THE FUTURE IS NOW & DR. IYPE CHERIAN

Neurosurgeon, Director and Chair of Nobel Institute of Neuroscience, Nobel Medical College and Teaching Hospital, Biratnagar. He is also the counselor general of Asian Congress of Neurological Surgeons (ACNS) and in charge of ACNS Education Course.

Text by Avant Shrestha

Dr. Cherian is someone who may not have been a neurosurgeon let alone be one of the best in his field. In fact, he reminisces wanting to be in the military as a doctor and was all set to join the army. But his path was perhaps preordained. Dr. Cherian was guided by his dad’s uncle and mentor Dr. KV Mathai to undertake a six-month stint in Nepal.

Prior to arriving in the country, Dr. Cherian thought that this decision would be a professional suicide coming to a place like Nepal after finishing his neurosurgery from Vellore and ‘skull-base’ and ‘vascular’ from Japan. Many would have agreed with him as well. But in hindsight his decision turned out to be fulfilling, not only personally but to the medical and neurosurgical sector in the country as well.

Dr. Cherian has been in Nepal for the past 11 years and in his time in the country he has realised that if an individual puts their mind and effort into their work, they can work anywhere. “Third world is only a mentality,” he states. Today, along with his team, Dr. Cherian has turned not only the teaching hospital’s vision and goal to produce doctors of tomorrow but has also established the Nobel Institute of Neuroscience as a center of excellence.

One would not imagine Nepal to have one of the best medical and neurological facilities in the world. But after a brief tour of the hospital, this writer was set to think differently. The state of the art facility is astonishing.

Dr. Cherian has gone and taught with the most capable faculties all over the world. He has accomplished much in his field and his achievements should be celebrated.

Dr. Cherian narrates an interesting story of a man who was asked to run in a circle by the King. If he ran and completed the circle within the given time, the land within the circle would be his. In his greed to acquire as much land as possible, the man ran trying to create a huge circle and eventually failed. He was tired, breathless and in tears, unable to complete his circle.

The message and the importance of keeping your circle close and complete can help an individual achieve what is within their grasp and more is well articulated in the story. This notion is what Dr. Cherian stuck by and thus has been able to achieve what he set out to do. He explains, “You know the problem with us is that we keep running without knowing where to go or what we want and need to be happy; we just keep running. Whether it is in business or surgery or just life in general. People, once they start running, keep on running and while they are running, they see others running faster or slower, and they keep on running. But at the end of the day, the circle of life is just your family, your friends, your passion and what you want to do. If you keep running, you will never be able to complete your circle. You will be tired, breathless and sad. If you can complete your circle, that is the best thing. This is what I want to tell our readers because I come from a business family and I find that most businesspeople never complete their circle and that is why at the end of the day when you reflect upon your life, you understand that unfortunately you haven’t completed your circle. Being in Nepal probably helps me complete my circle.”

Excerpts of an interview with the exceptional surgeon and human being:

What has your journey as a student of neuroscience and as a neurosurgeon been like?

I joined neurosurgery 20 years back in Vellore, India. After finishing my MBBS, I did my neurosurgery in vascular and skull based fellowship from Fujita, Japan, which is one of the finest places on earth for this. I was on the way to New Zealand for a job but in 2007 my dad’s uncle Dr. Mathai, a neurosurgeon asked me if I would like to go to Nepal for six months. Dr. Mathai is responsible for starting neurosurgery in Nepal. In fact, he used to be invited as King Mahendra’s guest and he was also responsible for starting the neurosurgical ward in Bir Hospital.

Nobody expected me to say yes. In my South Indian perception, Nepal stood as a mystical place. I had no image of Nepal apart from the Himalayas and mysticism.

So I agreed to come to Nepal for a stay of six months. I joined the team of the late Professor Doctor Upendra Devkota. After a brief stint with him, I moved to Pokhara. I really fell in love with the Manipal Campus and I began establishing a unit there. At that time, Nepal had very few neurosurgeons. Probably less than ten and there was literally no neurosurgery in the peripheries. To heal the geographically disadvantaged people outside the valley, we started the department of neurosurgery in Pokhara; it is still running. And after two years, I moved on to Chitwan, another place in the periphery, where we started neurosurgery as well as the first training program for neurosurgery outside the Kathmandu Valley. I was in Chitwan for eight years and moved to Biratnagar two years ago.

You came when the country was going through a rough political phase, plus there were also challenges of power outages and water shortage. The timing was probably not the best, yet despite the hurdles, what made you stay on?

When I arrived in Nepal, all these problems that you mentioned were there. And frankly, I really wanted to go back. It was not so much about the instability but the water shortage and the load shedding made me reconsider my decision as life without basic amenities would be a difficult.

