DR KELLEE SLATER performs all types of abdominal surgery and is a member of the liver transplant team at Brisbane’s Princess Alexandria Hospital. She lives in Brisbane with her husband and four children and this is her first book.

HOW TO DO A LIVER TRANSPLANT

Stories from my surgical life

Kellee Slater

A NewSouth book

Published by

NewSouth Publishing

University of New South Wales Press Ltd

University of New South Wales

Sydney NSW 2052

AUSTRALIA

newsouthpublishing.com

© Kellee Slater 2013

First published 2013

This book is copyright. Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part of this book may be reproduced by any process without written permission. Inquiries should be addressed to the publisher.

National Library of Australia Cataloguing-in-Publication entry

Author: Slater, Kellee

Title: How to do a liver transplant: stories from my surgical life/Kellee Slater.

ISBN: 9781742233420(print)

9781742241487(epub)

9781742243931(mobi/kindle)

9781742246437(epdf)

Subjects: Slater, Kellee – Anecdotes.

Liver – Transplantation – Australia – Anecdotes.

Surgeons – Australia – Anecdotes.

Transplantation of organs, tissues, etc. – Australia – Anecdotes.

Donation of organs, tissues, etc. – Australia.

Dewey Number: 617.556

Cover design Natalie Winter

Cover images Shutterstock: Plain Picture

Contents

Prologue

I was born to be a general surgeon

You might get into medical school, you know

What body part is that?

Girls shouldn’t do surgery

I heart gallbladders

It seems that I’m a doctor now

I can’t believe they are going to let me operate on people

The life of a surgical registrar

In the poo

The call of the bile

Rocky Mountain High

You want me to start at what time?

Kellee, there is a donor

How a donor is done

We have found a new liver for you

How to do a liver transplant

Born in the USA

Do you think I could have a piece of your liver?

Love you Lynn

Transplant Mom

A fully fledged surgeon at last

Give me the gun, this liver’s coming out

We will not let your daughter die

Buy a bra, save a child

Transplanting babies

You have three months to live

How do you do it all?

Acknowledgments

References

Prologue

Like everyone, there are some days when I don’t want to do my job any more. These are the days when I have to tell four people in a row that they have cancer. Then there are the times when I have worked all night and feel like my eyes will bleed if I don’t close them soon. I want to give it all up when I haven’t seen my husband for three days.

But all of this pain is balanced out by the days when I get to do a liver transplant. This is the one operation that keeps me coming back for more – those six hours or so when I am totally focused on the task of taking the old liver out and putting the new one in. When you say it like that, it seems so simple, but it has taken me hundreds of hours to learn how to do it and I just love it.

This is the story of my life and how I came to be a doctor, a surgeon – and a mother.

I was born to be a general surgeon

I realised that I was going to be a surgeon pretty early on by figuring out what I didn’t like about medicine. Take phlegm, for example. Some patients think there is nothing I’d like more than to inspect a giant lugie they have coughed up and spat into a cup. They are just so wrong. Then there are feet – if you show me any problem concerning the foot, you will be sure to see me using mine to run in the opposite direction. This phobia stems from two of the most ghastly things I have ever seen.

As a medical student, I travelled to India to work in a community hospital to experience health care in a developing country. It was the height of summer and the temperature was a sticky 40 degrees. My next patient was a young man with diabetes, who entered the room on crutches, dragging his foot behind him. The foot was swaddled in a filthy bandage and he hobbled in leaving a trail of pus in his wake. The smell was bad, even from some distance away. I thought the dressing was black with dirt but, as he came closer, I was horrified to see that the colour was from hundreds of flies. As I crouched down, shooed the flies away and gingerly unwound the stinking layers of gauze, I held my breath to avoid inhaling the smell. As I unwrapped the last few strips, I felt something soft come away and fall into the palm of my hand. I closed my eyes for a moment, not wanting to acknowledge what I suspected had happened. As I opened them again and looked down, nestled there in the bandage were all of his toes. I instantly recoiled and the toes fell, making a soft plopping sound as they hit the ground. This poor boy’s gangrene was so advanced that his toes had amputated themselves. I promptly vomited on the floor, right next to the toes.

The second time I vomited in front of a patient was back in Australia, and again it involved feet. When I was a very junior doctor hoping for a career in surgery, one of my jobs was to work in vascular surgery. This specialty involves unclogging blood vessels that have been damaged by years of smoking or diabetes. I was in a vascular clinic that looked after patients with nasty ulcers on their legs and feet, and I was confronted with a lady who had a similar dressing to the one I had seen in India. Suffering post-traumatic stress from my previous experience, I unwound the bandage with significant trepidation. The dressing came off, this time with toes intact. I let out a sigh of relief. Feeling slightly more adventurous, I moved in for a closer inspection and I could see a deep, crevasselike ulcer between two toes. Very professionally, I pulled the toes apart to inspect the fissure. At that moment a fat and juicy maggot wriggled out of the wound, like a worm out of its burrow. Again my reaction was to turn around and throw up, this time into the sink. The unwitting patient looked more than a little alarmed and asked me if everything was all right. So as not to upset her, I told her that I had food poisoning.

