it looks like that in the hospitals. Sometimes there's over 1,000, 1,500 bases OR. More, there's no room in the rooms. And this is what you see in China. You see the panax, this is something very special you never see in other countries except Russia. And China is a Pyonist. "We are the successors of the communism," they say, but China, what is the god in China is money. Only God is money. But they speak about communistic party is not the way I like communism was. But now, you know, Xi Jinping is the leader now for his lifetime. So this is the Yellow River, it's the second biggest river in Zhengzhou and in the beginning, before the COVID time, we had visitors around the world, like in Helsinki. But then, everything stopped. No one could come inside the country. And when we went outside then we had six, six weeks quarantine time, so it was not possible to go to anywhere in the world, then coming back you had to stay six weeks in quarantine. This is like a copy from Helsinki they made, wonderful operational room. This is Ping Chen, excellent nurse, and we are operating together. We are doing the same kind of team, like was doing Helsinki and here Ping Chen is looking at the screen and we don't have to speak. She could speak English, but we don't have to speak because she knew what I'm doing here. This is the same thing here. Good team. What was difficult? Communication. Only 5% of the neurosurgeons were speaking English and made also teaching very difficult. This was my team, Juha Hernesniemi, Juha International Center. I'm sitting here, this is my Chairman, Professor Li Tianxiao. And the senior , this is Firtri from Indonesia, and then in the back you have residents and fellows, she made her medical studies in Shanghai and she wanted to come to America, so she's clearly different from people here. So what I was doing in China, teaching, teaching. Besides operating on. But of course the communication was difficult. So difficult, 'cause very few people were speaking fluent English. So I decided that I will learn Chinese and I was teaching always how to become a good neurosurgeon, international neurosurgeon, famous neurosurgeon. I have never seen a person who wanted to be a bad neurosurgeon. So find heroes, mentors, friends as mentioned. And neurosurgery has three paths. Operative skills, these are extremely important. These are extremely important. Then you can do research, clinical research or basic research. If you're doing good in operation, do clinical research. Basic research is different than clinical research. Then teaching high number of residents and fellows, visiting other clinics around the world. Like I said, I have been stealing the experience. I have been sitting close to three years in the cold corners of different operation rooms and I have been involved in big number of important publications, so called the congresses, life courses, webinars. Webinars are very important nowadays, because you cannot travel so easily. So my principles are, "Great leaders don't tell you what to do. They show you how it is done." I was always between the people I was teaching, I was in the middle in front of them and I was doing the work. So to train your best young people, they should become better than you. It was Dr. Drake was saying that if you do not find that kind of people, then we wait, one day they will come. And you take these people for your training, because they must become better than you and then you can be proud of what they have done. So this was Helsinki. A lot of people coming around the world visit Helsinki. This is one of my proudest moments. This is World Neurosurgery 2014. These are 70 most important neurosurgeons in the world. In the last 100 years, we will see Cushing Nandy, and here North, you'll see me. This is Finland, North. So I had more than 750 publications, citations here, and H-index is now 74. This is good for neurosurgeon, because our field is very small. We are only 70,000 neurosurgeons in the world. So this is good, good numbers, for a boy coming from small village and from a small country. So what is good microsurgery? Only training makes a master. You have to train in laboratories, you have to eliminate the tremor. Everyone has tremor in the beginning, because you're excited, this is something new for you. And then you should analyze your experience. And nowadays, it's easy to save every operation you are doing in your own files and fear, this is very important, fear. If you're a fearing operation, this means self critics and this means experience. So if somebody's sick, I have no fears to operate on. Then he's not a real cowboy, not real neurosurgeon, he's a bastard. If you are not afraid of operating on, if you're not excited, nervous about the operation, then you are not doing the important, good work. So neurosurgery is not different from soccer, ice hockey, skiing, playing an instrument, cricket, ballet, painting, learning new language, writing. What is needed? Hard training is needed. And this is old rule. 10,000 hours, 10,000 hours you'll come to the world top. And this is my role with 10,000 days in operation room. You are at your best. This is around 60 years and you are still in good condition and you have huge experience of 10,000 days in operation room. You are at your best. So, there have many ceremonies in nonprofit hospital. This is administration, very strong