How to Do a Liver Transplant (5 page)

The real genius of laparoscopic surgery is that it is a great spectator sport. Everyone in the room can watch what I am doing on the big screen. If you record your operation and put it on YouTube, the whole world can watch too. There is no capacity to have a bad surgical day because everyone can see your hesitation. In fact, keyhole surgery is like a computer game with real life consequences. Your hands are working at waist level while your eyes are looking up at a screen. Who knew that what I thought were misspent hours on the PlayStation playing Tomb Raider were actually excellent preparation for laparoscopic surgery. This type of operation becomes exhausting if the surgery is not done with the fewest number of movements possible, using relaxed and graceful hands. Learning laparoscopic surgery can be torturous, as you maintain your pincer grip with your arms up in the air for hours. All the tension is concentrated in the small muscles of your hands and they ache for days afterward. Using long slender graspers and
scissors, the gallbladder is separated from its attachment to the liver. The little artery that brings blood to the gallbladder and the tube that connects it to the bile duct are secured with permanent and very expensive titanium clips. It is amazing how many people worry that they will set off the metal detector at the airport with these fastening devices, but I reassure them that they are way too small to trigger the machine. When the gallbladder is free, a plastic bag is unfurled in the abdomen and the gallbladder is stuffed inside it. The bag is extricated via the hole in the belly button and this can be the trickiest part of the operation. If the stones are big I have to manhandle them out or crush them up. A clamp, not unlike infant delivery forceps, is used to grasp the stone, then I lean back and pull really hard. Slowly but surely, the skin yields around the bulging stone and when it gives, it is like popping the cork of a champagne bottle and everyone in the room gives a cheer. This is really fitting, because the end of the operation is usually a great celebration of the patient setting out on the road to recovery from this dreadful disease.

It seems that I'm a doctor now

A
fter a fun-filled graduation ceremony at Brisbane's City Hall that involved more than one bottle of red wine and a midnight dip in the fountain out front, it was time to grow up. I was now Dr Kellee Slater MBBS, with second class honours, I might add. Internship and the realities of daily working life loomed. It began to dawn on me that I would actually be responsible for looking after real patients who might die if I made a mistake. This worried the hell out of me (and still does). That last carefree week of university also saw another big moment in my life – my marriage to Andrew.
The two ceremonies were held within days of each other in order to squeeze in a short honeymoon before I started work. While I was not so confident about the doctoring part, I was more than ready to be married. I knew for sure that Andrew was the only one for me. He understood me so well and gave me the wings to follow my career aspirations. His calm and gentle ways balanced me out perfectly. I am so grateful that I have found a guy who is sure enough of his own self to kiss me goodbye in the morning and say, ‘Have fun, darling, see you in two days.' I had worked extraordinarily hard in medical school, which translated into a pretty decent graduating grade. Andrew knew that I would carry that drive for success into my doctoring life. I had already decided that I wanted to be a surgeon and we also knew that children were definitely in our plan. In the early 1990s a woman managing to have both a big career and a family was pretty uncommon, but with Andrew's support I didn't ever think it was impossible.

Dr Smith, my medical student mentor, was the reason that I chose to go to Nambour Hospital yet again for my first two years as a doctor. It also didn't hurt that all my friends were heading there too. I thought that being in Nambour would go a long way to set me up for a career as a general surgeon. Traditionally, if someone wanted to be a surgeon, they tried to be an intern at one of the large metropolitan hospitals, where they would be more likely to be known to important surgeons who populated the surgical
training selection committees. I worried, however, that being an intern at those hospitals could also be a disadvantage. There were many more junior doctors to compete with there and it would be very likely that all I would get to do was mountains of paperwork. It would have been hard to get the opportunity to stand out, let alone get to spend any time in the operating theatre. Nambour had a great reputation and was a busy hospital doing most types of major surgery. More importantly, they only accepted nine new interns that year, so I thought it would be much more likely that I might get the chance to step up, take on more responsibility and get a little more hands-on experience than my big city counterparts. I also knew that having a mentor like Dr Smith looking out for me and hopefully recommending me for selection for surgical training was really important. I felt that Dr Smith was keen to see me succeed and I worked very hard not to disappoint him.