That was not the end of my torture with legs and feet in that vascular term. As I was the most junior member of the team, my main job during that six months was to amputate more than 40 rotten legs belonging to crumbly old smokers whose ‘best by’ dates had well and truly expired. The unfortunate victim of a surgical amputation is usually subjected to a local anaesthetic (they are often too sick to go to sleep) so they can frequently hear everything that is going on, including their leg bone being sawn through. One patient, who suffered from dementia, even yelled out distressingly, ‘Don’t take my leg!’ as I took my big knife to their skin, muscle and tendons.

I would use a serrated wire with little handles on either end and place it under the bone. I then stood on a box to get enough purchase and ran that wire back and forth just like a competition woodchopper. The friction produced by the wire burned through the bone and broke it in two with a grisly snap. There are no words to describe how horrible it was to do this. To me, surgery is about repair, not destruction, and even though removing that leg meant saving their life, it was a pretty difficult thing to do. Once the leg was separated, I would pick it up and have to feel its dead weight before tossing it into a big trash can at the end of the bed. The sound that a leg made when it hit the bucket was so disturbing that I would have to turn the music in the theatre up loud so I couldn’t hear it. Those legs would appear in my dreams at night, dancing through my subconscious, trying to kick me in the arse as punishment for cutting them off. No, no – a life as a foot doctor just wasn’t for me.

I believe that I was born to be a general surgeon. Yes, I admit it, I have always loved to squeeze pimples, pick scabs, release pus and generally unclog things. When you break it down, this is what a general surgeon does, so it is definitely the right job for me. I can happily work away in someone’s abdomen all day long and not give it a moment’s thought. If I couldn’t be a general surgeon, there would be no point in my being a doctor at all. I love the diagnosis, the physical steps of the operations and caring for the patients after their surgery. It is the only thing I have ever been interested in. One of the real joys of surgery is that almost every day I’ll encounter something I have never seen before, and even after all these years I am constantly surprised as interesting problems walk through my door. My heartbeat quickens when I make a rare diagnosis or do a difficult operation. I dream about the surgery at night. Being a general surgeon is a lot like waking up on Christmas morning, anticipating with excitement what gifts will be underneath the tree. Diagnosing a patient’s problem is just like shaking the presents to figure out what’s inside, and getting to operate is like tearing the paper off to find out if my deduction was right.

General surgeons get to fix people (for the most part) with terrible, life-threatening problems. These patients come in broken and, I hope, after I have operated, they leave the hospital just a little bit better than they were before. Unbelievably, this idea that surgery makes people better didn’t really crystallise with me until recently when I had to have a procedure myself. My primary focus, just as it is when I operate, was on all the things that could go wrong. I’m sure that this is not what the average patient is thinking when they go off to sleep, but I do. I was pleasantly surprised when things went really well and my problem was successfully fixed, making my life much better.

I worry a lot, but this may not be a bad thing. It keeps me sharp. I have an intuition about when things might be going wrong. I am regularly known to call the ward in the middle of the night to check on someone I am concerned about. The nurses think I’m crazy, but knowing everything is all right for now is the only thing that will allow me to sleep sometimes. My mind is always ‘on’ and I wonder if I will burn out one day. Being a general surgeon is all about predicting what could happen to a patient and how I will fix it if it does. During surgery, this is what is running through my mind. I have to have eyes everywhere. I need to see when the assistant is pulling on something too hard and is about to snap it. I have to ask for an instrument that may not be in the room well before I might need it in an emergency. Before I start a liver transplant, I need to make sure that the cooler with the liver in it has arrived. A general surgeon needs to be in control of everything and totally focused on the job all the time.

It is not all toil, though. There are the funny situations and stories that patients bring into my life – both intentionally and by complete accident. This is what makes my job really fun. Like the patient who brought a fish tank complete with filter into the hospital for a one-night stay to help them relax, or the lady who thought it was outrageous that the hospital could not supply her with an organic peach when she was hungry late at night. I am privileged to get an intimate glimpse into the many quirky things that people get up to and the offbeat way some of them choose to live. It can sometimes be hard to keep a straight face but of course I try my best always to be professional. I see the lighter side of most things and you will have to excuse some of the black humour in this book; it is my coping mechanism, I suppose.

There are a lot of grim moments in general surgery, what with all the cancer and dying. Some days I cry and some days I don’t want to get out of bed because I know I will have to tell a patient that their life is going to end. There are also the less-than-glamorous aspects of the job, but I can easily put up with them because the rest of general surgery is just so darn interesting. Take dead gut, for example.