administration, everything goes upwards. And then finally the President of the hospital, member of the Chinese Communistic parties, deciding how to do this is Professor Chaoyue Li's team. This is the man. He has done around 5,000, five or six. He's a student of Xu Bin. He's doing 600, 700 bypasses a year. So big numbers, why they are doing so many bypasses, because there is moyamoya disease. We are doing research in moyamoya disease, and this is one of the specialties of the Chinese hospitals. All the family is bringing the food for the patient. So, this is no kitchen in the hospital. The family is coming with the patient inside the hospital and always bringing food to the family and taking care of the basic care of the patient. So there was a big operation, central operation room with 80 operation rooms and nine operation rooms for neurosurgery. Two hybrid rooms, three endovascular rooms for cerebrovascular diseases. All rooms were running late in the evening, but changing times in this huge hospital were long. There were many intensive care beds. 30, 30, 25 beds, and huge number of recovery rooms. When you saw the operating room list, you were wondering how they don't fix the pace, because most common names were Shen, Li, and so on. So they were never doing mistakes. And what was extremely strong in Zhengzhou.. Extremely strong endovascular team doing 7,000 aneurysm procedures a year. 1,300 aneurysms a year. 70% per treated by endovascular means. And then those patients who didn't have any insurance or were poor patients, they came to surgery for me for open microsurgery. 130 AVMs, number of AVMs is always who 10% of the number of aneurysms, if you get to all the patients. And then 600 moyamoya bypasses a year. 3000, 3,500 brain tumors. China operation increasing all time, that was when very skillful nurses doing 10, we could do six patients a day. And then endoscopic surgery is how figures they were increasing all the time. And also special spine was done by orthopedic surgeons, except intradural surgery. So, this was a field I have done a lot of spine surgery. I tried to get involved in spine disc prolepsis and lambatics prolepsis, but it was impossible. Impossible to change. Why? It's impossible change because the neurosurgeons and orthopedic surgeons, every surgeon is keeping some bonus for the number of operations they're operating on. And this is a 18 years old boy. Third bleeding from this huge impossible looking AV third bleeding. He was in poor condition. In Helsinki, we would have tried to embolize, and then to try to help him. But in this case the family was poor, was taking the patient home, and the patient died some days later, so they didn't have the money to pay for it. So this is how it is in China. This case, we could manage immunization then finally surgery. Good outcome. Endovascular surgery, skillful in Henan Provincial People's Hospital, that kind of central AVS, where they were treating very skillfully and total occlusions. Of course, these are very hard pieces to be operated on by open surgery. I have done more than 600 AVMs, it's, of course, very difficult for me also, but I could do them. But then it was coming easy, so of course by far better. So work profile, my work profile was outpatient clinics, helped with my secretary, because I didn't speak any Chinese. Operation room, I was doing well. Operations were good. Directors were speaking seldom English. Case discussion, ward rounds, Thanksgiving. Annual awards, I get annual awards. This is how it is. So I was slowing down, Helsinki was doing 10 to 15 operations a week. But now I was retired from Helsinki. I was doing two to four personal operations a week. Mainly cerebral aneurysms in poor patients, AVMs and deep cavernomas, seldom brain tumors because it was more centered, mild. And that was surprising change. So this one I remember, a lot of noise in operation rooms. I'm a student of this is like a church, you have to be silent, even smallest noise in the operation was meaning coughing. He was saying you are sick. He was throwing you out, and in Chinese operation room, sudden shouting with loud voice, sudden noises, speaking several words, et cetera. I was thinking it cannot be changed, but I could change it in one and a half years, how I could change it. I was swearing heavily in Finnish and looking very angry. But they were speaking, it was understood that you had to be quiet in the operation room. There was some learning, which made the surgeries more enjoyable. I was trying to find out in China, where is the loud shouting coming from? The best explanation was that it was coming from the working at the paddy fields. People were shouting on the paddy fields to which another paddy field, and it continued. It continued in different generations, also in the young people who have never seen a paddy field. They were speaking loud and also loud in cinemas. And this is what we were doing. We were not shaving the head. Since 1982, I have never shaved a female or shaved the whole head. And this is Peng Chen, helping in operation. You see, I'm using very few instruments, then maximally not to close time when chasing the instruments. And this is from originally from Venezuela. He has been 12 years with me. Met PhD in Helsinki on approach to and he's opening for me. I have always opened myself, because this has been my practice. I learned