Tiresias - Icarus or Phoenix?

"Success usually breeds a degree of hubris. When you fail, that's when you learn."

Moby (Richard Melville Hall)

My friends,

This week we have seen the unfolding of a classic Greek Tragedy. Tiresias, like most Australians, is Taware of the talented, prominent Sydney neurosurgeon, who, having soared too close to Sol, has plummeted Icarus-like toward Okean. Tiresias does not know him personally, and Tiresias does not wish to judge. Tiresias is however familiar, all too familiar, with this trajectory he has seen many many times. An individual, gifted by the gods, carried away by his gift, attributing it to himself, losing touch with humility; brought down by Zeus-sent Nemesis. So sad.h

But why should Tiresias talk of this, in a post on his favourite subject, Optiscan Imaging? Well, my friends, had things gone differently, the story now would be very different for our neurosurgeon friend and many Australians who have died or are now dying of malignant brain tumours.

The irony and the tragedy cannot go by uncommented. You see, the answer to the Neurosurgeon's problems, and the answer to the other Neurosurgeons, the answer to the patients’ desperation was here, right here, right under their noses, had they but looked, and had it been pointed out to them. Optiscan Imaging Confocal Laser Endomicroscopy (CLE), would have changed everything. You see my friends, to explain the issues without belabouring; malignant brain tumour does not have a margin. And therein lies the problem. Neither MRI, nor direct visual inspection at operation, nor frozen section biopsy, can tell where the tumour edge is. This leads to the classic case of the Hippocratic Paradox. The primary Hippocratic directive, to all doctors is ;

"Primum non nocere" (first do no harm).

That seems straightforward and clear. Unfortunately, it is an
ything but straight forward. Certainly, the worst thing that a surgeon can do, is that as a result of surgery, for the patient to come out of an operation worse than when they went in. And in neurosurgery, several millimetres “too far”, and the patient ends up dead, or with a severe permanent Neurological deficit. Neurosurgeons naturally err to the conservative. If there is a possibility, that in attempting to remove malignant brain tumour cells, but doing some harm and making the patients worse, than most neurosurgeons will hold back, stay away, and leave the malignancy and let nature takes its course. Hippocrates is whispering into their ears! Some, however, will say I can do better. I may cure this patient. It is a risk, but it is worth it! And sometimes they can. And sometimes they do. But sometimes they don’t. But up till now they had no way of knowing when to be conservative, when to be more radical. They cannot tell, whilst they're operating when to stop, as there are no more malignant cells present, or if they should go on, that little bit further, that could make all the difference. And our current system favours conservatism. If, after surgery, even if the surgeon claims to have, ”completely cut out the tumour”, the patient is not cured, the tumour grows, and the patient dies, well then, blame the tumour. It is an “incurable” disease after all. If, however, in pursuing a cure, with more radical surgery, the patient comes out of the operating theatre with a worse neurological deficit, the conservative surgeon, shakes his head, points to the Hippocratic directive, calls the more radical surgeon arrogant, a fool, and accuses him of doing the wrong thing, and harming the patient. “You should not have operated!” they say. But who is right? Not operating removes all hope. It is certainly preferable for most of us human physicians, including all too human neurosurgeons, to shrug shoulders, and to say, “it was written in the stars”. There was nothing that could be done. Blame nature, blame the Three Sisters – The Fates, and move on. But all progress depends on those who will push the envelope; but they must push the envelope with humility, wisdom, caution, science and the best technology available. And herein is the real tragedy. Our Neurosurgeon friend, who has now had his wings clipped by AHPRA, that overwrought legalistic Kafkaesque medical bureaucracy, could have had things go the other way. Had he known, or if he had known, had he thought, he could have done so much better. Was it his fault that he did not know of what was available or had he pushed could have become available? Could he have done better in following the technology just under his nose? If he didn’t know, was it entirely his fault? Should Optiscan management have contacted him. It’s not like he was not in the public eye in a field of direct interest and importance to Optiscan? Tiresias is saddened by both. A call from Optiscan, or Carl Zeiss, “Hi… we have the answer to all your problems.”. Use this new revolutionary technology. Show why what you’re doing is better. Show how what you are doing is better than anyone else in the world. Justify yourself. Prove it. Had this spirit happened, the trajectory of this Greek tragedy could have gone in a very different direction. Instead of Nemesis, Zeus may well have sent a crown laurel leaves. Patients could have been cured and many less harmed. There would have been little criticism. The irony of all this is not lost on Tiresias, and Tiresias is no friend of irony. Tiresias leaves this to my friends; was the answer there all along. Does Optiscan management share responsibility? Does Carl Zeiss have any responsibility? Or, my friends, is it The Fates, Hubris and Nemesis? Can something greater come out of this for Optiscan? It all depends if hubris and tragedy have taught lessons.

Post Scriptum:

My friends, Tiresias enjoys publishing his humble epistle for his friends. Next week, Tiresias is going off grid, travelling to the dark parts of our southern continent, where there is no light pollution, to commune with the stars. Tiresias has not viewed the full glory of the Milky Way for several years. Tiresias is a student of Archaeo-astronomy and naked eye historical astronomy. He is however taking his largish telescope as well and will enjoy a week in the darkness looking at the stars with naked eye and his telescope whilst listening to Mahler, Beethoven, and Bach. Please have a healthy week off and I will be back the following week.