From time to time a patient will show up with this terrible problem. It can happen when something blocks the artery or vein supplying the bowel, starving it of its blood supply. The afflicted section of bowel will rapidly die, usually just a few hours before the patient does. If you catch it early enough, an operation can occasionally save the day. When you open the belly of a person with dead bowel, the smell is so foul it goes straight up your nostrils and socks you in the brain. The memory of it lingers for days afterwards. I find this smell so sickening that when I know it’s potentially coming, I douse my surgical mask with a powerful menthol solution that goes just a little way toward disguising the stench and distracting my nose. This is an odour so powerful that it also somehow manages to transfer itself onto my fingertips, even through two pairs of gloves, and I have a weird and terrible compulsion to keep smelling my fingers long after the operation is over.

Another extraordinarily unpleasant smell that emanates from a human being is melaena. Such a pretty word that belies its true meaning. It is the term used to describe faeces that contain digested blood, usually from a haemorrhaging stomach ulcer. It is another aroma that must be smelled to be believed. Nurses (usually with a wry smile on their faces) will often save a melaena stool in a bedpan for the doctor to inspect on rounds in the morning, just in case we might not believe that it has occurred. There is usually no need to see it, though, because the diagnosis can be made from anywhere within a 200-metre radius.

What we do in general surgery is a little bit of a mystery, I think. Everybody seems to have heard of plastic surgeons, ear nose and throat doctors and even brain surgeons, but plenty of people stare at me blankly when I mention what I do. General surgeons deal with every surgical conundrum that the human body can dish up. We largely work in the abdomen and when things go wrong there, it can really mess up how everything else in the body works. Twenty years ago, general surgeons were jacks of all trades, proficient in repairing bones, bladders, brains and bowels, but as technology has advanced, general surgery has evolved to the point where a surgeon might focus their attention on just one microcosm of the body and become a so-called ‘super specialist’. We are now loosely united under the general surgery banner but might spend all our days operating on just the breast and thyroid (breast-endocrine doctors), the bowel and anus (colorectal doctors), the oesophagus and stomach (upper GI doctors) or in my case the liver and pancreas (hepatobiliary doctors).

My official job title is Hepatobiliary, Pancreas and Liver Transplant Surgeon. This essentially means that I do life-threatening things to high-risk patients that take many hours and involve copious amounts of bleeding. I then spend the days and weeks afterwards trying to keep them alive and helping them recover. Liver and pancreas surgery has only really become safe enough to do relatively recently, and in the early days of the speciality, it was frequently fatal. Even in my surgical lifetime, the aftercare and chemotherapy available to these patients has evolved to such a point that I am now operating on people who we would have never considered before. We are really pushing the boundaries of what is possible and it is a very exciting time to be a liver surgeon.

Not very many folks think too much about what their liver and pancreas do. Whenever people ask what job I do, I usually say that I am a liver transplant surgeon because that’s the only thing that they seem to have heard of. There are so many things that can actually go wrong with a liver – cancers, lumps, infections, worms and stones – and I can do a great many things to it besides replacing it with a new one during a liver transplant. In fact, only a minuscule number of patients I see ever end up having one of those. Most of my time with the liver is spent neatly cutting pieces out of it in a multitude of permutations. Liver resection (that is, removing part of the liver) is the most technically challenging part of the job. Sections must be cut away using only my mind’s eye to visualise invisible lines that represent the eight segments of the liver. If I am even a centimetre or so off in my calculations, the blood supply to the remaining section will be compromised and the consequences can be fatal.

The other part of my job is removing sections of the pancreas. Yes, you can live without your pancreas (this is a common question) and I do regularly take it out when it is invaded by cancer and other horrible problems in what can only be described as operative extravaganzas. Operating on the pancreas can be treacherous because it is so soft and delicate – like butter. As one of my colleagues eloquently put it, ‘to stitch the pancreas is like sewing flatus to moonbeams’. These surgeries require precision, judgment, attention to detail and extreme dedication. It is a lifestyle and it is often all I think about, much to my husband’s annoyance when he is trying to talk to me about whether we need to buy more milk for the morning.

You might get into medical school, you know

My mum grew up in a small town in far north Queensland called Ravenshoe. In the late 1960s the only jobs for a single woman were either hairdressing or working at the local bank. Mum chose the bank and it was there that she met my dad, a peanut farmer’s son from Kingaroy who had been sent to the Ravenshoe branch as a teller. They were in their early 20s when they married and were transferred to Townsville where, within a year, I was born. I was joined four years later by my sister, Lauren. Mum and Dad were hardworking people who often had more than one job at a time. Anything from Mum taking in ironing and childminding, to Dad working as a bookmaker at the local races to make ends meet. The bank moved us around a little too often for Dad’s liking and he soon tired of the itinerant life while trying to raise a young family. He decided to settle us on my grandparents’ sugarcane farm in Bundaberg and to have a go at making a living off the land. My carefree childhood was spent playing hide and seek amongst tall rows of cane, riding my bike and catching fish in the local dam. Farming, though, is a feast or famine lifestyle and I’m sure there were times when Mum and Dad found it hard to put food on the table.