from Professor Yasakil. It has decreased my nervousness to operate on the patients and I get the scalpel in my hands, then I lose the fear, nervousness, excitement. And I go like I go home inside. Then inside in echo like in my home in . So this opening for me and this is again opening is doing the same way than me. This is my secretary. Chen Toksang was also neurosurgery. He was speak English and I was totally dependent on his help when speaking with patients, outpatient clinic or every effort this anesthesia side, he fit maybe sleeping. They have very good screen here to see what's happening. And they were improving in anesthesia in the beginning, the brain was not slack. First thing in healthy what the people were saying, how the brain is so slack and neurosurgery in health, they were excellent. And we were improving in three years here, but not that level in Helsinki. This big AVM I was operating on. I was very careful with follow but seniors. And we were using also seating position. We built up sitting position here is making sitting position with the anesthesia. And when they were following PCO2 and PCO2 drops down, then there's error , then you are compressing the neck veins and then you will find the bleeding side and stop it. So this is how we're doing. This is the strategy from the operation room. Very good microscope, mobile microscope. And this is the mouthpiece. This makes your operation 40% faster, because I was always extending and with the mouthpiece I was extremely mobile and changing angles and I was very fast. So the record from skin to skin in MCA aneurysm and one aneurysm was 25 minutes. It's difficult to believe, but it is so. So, I was thinking about China population. This is the China population. 1,410 million people. So this means around 40 to 80 million aneurysms in this populations. Chinese are carrying 40 to 80 million aneurysms. To treat them all, pipeline is very expensive. This, the price is like a small house or good car. A clip is so cheap. So this is the difference to treat all those aneurysms, they are finding the regular health checking is extremely different. So consequently, forensic patients have open surgery. They were my patients and what you find in Chinese patients. Terrible atherosclerosis. Why? Also young patients, 30 years, 35 years. They're eating what was called Mao pork, because this was the favorite food of Mao. Machato pork with a lot of fat. And then males were heavy smoking. 70, 80% of males were smoking. I saw only seven, eight females smoking the whole time. And there's a lot of pollution, not so much India now. And then there must be some genetic things, because we have so many moyamoya cases, they're like flowing inside the hospital, moyamoya cases like Xu Bin is operating more than 1000 moyamoya cases a year. And this student lead, Chaoyue Li was doing 600 cases a year. And more about smoking, no smoking, all everywhere have these tables, no smoking. But the people went to restroom, looked at the cellular and were smoking there or everywhere, smoking no effect on the people who were smoking. And before COVID time, there were many conferences. I went to conferences. There was also neurostic competition in Shanghai. We were there to see who is the best clipper of aneurysms. This is organized every year, one or two times by academic. And what I didn't understand, the admission policy. Wild and confusing. Also, regular patients try to select a place of their treatment. They go around shopping and ask many opinions. I advance a patient with AVM, young lady, she went to 10 different neurosurgeons and then came back be operated on by me. So, many patient consult big units in Beijing and Shanghai. I saw only one patient that was operated abroad, in Germany. So they trust in Beijing, Shanghai, Guangxiao, big cities. And for this, all over the time, follow up with the patient extremely difficult, because the number of people is so big. It's not well organized. Nowadays, you could call every patient, because every patient has a cellular, but it was not organized. Follow up is actually nonexisting. I saw maximum 10% of the cases I was operating in China around five to 600 cases. I saw in the outpatient controls only 10% of 10 because they stayed at their home and they didn't understand the meaning to be seen by the operator. Communication extremely difficult. Few people speak, few neurosurgeons speak Zhengzhou English. 5% maximally. So I thought I will learn Chinese. I thought I take a private teacher. In one year, I will manage. I speak five languages, so I was thinking I will learn Chinese. But it's very difficult, because that's in every word. That's all word like aneurysm is . Microscope is something different. So I had five times a week, I had two hours private teaching of Chinese. But I didn't manage, I didn't manage. I learned maybe 800 words and phrases. But when I was speaking them out, they didn't understand me because intonation is so difficult in China. So it's so, so difficult. For example, for the number four, there are 200 different meanings. It means four and death. So you don't have the thought. And number four. How do you say number four is the bad number, like 30 in the Western world. So we don't have the thought. So in China, I was like a child. Can't speak, read, write. I was living in my brain and experience was totally different from my, it