Dr Smith was a larger than life character, quick off the mark with witty comments like the ‘girls can't do surgery' one. For all his joking, however, he could not have been more encouraging of my surgical career during my time as a student in Nambour, and it quickly became obvious that he truly believed that girls
could
do surgery, and do it quite well. Dr Smith was a terrific general surgeon, adored by many of his patients for his no-punches-pulled, commonsense approach. It could also be extremely tough to work for him at times. He was well known in surgical circles
as a strict taskmaster, expecting hard work and meticulous care from all his staff. Not such a bad expectation, I suppose. Everyone really had to be on their game. His fearsome reputation was such that merely mentioning to a colleague that I was going to work in Nambour often produced gasps about how hard it would be. But, everyone also knew that doctors who came out of Nambour had a really good grounding in surgery because of the sheer hard work and the teaching Dr Smith provided.

Having worked with Dr Smith as a student, I knew what he expected and how many hours I would have to put in to please him. I tried hard to do what he asked and, knowing what a great doctor he was, took advantage of every pearl of surgical wisdom that spilt from his lips. He loved to talk about what he called clinical acumen – a type of surgical magic, really. This was all about coming to the right conclusion with insufficient information. In other words, to be a great surgeon, you couldn't rely on a lot of tests, you had to be a natural; you had to have surgery flowing through your veins. Whenever I delivered some sort of diagnostic blunder, Dr Smith would poke his finger at me and say, ‘Clinical acumen is something you have, doc, not something you get. I was born with it, were you?' I hoped I was and if not, I wanted to be the exception to the rule and at least try and get it before I was much older.

Dr Smith had eyes and ears everywhere in the hospital. His nursing staff were very loyal and very good, so there
was nowhere to hide and no room for cover-ups. Rounds were at 7.30 am sharp. My fellow interns and I would be there before the sun rose to ensure everything was in order for this round. This included having all the patients' medication sheets written up neatly without any errors or overwrites, and all the orders for intravenous fluids charted. Not a single scrap of notepaper was allowed on the rounds because Dr Smith insisted that we have every detail about our patients memorised. We would practise by reciting the patient's blood test results to each other over and over, deliriously happy if the sodium was 145 and potassium was 4.5 because at least that made it easy to remember. Even though it seemed harsh at the time, I eventually recognised the benefits of training my mind like this and to this day I can automatically recall any important blood test a patient has had for the last month. Dr Smith was teaching me to know, almost instinctively, the important issues for each particular patient. After a while it became effortless.

On these early morning rounds, we were also keen to ensure that all patients were showered and sitting in their beds, ready to be presented when Dr Smith came around, as he did seven days a week. No one could be on the toilet or wandering aimlessly around brushing their teeth when he came past. A fast round was a good round and anyone not in their bed would slow things down, making it more likely we would be asked more questions that we may not know the answers to. A hilarious quirk of the ward rounds
was banana pillows, which Dr Smith disliked intensely. We took it upon ourselves to always ensure that there were absolutely no patients propped up on these oversized frilly bed accessories that were popular at the time. It seems that banana pillows were a sure indication that the patient was ready to settle in for an unnecessarily lengthy hospital stay. Years later when I returned to my hospital room after giving birth to one of my children, I found a banana pillow on my bed and I had to hide it in the cupboard because of the flashbacks it gave me of that time.

At the end of the day, we would all loiter on the ward long after dark to make sure that Dr Smith would not launch a surprise evening ward round and quiz us about a blood test or x-ray result. We would be ready if he did. Each night, someone would be anointed the ‘car park resident'. This person's job was to run out to the parking lot to see if Dr Smith had left for the day. Only then was it safe for the rest of us to go home. The long hours seemed really difficult at the time, but now I realise that without Dr Smith's training, I would never have become the doctor I am today. I was sensible enough to understand the lessons I was learning. Now when
my
junior doctors are rifling through sheets of paper looking for results they should already know, it is my turn to get upset at them.