When the bottom fell out of the Australian sugarcane industry in the early 1980s, my parents again searched for a better life and the year I turned 13, they moved us to Nambour. They bought a newsagency and started working 100 hours a week. They are still there 31 years later doing the same thing and I can smell the newsprint whenever Dad comes into the room. The long hours they spent at work meant my sister and I had to look after things on the home front. We would have dinner on the table at the end of the day and manned the front counter of the shop on the weekend to earn a little pocket money. As much as we disliked seeing our parents so infrequently, their work ethic left an indelible mark on me.

I started high school at Nambour High, a huge public school with a pretty good reputation. It was a school that would go on to produce an Australian prime minister in Kevin Rudd, a deputy prime minister in Wayne Swan, and a rock star – Powderfinger’s Jon Coghill. In the final year of high school, with the rest of my life ahead of me, I didn’t really have any idea what I wanted to do aside from the usual teenage plan of making a lot of money in exchange for very little work. It was the late 1980s and the widespread use of the internet was still a few years away. Career opportunities were fairly limited and it was not necessarily expected that a student from Nambour High would go on to university. Many of my classmates were planning to leave school and work for a few years before they got married and had kids. The likely occupations for someone like me were nursing, secretary or shop assistant. I learned typing and shorthand in Years 9 and 10 in preparation. I vividly recall my dad – a lover of the sweeping statement – regularly pronouncing, ‘The problem with the world today is married women in the workforce.’ That was more than enough impetus for me to want to contradict him. He certainly whistles a different tune now that both of his daughters are university-educated working mothers.

Even though I didn’t know what to do with myself, I was quite sure I wanted to go to university. The thought of striking out and moving to a big city on my own was really exciting. If I got into university I would be the first in my family to do this since 1905, when distant cousin Robert Alexander Slater from Scotland also became a doctor. Sadly, he died of tuberculosis aged 34, so I had to do better than that. Still, there was very little encouragement for me to get there. This was vividly illustrated during my schoolsponsored work experience in Year 12. I had to choose somewhere to work for a week so I could see if the job was something I would like to do as a career. I became much more interested in maths and science in my final years of school but the only thing on the list of jobs available for work experience that was even remotely scientific was optometry. I signed up for it, but at the end of the week when all I had done was run the reception area, vacuumed the floor and fetched the mail, I enquired if I might be able to sit in on some patient consultations and, heaven forbid, look into a few people’s eyes. The optometrist suddenly looked sheepish as it dawned on him that I was not there because I aspired to be a secretary. To his credit, he was really embarrassed at his assumption and let me sit in with him for the last few hours of the day. He even threw in a free pair of Ray-Ban sunglasses. I was pretty excited about the sunglasses – optometry, not so much.

I thought about a few different careers that year. My boyfriend at the time was a Black Hawk loadmaster for the Australian Army and that, combined with the movie Top Gun – a huge hit at the time – made being in the military a very cool prospect. I made enquires and got the forms to apply for officer training in Canberra. I could fly planes and earn a degree at the same time. I was all ready to be a female ‘Maverick’ until I found out that they wouldn’t let girls fly fighter jets at that time – something about the uterus’s propensity to fall out under negative g-force. I was indignant and swore I would not enter an organisation that didn’t treat women as equals.

My next idea was to be a home economics teacher, and I forged ahead with this plan until the day before university applications closed. I loved to cook and sew and still do. It’s really not very different to being a surgeon – both jobs involve stitching and there is a simple pleasure that I derive from making or fixing something with my hands. It wasn’t until I went to see the career counsellor at school about my university options that she suggested that I apply to medical school. This was really the first time that I had thought of such a thing.

‘Hmm ...’ she said, peering over her spectacles, ‘I had no idea you were getting such good grades. You could get into medical school, you know.’

I considered what she said for a few days. I loved biology and chemistry, so maybe medicine would be all right for me. I only vaguely knew what doctors did. They wrote prescriptions, delivered babies and took blood pressure. I didn’t think of doctors as surgeons. The one thing I did like was that it would probably be easy to find a job at the end of all that studying. Doctors also seemed to be very well off, and that is an attractive thing when you are 17 and earning $5 an hour working at your parents’ shop. What didn’t occur to me was that jobs involving high incomes were not actually very easy. If I knew then how hard I would be working now, I might have run a mile.