is totally different from my surroundings. And then I was six weeks in isolation and I was writing my memories 16 hours, 18 hours a day, because there was nothing else to do. And what I saw. In China, there is extreme high number of very skilled neurosurgeons. That is high number of cases like yellow. We were at low number of sharing to experience in international journals. The people think the most important thing is to operate on, have good food and then go home and sleep. So these skilled, they remain local hero because they publish in this is WeChat, this is WhatsApp. And this is more advertisement than real scientific work. And there's heavy competition of the patient, because you get some bottles of the cases you operate on, so you can good number of money. And that's why there is big competition about patients, not about . So I was thinking change something in the Henan, China, the world? This is big fashion change. China is very difficult and I was thinking maybe in many years, I can say change something that needs many years. And this you could say always when you have a difficult task. My country has saying that year 1947, the year I was born. "First they ignore you, then they laugh at you, then they hate you. And then you win." This is very important. It's very important because always when you're picking something new like microsurgery, people were laughing at him and we're telling that real good neurosurgeons can operate without microscope. So, but now everyone is operating with microscope, difficult neurosurgery calibration and with micro instruments. So, for my goals in China. In surgery and all the time. But in my 50 years, no hair shaving, anesthesia, good anesthesia with slack brain. So you can avoid skull base surgery, head high, sitting, semi-sitting position means little cleaning. And then different approaches. I was operating on brain stem cavernomas and AVM surgery. These cases, I cut. Take look on this beautiful Chinese female hair here, here, beautiful Chinese hair and what happens to them? In Henan Provincial People's Hospital practice now, all the hair is taken very, this is very in life and also in practice, it takes more than one year. The hair is okay, so this is my practice. This is 10 years old girl with medium sized AVM with large hematoma. I operate urgent. So she looks good, she can go back home and to school very soon. Another case, young based on 18 years old with AVM operated on, she looks totally normal. She could go back to school to learn her job is from my office, always wearing masks there. And this also young female after AVM, went home. Husband was very happy that she didn't lose her hair. So slowly they are improving, they need something. And the patient were thankful they were bringing that kind of blackout and they went home, their whole family was there and they went home. It was important. The situation, I cannot read what they are writing, but they say thank you very much. Thanks giving and positive comments from patients and other doctors. So I give a try publishing huge number of rare cases, wonderful series post three or four subdural AVM plus 56 cases in the cranium. Server called we couldn't publish because they didn't give any efforts or minor success in publishing. Changing attitude, more international minor success, one part to the COVID time and then connecting people for international change of experience, minor success, some part goes to the COVID pandemic here, but also difficult. Chinese doctors are not so open-minded, they don't go easily outside of the comfort zone. So what our leader, Li Tiangxiao, was doing, he hired a group of best scientific writers. We had put writers, and he told that every senior should write one paper a year, one paper, only one paper per year. It never happened. Never happened. They were only interested in surgeries and never happened. So it was difficult to have the people to do research and publishing. Spinal injuries, there were many. So we failed totally to do a study on spinal injuries. But in moyamoya, we could do there was good in that, it was eight months involved with the moyamoya disease and he did 150 bypasses in this eight months, this is extremely good experience. Now he's in Toronto, working as professor . This one you cannot get in Europe. In China, you can have so many moyamoya cases. Then cerebral aneurysms, huge number, 1,300 a year. Nothing, think can we make a database? We followed after patients and how they're doing after treatment, but didn't happen. No one was interested in doing databases. To do a database is the hardest job of all. And we were thinking that we have international fellows involved in writing and publishing, but China was closed and so we didn't get anyone. This was, I was always telling, I tell it all over the world, that English is the language of science. And if you want to be a good, excellent neurosurgeon, you have to be able to speak and write English. And in my own hospital, very modest steps, even deterioration during the time I was there. So finally there were meetings where Chinese and then just sitting there and asking my secretary what they are speaking. So this is important, important if you want to fly high, be excellent neurosurgeon. You have to go to be able to do good neurosurgery and to speak and write English and publish a lot. Otherwise, you be remain local. Here