As he watched my enthusiasm and aptitude for surgery grow, Dr Smith was eager to get me started on learning how to operate. He suggested that I tag along at night with
the on-call surgical registrar. A registrar is a doctor who is four or five years out of medical school and is formally training to be a specialist general surgeon. In those days, the surgical registrar would stay in the hospital overnight and often have to operate into the wee hours. It was their job to see all the surgical patients and accident victims that came through the Emergency Department and to figure out what needed to be done before calling the boss to get their plan approved. The hours that registrars worked were heartbreakingly long, but those four years of training were the foundations for the rest of your life.

Dr Smith thought that it would give me a great headstart to follow around a registrar called George Hopkins. George, who bears more than a striking resemblance to George Clooney, was an instantly likeable guy and seemed more than happy to have me as his acolyte. Keen as mustard, I was by his side every third night, as the call roster dictated. Together we would prowl the corridors of Nambour Hospital, tending to any patient in peril. We would sleep on the uncomfortable sofas in the tea room, getting up and down to answer our pagers. As there were scarcely any scans available when I was a junior doctor, we would often have to rely on our judgment or ‘clinical acumen' alone to figure out what was wrong with someone and at that early stage of our training it sometimes wasn't all that good. There were so many times that neither George nor I would have any idea what was wrong with a patient and
would have to call Dr Smith to tell him so. We would sit and argue for half an hour about who was going to pick up the phone and bear the brunt of the inevitable lecture about what hopeless doctors we were. We usually deserved it and the benefit of this was that we got our textbooks out for each patient we saw and tried to at least formulate some sort of coherent story before making the call.

After I had been working with George for a few months, I saw a young man with abdominal pain. I managed to correctly diagnose him as having appendicitis and I rang Dr Smith to tell him about it.

‘Well, what are you waiting for?' he said. ‘Get on with it. Do you think you can handle it?'

I wasn't sure if he meant that
I
was supposed to handle it, so I handed the phone to George, who listened and smiled.

‘He means you do it alone, Kel,' he said warmly, sounding like a proud father. The plan was that George was to sit in the tea room, poised to come to my aid, and I was to perform my first solo operation. This was a big day for me, and a virtually unheard-of opportunity for a junior doctor.

The moment came to commence my maiden operation. I had helped George take out appendixes several times before, so even though I was nervous, I was pretty sure I was ready and knew the steps of the operation off by heart. I checked everything, twice. Patient asleep, check; nurse ready, check; instruments ready, check. Surgeon ready, not
really. My sphincters were tightly clenched as I clutched the scalpel and stood over the patient, poised to make that first cut. I could feel the eyes of everyone in the theatre upon me, ready to call for help if I exhibited a moment of ineptitude. I stood up straight, let out my deeply held breath and made a purposeful and reasonably straight cut in the patient's right lower abdomen. I carefully split open the muscles of the abdominal wall, layer by layer, just as I had been shown. When I had gone through what I thought were the necessary three layers, I was dismayed not to have arrived in the abdominal cavity where I should have been looking at glistening bowel. I fluffed around until the scrub nurse said, ‘I think you have to go through one more layer.' Happy that my surgical mask was in place to hide my red face, I broke through this last impediment and finally entered the abdomen. Lo and behold, the offending appendix, dripping in pus, was just sitting there looking at me. Thank goodness it wasn't hiding up behind the liver or some other godforsaken place. I removed it without further delay.

Dr Smith telephoned the operating theatre at least three times during the surgery, just checking if I was all right and, more importantly, that the patient was. It is only now that I am a surgeon myself that I can appreciate just how anxious he must have been feeling, freeing a junior doctor from her training wheels. A few days later, my patient left the hospital alive, minus one appendix. I couldn't
believe I had done it. I replayed the surgery over and over in my head. I was walking on air, in a euphoric state that was the reward for all the other, less than desirable stuff I had had to do in my day. That excitement has never diminished, even now after I have been operating for years, and I guess when it does, it will be time to stop. Those nights following George around were an incredible experience. We forged an unbreakable friendship and George is still always there to help me out when I need him.