At the counsellor’s insistence, I filled out my university application, and almost as an afterthought wrote down medicine as first choice and home economics teacher as second. I readied myself for teaching because I never thought I had a hope of getting into medical school. That didn’t happen to people like me.

The day came for the university offers to be delivered in the mail. It was Christmas holidays and I was working in the newsagency that day. I went home at least three separate times to check the mailbox – nothing. It wasn’t until 5.30 in the afternoon that the postman, exhausted from the increased volume of work that day, finally delivered that official yellow envelope. I held the letter for a few moments and eased it open. I slid out the thick white paper and to my surprise it said ‘Medicine – University of Queensland’. All right, that was unexpected. So I was going to be a doctor.

My biggest concern about going to university was that I felt they might be letting me in under false pretences. It was my distinct impression that I only did well at high school because 80 per cent of my classmates were more interested in going to the beach than studying. I would look up from my Year 12 calculus exam to see everyone around me flicking through surfing magazines, so I figured I had had a pretty easy ride to the top of the academic heap. University was the big league and I was thoroughly intimidated by the private school kids. They seemed to be smarter, prettier and better dressed and I wasn’t sure I could compete. It is something that I still struggle to overcome and even now when I sit in a room with other doctors, I feel they know much more than me. This inferiority complex is what still drives me to do better all the time.

Happily, most of my fears about not fitting in at medical school turned out to be unfounded. Within a few weeks of starting, I knew I had found my people: the other medical students were my kindred spirits. Six years of serious study and exams stretched out before me. Mum and Dad set me up in a share house with four school friends in a leafy riverside suburb near the University of Queensland. I packed up my teenage bedroom, got some garage sale furniture and prepared to face the world on my own. Well, not quite. Mum and Dad paid my rent and gave me $60 a week to buy everything else. We ate generic brand dim sims and were regular attendees at the ‘$5 Tuesday’ all-you-can-eat buffet at the local Pizza Hut. I didn’t have much, but I was living on my own schedule and it was an exhilarating feeling of freedom.

What body part is that?

The first three years of medical school were all about cramming my head full of the fundamentals of medicine – anatomy, physiology and pathology. These subjects are the building blocks for understanding diseases. Even in those early days I had a surgical bent, tending to think that the lecturers teaching psychology subjects took themselves a little too seriously. I arrogantly thought that I had learned all the psychology I needed from watching a few seasons of Oprah Winfrey. I’ve since learned that psychology is often the subject I need to call upon most in my practice, so I wish I’d paid more attention.

One of my first priorities when I entered medical school was to debunk my mother’s theories about the human body. I looked up the oldie-but-goodie ‘you’ll catch a chill in the kidney’ and found out that not only did no such condition exist, but that wearing an unattractive white undershirt wouldn’t prevent one. I also learned that sitting on concrete would not give you haemorrhoids; you don’t have to wait half an hour to go swimming after eating; and when you swallow chewing gum, it does not take seven years to pass through your bowels.

An essential part of studying to be a doctor was the afternoons spent in the anatomy lab. Anatomy class was by far the most interesting and strangely social aspect of life at university. When I told my family I might be going to medical school, they seemed to delight in telling me, ‘You will have to see dead people, you know.’ To me, this was only commonsense. However, the dead body thing confronted me sooner rather than later. In the week before starting medical school, there was a time-honoured tradition called ‘O Week’, short for Orientation Week. During these five days, older medical students took rookies on tours of the university, and at night they dressed us in togas and plied us with vast amounts of alcohol. One of the most infamous tours in O Week was a visit to the anatomy lab or – a better word for it – the mortuary. It was a rite of passage for all medical student inductees.

In the basement of a nondescript building displaying no visible signs of the chamber of death it housed, was the anatomy dissecting lab. The general layout of the lab had been explained to us before we went in, but it was hard to prepare my senses for what was inside. Even before I saw anything, the acrid aroma of formaldehyde burned my nostrils as I descended the stairs with my ‘tour group’. We were instructed to don long white coats, shower caps, overshoes and gloves. We were ushered down a long narrow hall that opened out into a room the size of a basketball court. It was brightly illuminated by rows of fluorescent lights, the floors and walls lined with sparkling white tiles. It had the sterile, easy-to-hose-out appearance of a butcher shop. My eyes were immediately drawn to the neat rows of stainless steel tables. Lying on each one was a human-shaped plastic bag. There were at least 40 of them. Pickled people, drained of blood, preserved with formaldehyde and wrapped in plastic. These corpses belonged to the generous folks who had donated their bodies to medical science. It was their hope that in death they might contribute to the betterment of man by allowing us to cut them up into little pieces. Apparently it is quite a popular thing to do and there is a waiting list to sign up for it. Imagine not making ‘the cut’ even after you are dead! The whole thing was scary and fascinating all at once. It made being at medical school all very real and I felt quite important that I was allowed in there.