in the beginning, we were organizing live courses, legends, and stars of international neurosurgery, involved and then Professor Tiangxiao Li was organizing the, Congress, temple is close to 10 so, 1,500 young people learning and playing heart and doing the school at the same time. The best thing we found, Xu Bin from Shanghai was hospital. We were giving weekly on Friday, webinars and we had up to 5,000 people audience in China from in all the world stars were speaking there, and Xu Bin was translating similar Chinese and in Japanese. So in one year, we had a total in China 140,000 people. And outside of China, the same number, so 300,000 were following our webinars. This was very good, good teachings for China and Japan, and also outside of these countries. So we made six live courses since December 2017. And COVID came, pandemics came, only Chinese neurosurgeons could come there. Shaolin Congress, I was meant the first Shaolin Congress, I was president, 1,000 participants. And with webinars, 30,000 people could follow excellent foreign speakers, but also best ones in China. So we're trying to improve follow up of the patients, publishing instead of feature in international journals. We could make some papers, but the Chinese neurosurgeons were not so interested in that. And actually, they were not so good in writing. I had papers like and me, we have done so much with them. So we were very well trained in doing that. But we didn't get any big support from the local ones. Before going to Guangxiao, I was planning that we make HART and and also randomized study. Immediately when I came to China, I thought that it's not possible. Why? 'Cause there's no follow up and 15 different seniors and these big departments, 650 people. So they are not able to adapt to randomizing the paper, so it was total failure. But I was consulting about that. We had good plans and very good strategy to do that. It was not possible for practical reasons. This is the first Shaolin Congress as president. I'm speaking here, giving my lecture. This is very popular and wonderful course, we gave lifetime prize for people in neuroscience. First one was given by Professor Yasakil, second one, the third one, Professor and leader of Moscow . So this congruents here, second prize, Victor Hugo from Mexico, William Caldwell, president of the World Congress is from Indonesia. And we're giving five courses from masters in surgery see here Xu Bin, and Victor Hugo, from Mexico, number of people involved must pick one, even no foreigners were able to come. So we had many, many there. So I didn't see this child, I didn't see this child because COVID time pandemics came just first six weeks quarantine, then two months lockdown. And then it was for forbidden to go outside of China. So I didn't see Mongolia, I didn't see few places of China. I didn't see Tibet, I didn't see actually anything from China. I saw only Guangxiao hospital or flat. And the food store. Xi'an, I have been many times, this is Xi'an Terracotta soldiers, they say this a small city with six million people. There are Terracotta soldiers found. The number of Terracotta soldiers is around 1,500. So when I see these Terracotta soldiers, I think I have done more than 16,500 operations and 90%, but 10% have difficulties some part. So she had injuries, suffered hemorrhoid, they died. I cannot take them on my account. But the other 5% I haven't taken on my account. I made something wrong in these patients. So I can say this one died, this was paralyzed, this lost memory. And so this is what I'm thinking when I see pictures of Terracotta soldiers. I wanted to see also a psychiatry hospital in China. And we were brought to the Henan Province Psychiatrist Hospital has more than 10,000 beds and beautiful research facilities. And we were also of course the best department for psychiatric patients. Yeah, psychotic patients eating. It was beautiful and it was well-organized. They had they also building all neurosurgical center there, three excellent rooms with more neurosurgery. So not for the psychiatrist, they were beginning to do neurosurgery on their own. And this is how the COVID is. They were working hard, they're extremely hardworking. They were put for one week inside the hospital with COVID patients. They were sleeping there and then came after one week and to work in this dress, extremely heavy. So they didn't know who they are, their names were written on their back or belly. And this is, the mother said goodbye for one week to the children. After one week they came back, coming back in London, Helsinki already one day or 12 hours was extremely heavy for the nurses. And this was my isolation. Behind this door, I began to do my memories. You see, it's a sealed door. And once a day I was brought some Chinese food and something to drink, but no going out. And also recorded by, it was automatic recording that you couldn't go out. You couldn't go out, so it was impossible. So I was doing 16, 18 hours, I was doing my memories. At six weeks, I had 300 pages, and then I continued. So now I have published my memories in Finnish and bestseller in Finland. And I tried trans, I tried to get it translated, it's all translated in English and then in many other languages, in Chinese and Japanese and Turkish and so on. And this was how to come inside the hospital, guards, checking everyone's cellular