In fact, when I relocated to Pokhara, I was shifting myself from a place where I had all the facilities for neurosurgery to where the facilities were limited. So, I asked my uncle, who sent me here, that I needed to return because I thought that I was simply wasting my time here.

What he told me then stayed with me. He told me that the best surgeons in the world didn’t do surgery with all the fantastic infrastructure; they started with limited facilities. I understood that more than the instruments, it’s my effort and ability which matters. Plus, I gathered that I could make a difference to a lot of people here.

Rather than going back to India and become one of the 2000^th or 3000^th neurosurgeon, here outside of the valley where there was literally no neurosurgeon, I felt I could make a difference. At that time, all the neurosurgical patients were either dying or being taken to Kathmandu. Most of them did not even survive the trip. I thought I could make a paradigm shift. I am proud that we started three departments in Pokhara, Chitwan and Biratnagar. All in the periphery, geographically distanced from the valley.

The population of Nepal is 30 million and still there are not more than 35 to 40 neurosurgeons to account for. It is still a very low ratio but 11 years back when I came, there were not more than 7 or 8 surgeons.

But more than that, I am very happy here and content; it is all that counts. I am not overworked, and I am not in competition with anybody. I am not rushed like in the corporate sector. I do my work. I enjoy it thoroughly. I enjoy my time with my family and whatever I do here. At the end of the day that is what is most significant.

When and how did you know neurosurgery was the right path for you?

Dr. KV Mathai was one man who really inspired me. However, we were antithetical in temperament. I was a very driven and aggressive young man but he was a very calm and down-to-earth and a really nice man. He never uttered ‘the four letter word’ or got angry. I was the exact opposite. But I was so inspired by him that I wanted to be like him.

In my childhood, I met many big neurosurgeons as Dr. KV Mathai had friends from all over the world; so I always fancied that I would one day become like them.

You have been credited for developing Cisternostomy. Tell us about it.

I developed a new technique for head injuries which is called Cisternostomy. Cisternostomy is basically opening the basal cisterns to atmospheric pressure. This technique helps to reduce intracranial pressure in severe head traumas as well as other conditions when sudden brain swelling troubles the surgeons.

Today, cisternostomy is listed as one of the primary treatments for head injury surgery. So much so that when Michael Schumacher had his head injury, they sent the scans to us for observation and Roy Thomas Daniel who was taking care of Schumacher came to us from Switzerland, he learned the technique and he started the first ever European trial in Lausanne.

Consequently, after the trail, the technique that we started got famous all over the world. And it has since been a part of the world’s most leading trauma study known as GNOS (Global Neurotrauma Outcomes Study), the biggest trauma study being undertaken at the moment. And I, along with the President of the World Federation of Neurosurgeons, happen to be one of the advisors. Currently Professor Peter Hutchinson is the Principle Investigator of GNOS. And I am in the honorary advisory panel among professionals from all the continents. And to represent this small country is something we are very proud of.

Once cisternostomy got listed, we also started something called a theory on cleaning and cooling the brain. And this theory was the consequence of cisternostomy. We proposed the theory and it got accepted. It is now in one of the chapters of the Springer Neuro-Series. So things like that have been extremely prestigious for us.

Additionally, one of our sub-specialties is a skull base and vascular training. After starting the training in Biratnagar, fellows from all over the world started coming in. We have had fellows from Italy, Russia, Egypt, Yemen, Venezuela, Peru and India. So we take the influx of foreign professionals as an achievement because they are coming to our place to learn which is literally a reversal of the trend. Earlier, the culture was that people from Nepal and India went abroad to study; now, it is the other way round.

Today, I could say that the treatments for head injuries or surgeries that we perform here can be regarded as the one of the best in the world if not ‘the best’ in the world. So we are quite proud of this department.

[su_pullquote align="right"]My uncle told me that the best surgeons in the world didn’t do surgery with all the fantastic infrastructure; they started with limited facilities.[/su_pullquote]

How do you view robotics is neurosurgery and the use of stem cell transplants to treat degenerative neurological disorders?

Stem cells are going to be the future. Robots are going to be the future. I mean whatever we are looking at right now is going to be debunked in the next 10 years. In fact, we are looking at robot, a visualisation robot. This is completely my project which is designed by me and it was done in Alicante, Spain.

The visualization robot consists of an endoscope and a camera; so the surgeon doesn’t have to do anything as it positions itself by AI. There will be small mark and it will go and focus on that mark. So on the scan if we show them an area of interest, it will focus there. And these robots are going to be much smaller.