I spent hours and hours over the next three years in that smelly room. Our class of 200 was organised into groups of six and each of us was given a body that would stay with us for the duration. My group was assigned a lovely old girl who must have lived an interesting life with her breast implants and organs missing from various surgeries. We fondly concocted wild stories about what she must have got up to. We gradually dismembered her, spending hours reciting the names and routes of all the nerves and arteries, the attachment of muscles and the qualities of her internal organs. We had a fantastic time doing these dissections and I bonded with my anatomy lab partners. They went on to become my lifelong friends and three of them eventually became bridesmaids at my wedding. To an outsider, it may seem a little strange to be having fun in such a confronting place, but sometimes the only way to cope with this job is with humour, and the anatomy lab probably set the tone for how I deal with difficult problems to this day.

One especially light-hearted moment came on the first Tuesday in November – Melbourne Cup Day. This is a big day for many Australians. We were dismayed to discover that our final anatomy exam was to be held at the exact same time as ‘the race that stops a nation’. The exam was being held in the anatomy lab and we were each assigned to a table containing various dissected body parts. We were required to display our knowledge of anatomy by pointing out different body parts and naming them correctly. Close to the time that the race was due to be telecast, everyone became more and more restless. Many of us had never missed it and were sad that we would have to do so this day. It was quite clear the examiners were feeling that way too, with several of them whispering about it during the exam. Then, without warning, the examiners halted the exam and the television screens in the rooms flickered to life.

‘There will be a brief pause so we can all watch the Melbourne Cup,’ one of them announced. ‘Please don’t talk to each other, because if you do you will fail the exam.’

A loud cheer erupted and 150 students accompanied by 40 dead bodies watched the horses race. Only in Australia.

There was another facet of anatomy teaching that was memorable for its distinct lack of dead bodies. This part of the course truly involved the living – it was the surface anatomy class. Part of the study of the human body is to learn how the contours of the skin correspond to the muscles and bones that lie beneath it. The whole idea of the exercise was to observe and feel these things in real live subjects – those subjects being our classmates. This class was nervously anticipated because it required all of us to strip down to our bathing suits in front of our group and explore each other’s bodies. This disrobing also extended to our lecturers who did not seem to share our embarrassment. Rumour has it that some groups got completely naked, but thankfully no one in our group was devoted enough to the pursuit of complete anatomical disclosure to go that far. It was bad enough having a bunch of strangers staring at my cellulite without having to decide if someone had one testicle hanging lower than the other. Whilst all of this sounds like an exercise in perversion, I understood the point. One of my lecturers described it well. He said, ‘Doctors are not like other people, we put our hands in strange, intimate places and seem to be able to detach ourselves from the fact we are doing it. This is not normal.’

For those first three years, the study was relentless. There were endless lectures, note-taking and learning by rote from dry, humourless textbooks. There was little time for anything else. There was a lot of basic science and very little actual medicine, so it was hard to stay focused on the ultimate goal. Sometimes I would forget that one day I would be seeing patients. But there was no way they were going to let you near the infirmed until you had learned the basics, so I did my best to study everything I could. There were major exams every six months, and the week before these was completely devoted to study. This time was called ‘Swot Vac’ and was largely spent irrationally panicking about how little I knew. My butt was planted firmly at my desk, surrounded by dozens of books and papers in a frenzy of learning. I lived on Diet Coke and caffeine tablets. It was outrageously unhealthy and some nights I could not go to sleep because of the caffeine-induced palpitations. There was no time to lose so even eating became a low priority. I suffered terribly with constipation and my mother suggested I try to eat a few prunes to get things working again. I was so hungry and they were so delicious, that before I knew it I had eaten a whole packet. A few hours later I felt the deep rumbles as the prunes worked their magic on my colon. I spent the wee hours prior to my pathology exam sitting on the toilet with profuse diarrhoea. Even this couldn’t stop the study. I just took the textbooks into the toilet and got on with it.

After the first three years, the learning switched gears and my study became dedicated to applying my basic knowledge to patients and their diseases. This was a big change. I no longer had carefree days of skulking around the university campus in flannelette shirts and Ugg boots. I now had to dress like a professional and act like a doctor who knew what I was doing.

Around the same time, something else happened that would change the course of my life. This was the day I met my future husband, Andrew, an extraordinary man who would soon share my life and put up with the demands of my job. Andrew was at university studying economics. As it turns out we had already met 15 years before, when we attended the same preschool together in Toowoomba. Our memory of that encounter was less than dim. The second time we spoke was one afternoon while I was lazing around the college dorm room of my best friend and fellow medical student, Jamie Von Nida. I was going through my short-lived goth period and was wearing black leggings and what I felt to be a particularly cool black leather motorcycle jacket. Andrew had gone to school with Jamie in Toowoomba and they now lived in the same dorm. Andrew had dropped by for a visit. He had long flowing hair, just like George Michael from Wham!, and was wearing blue John Lennon sunglasses. I thought he looked great.