where have you been, if you having, you know, city place where there is COVID cases, you couldn't come in, was showing that we have been in a forbidden area. And then the control continue here. And of course there was no possibilities to hold a distance in China because the people are so many. So this is waiting for a lift and it looks like that to lift. But everyone was wearing a mask there. And now the number of COVID cases increasing heavily. I don't know what the Chairman, Jinping will do, has big demonstrations now in China. And let's see what happens now. I have to go in March to China to get my two years salaries paid because they can't send it to the Helsinki Finnish, my account in Finland. So I have to go to China. It's certainly the most difficult trip because now I have to be eight days in quarantine or 10, I don't know if that's lockdown in the place where I'm going now change, so is in lockdown. And when you have lockdown, it may take like last year Shanghai was 62 days in lockdown. So it is extremely difficult when I have done this, this traveling to China and I'm continually to be in contact, but far away I cannot go to China, because it's so uncertain. Uncertain to come out. So this is my memories in Finland, bestseller. Now even, I'm not a writer, auter, I'm a researcher. I was writing with the blood of my heart and this translated so totally English. And then in the other languages, and this is important. So I made my work and I wrote my memories. This is what I did. Others can follow, not the same if they can. So this is number one in Helsinki bookstore, number one, bestseller. And yeah, I'm signing books in the publishing company, it is not my office. I had a very lousy office always. But my office was in the operation and I was told, and my memories came out. Many people were writing in the writing that you have been only working, had no time for your family and you had no life. So I put this slide there. Here I'm sitting in the '80s with my children, Aida, Etta and Usik. So I had also some other life than neurosurgical life. This is important. This is very important. So, and this is extremely important. Never forget coach who helped and guided you. This is extremely important. Yeah, yeah. Basketball player is getting advice from the coach. And here is helping the old coach. Never forget those who have helped and guided you. These were my masters. There's Professor Yasakil, this is in 2018 or something in World Congress. And this is So on Tuesday, we had always dinner during live courses we gave live courses and they were very popular and famous all around the world, now it is finished. And this is Miami, '93. This is Professor Felix and this is Professor Drake. We are checking what I was doing with the London Ontario it was honors 1,767 aneurysms, a series that can never be repeated. I wrote the book, I had only one chapter ready from Dr. Drake. I wrote the book. I learned to write the same way like Dr. Drake, with very few words saying a lot. Moscow, I was invited to be honorary professor in Moscow event. All our team went there and this is was one of the best things in my life to avoid burnout, was a new family dog. Anna 13 years old, she was living and this is picture is '94, on the isles of Eastern Finland. So she was always happy when I came home, even being away one hour or 15 minutes. So my plans for the future is to take a new family dog like that. This puppy will grow to 70 kilos, big dock, big heart. And this will be my plans for the current time, because the Russian war in Ukraine stopped flights to China. And China has difficult situation with the pandemics now. This nearly impossible to go there. So these two things stop my working life. And this is good, this is good, because one day you have to stop your surgeries. I made 50 years surgeries. So one day you have to stop, otherwise you will fail and go down, have fatalities. And this is very important that you stop at the best time. Dr. Drake stopped at 72, Dr. Spencer at 72, I'm now 75. I was doing my last surgery one and a half years ago. So I am also lacking experience. But what is most important? I lost my team, I lost my team around the world, always now Toronto, is in Indonesia, Ajamal in Louisville, USA and Chinese stayed in China, the wonderful nurses, they stayed in China. So, and thank you very much. This is a girl, AVM operated on and here she's back in her dancing group. So thanks. Thank you very much for listening my memories and how I was teaching. One more thing is important. Younger generations are always doing better, support them so you can be proud of your younger generation and your students. They will do by far better than you did. This is biology, this important support for that generation. Thank you

- Juha, thank you again so much for this great lecture, two series of lectures. It means a lot. What you have done for neurosurgery is quite unparalleled. Your technical skills, how much I have learned from you and many other neurosurgeons has been tremendous. I wanna really appreciate to take the time today and give us these lectures and look forward to have you with us in the future. Thank you again.

- Thank you very much for your kind words, thank you.

- All right, thank you, Juha. Have a good evening. Take care. Bye-bye.

- Thank you. Bye-bye.

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