When the project is complete, the first robot of its kind will be in Biratnagar. Can you imagine that? This is what we are looking at, and I believe in looking into the future and you know if you look 100 years into the future then you will be lucky enough to be 10 years into the future. I am aware of the fact that what we did 5000 years back is laughed upon now; similarly 10 years down the line what we are doing now will be laughed at. The world is moving at such a rapid pace, we need to keep up with it and if I have any dreams of making this into one of the best centers; the only way I can do is to look into the future.

How much will it cost to be able to see through the completion of this project?

We are looking for grants because if it’s an entire robot suite we are considering; we need something close to half a billion dollars. But it will change the way neurosurgery is done. We are contemplating about talking to Google as well as Toyota Corporation’s robotic department.

For this project we have a core group of people from all over the world, for example, Bradly Nelson, who is one of the giants in robotics is with us. So we are in talks with people and we are trying to develop and push things. If I am not teaching, I am constantly talking to someone and pitching my ideas about robotics. I don’t know when this will be completed but definitely within the next 10 years before I retire.

There is quite a lot of state-of-the-art equipment in the hospital. Could you briefly outline what kind of equipment you work with?

We have the country’s first Intraoperative MRI Suite which basically means during the surgery I can do MRI while the head is open. In fact, when we did the ‘3 Intraoperative Tesla Suite’; no place in India had an intraoperative suite. Then we got ‘O-Arm’ which is a Spine-suite where you can see the spine in 3D and operate and then we got an endoscope with robotic arm. Even the hospitals in South East Asia don’t have these. Slowly but surely we are turning this facility into a center of excellence.

There is a zero shadow surgical table. The purpose of the ‘zero shadow’ surgical table is that it helps create no shadow while we are operating. We have the 3D viewing monitor which is again the first one in the country and the third one in the subcontinent. We have it so that my nurses can see in 3D what the surgeon is doing. These things can be picked up by the camera once it navigates; before the patient’s head is opened I will know where the tumor is. And lastly we have the ‘Pentero 900 Zeiss’, it’s not a simple ‘Pentero’ it’s a navigable Pentero which means the moment the patient’s scan is done, the scans give me a virtual image and with the virtual image whatever tools I require can be navigated which means millimeter precessions. I can go in and operate while I am able to see through a microscope.

The medical field is all about collaboration. What is your take on leadership and collaboration within a team?

I always say that if there is no good team, there is no captain. It would be foolish to talk about only M.S Dhoni and not his team, because Dhoni alone cannot win the World Cup by himself so it is always the team that is important and should be put at the front. I try my level best to develop the team. I perform as many surgeries and give free hand to all my team members. It’s not always that I want them to do what I instruct or that they follow me every step of the way. I want them to have the freedom and a sense of responsibility as well so that they can develop and once they do that I can go on to the next stage. That’s the only way: grow, develop and reach the next step.

In fact, I have got a pretty large team; probably the largest team in neurosurgery in the country. Most of them were educated and trained under me so they follow the very strict standards that I impose. We believe in working 24 hours. We believe in being the best not only in the sub-continent or in this country but the entire world. In fact, we present our work to the whole world, for example if you see ‘Neurosurgical TV’, which is on google and YouTube you can view the surgeries either live or after the procedure is completed and we have conducted lots of presentations for the channel.

Do you believe in the power of God? Does it not interfere with your trust in science? Is it like harboring two contrasting ideas if a doctor believes in God?

Yes, I do believe in the power of God. I believe that all the religions are the extension of mathematics. But then more than that I believe in the goodness of human being.

Actually, I am writing a chapter in Neuro-Series in Springer called ‘God Through Science’. Currently, I am researching on the patterns of ancient Hinduism and Buddhism and what they call the Mandalas and the Yantras, and I believe that the ancient concept of religion was pure mathematics, for example ‘Om’ represents infinity, ‘Shivaya’ represents 0, so Om Namah Shivaya is 0 worships infinity or infinity worships 0. So these are the concepts that we are looking at. When you utter a mantra you can see it, and seeing the sounds is called semantics. So we are doing some research with Sri Sri Ravi Shankar’s group. I truly believe in God but then I believe God is in goodness of men. Compassion, goodness you know. Rather than dividing it into Hinduism, Christianity or any other named religion.

You have been practicing MMA for the past 20 years and you are a black belt in Shotokan karate.

Sports is a huge part of my life because as you know it teaches you two important things: discipline and never-say-die attitude. And without these two things you can never win anything in sports and it’s the same for neurosurgery and life.

Discipline for me is getting up at 4 o’clock even when you really don’t need to. And ‘never say die attitude’ is when you have a really bad situation, and people say it is unsalvageable but you sit down and salvage the situation. So these are the two things needed for any sport whether it is martial arts or football or anything and people who have it generally end up being happy people. So this is what I imbibe in my life as well as neurosurgery.