‘Cool leather jacket,’ was all he said to me. I was quite strapped for cash at the time, so I smiled and replied, ‘Thanks, would you like to buy it?’ I sold it to him for $200 and when we moved in together six months later, I got that jacket back. We still have it in the back of the closet 20 years on as a memory of that time.

The beginning of the fourth year of medical school saw me shift my location from the main university campus in St Lucia, to the School of Medicine. This is a grand building in the Brisbane suburb of Herston, resplendent with Roman columns and domes, heavily steeped in the history of medicine. Its halls were decorated with portraits of wise and slightly angry-looking professors who had discovered amazing things. The building was designed to be an intimidating reminder of the special nature of the profession we were entering. Andrew and I, along with all our friends, moved into share houses a few streets away. We happily set about decorating our rented Queenslander-style house. It was dilapidated and came complete with natural air conditioning in the form of a big hole in the bathroom floor that you had to be careful not to fall through when stepping out of the shower. They tore the house down shortly after we moved out. We all turned 21 that year and it was an endless round of parties amply catered for by our substantial home brewing activities.

Lectures began every day at 8 am, outrageously early for a student. We would drag ourselves, bleary-eyed, into the back row of the stadium-style lecture theatre, listen to the professors talk about pathology and pharmacology and try to take copious notes to read later when we were more awake. The latter half of the day was spent in small groups seeing real patients in the hospitals. I was assigned to a group of six other students and each day we went to the hospital to poke and prod the public. We would wear stethoscopes around our necks and short white coats over our clothes, so we could be identified on sight as student doctors. Patients who were ‘in the know’ would run a mile when they saw us coming before they could be subjected to our stupid questions about how they were feeling and heavy-handed examinations. Just as many others would welcome us with open arms, happy to regale us with intricate stories about their bowel movements in order to break the monotony of their long hospital stays. We learned to examine patients from top to toe, practising over and over. Andrew became my very understanding practice dummy: he had his heart listened to, his abdomen pushed on, bright lights shone in his eyes and his eyelids everted. In some places this might be called torture but Andrew never complained. He did, however, draw the line at undergoing a rectal examination. Even he had his limits.

Girls shouldn’t do surgery

My passion for general surgery began almost as soon as they let me into the hospital. The moment I first got to see an operation, I was hooked. I loved the precise nature of it all – the smooth, organised way that things got done. The confidence of the surgeons was intoxicating as they worked away for hours, heads bowed in concentration, calling out the names of exotic-sounding instruments. I wanted to be just like them, strutting around in crisp surgical scrubs, barking orders and having people follow them. Surgeons appeared to be respected by everyone and they did things that no one else could. But the ultimate thing was that good surgery meant someone who might otherwise be in pain, or might even die, could be made well enough to return to a normal life, or at least a better quality one. I felt there was a real payoff that would make all the hard work and training worthwhile.

My parents were very keen to foster my newfound interest in surgery. Every afternoon a doctor called Allan Smith would come into their newsagency to buy the Melbourne Sun newspaper. A football fanatic, Dr Smith would buy the paper so he could read the latest gossip about his favourite team, the Brisbane Lions. My Dad was a fellow sports fan and the two quickly became friends. As luck would have it, Dr Smith was also a general surgeon at Nambour Hospital. Dad mentioned that his daughter was a medical student who was interested in being a surgeon, so Dr Smith kindly arranged for me to spend some time during my vacation watching him in the operating theatre. This one event was to have a profound effect on the course of my life, and with that simple gesture, my surgical career was born.

Dr Smith took me into the operating theatre and introduced me to all the masked faces. Using what I quickly found out was irony, he announced, ‘This is Kellee Slater, she is a medical student who wants to be a surgeon. Does anyone think that a girl should do surgery?’ I was already pretty anxious and now I was a little embarrassed to be the centre of attention in such an intimidating place. I tried to calm my nervous stomach with a few hard swallows. Obviously used to these sorts of tongue in cheek comments, the nurses and anaesthetist nodded a brief and indifferent hello in my direction before turning back to their work. Dr Smith asked one of the nurses to teach me how to ‘scrub up’. He was going to be removing a gallbladder via keyhole surgery that day and it seemed that I was going to be allowed to stand at the operating table and assist with the surgery. I was not expecting this on my first day and it brought about another wave of nervous butterflies. I thought I would be sitting in the corner, not actually taking part in the operation. I had never scrubbed before, let alone touched a live person while a cut was being made in their flesh. I stood excitedly at the scrub sink feeling more than a little important as I tied a surgical mask over my face. The nurse, obviously a bit tired of teaching surgical novices, rolled her eyes, clearly indicating all of this was a little beneath her. She began to instruct me on the finer points of a full five-minute surgical handwash.

‘Keep your hands up and elbows down,’ she barked. ‘Let the soap drip off and don’t touch anything!’ My nervous energy was causing my knees to knock together and I thought I had wet my pants but it was just the water dribbling off my elbows and down my leg. When she had had enough of watching me spray water everywhere, the nurse grasped the back of my shirt and frog marched me through the heavy double doors into the operating theatre. I held my dripping wet hands aloft, just as I had seen on TV medical dramas. The nurse then grumbled her way through the instructions for the ‘more complicated than it appears’, gown and gloving process.

‘Dry your hands with the little towel. Don’t touch anything. Now, pick the gown up in the tips of your fingers, let it fall open, one arm in and then the other,’ the nurse demanded. She roughly spun me around by the shoulders and tied the back of the gown tightly, like she was lacing me into a corset. ‘Now, pick up your gloves and put them on without touching them on the outside.’ Of course, in my haste to please her, I hadn’t dried my hands properly (or they were damp with sweat) and my fingers went in all the wrong holes. I could tell the frustrated nurse wanted to grab me and shove the gloves on the right way or put them where the sun doesn’t shine. Luckily for me, she could no longer touch me because I was now officially ‘sterile’. Finally, after a full ten minutes, I had everything on and I was ready to ‘operate’. I approached the operating table and then, without thinking, I rubbed my nose with my now sterile hand. The nurse swore and grabbed me by the shoulders once again, spinning me around and ripping my gown off in one movement, like a stripper at a bachelor party. I had completely contaminated myself and had to go and start the whole process again. The nurse turned on her heel and walked off in disgust, leaving me to it.

When I finally got to the operating table, the surgery was well underway. Dr Smith was standing on the patient’s right and told me to take my place in an impossibly small area wedged between his back and a tall metal table suspended over the foot end of the bed and laden with rows of shiny surgical instruments. I was so close to Dr Smith that every time he moved I had to take a tiny step backward otherwise his hip would touch my belly. I was not quite ready for this invasion of my personal space but I soon learned that this closeness is not given a second thought and that surgeons leave their inhibitions at the door. This proximity to each other soon makes you understand why it is not a good idea to have garlic for lunch.

‘Here Kel, hold this,’ Dr Smith muttered. His eyes did not leave the TV screen as he grabbed my hand and placed it onto the scissor-like handle of a long instrument protruding from the patient’s abdomen. I had no idea what I was holding but hold it I did, with a white-knuckle grip, determined not to move a muscle. I was going to be the best instrument holder they had ever seen. There was one slight problem, though. I didn’t appreciate that not moving my hand did not necessarily mean that I should not move anything else. My extreme stillness quickly resulted in the pooling of blood in my legs and within a few minutes I saw a dark veil come down in front of my eyes. I tried to stifle an incredible urge to vomit. I managed to utter the words, ‘I feel sick …’ before I felt myself falling and the lights went out. Fortunately for the patient on the operating table, I fell backwards onto the floor and not face first into the wound. I woke up a few minutes later on a trolley in the recovery room alongside all the patients who had just come out of surgery. Dr Smith was grinning down at me.

‘Gee Kel, are you all right? That was a pretty interesting way to start your first day. See, I knew girls shouldn’t do surgery,’ he joked again and walked away, chuckling and shaking his head. At least I hoped he was still joking. It was not the most illustrious start for a budding surgeon, but even after this small taste of the operating theatre, I could not be deterred. This was what I wanted to do. I got right back on the horse and returned to Dr Smith’s theatre for the rest of the cases that day and never went down again.

I heart gallbladders

For most surgeons, it is pretty easy to recall the first operation you ever saw and the feeling that it gave you. Getting to help Dr Smith remove the gallbladder that day (at least the small part I saw before I hit the deck) was the beginning of my love affair with that little sac of bile. Never let it be said that there was a gallbladder I didn’t like. Even after claiming the scalps of more than 2000 of them, I never get tired of taking them out. It is really relaxing and it sends me to my happy place. There is a reason I have been unofficially crowned the Gallbladder Queen.

Myths surrounding the gallbladder and its removal are plentiful – probably more than any other body part. Old wives’ tales about gallbladder surgery, previously passed over the back fence, have been amplified by the internet. Just ask Dr Google and be entertained by the fanciful stories about home remedies for gallstone removal. Whenever I think I’ve heard them all, along comes someone with an even crazier idea that makes me smile. People do love to hold on to their gallbladders and often have to be really talked into parting with them. The most common concern is that because it’s there, it must be required for something. Sure it is – when it works. But when it is diseased, the gallbladder doesn’t do a darn thing, other than threaten people’s lives. I remind patients all the time that the body is built to do without many of its parts if need be. Kidneys, sections of the liver, the pancreas, most of the bowel and the appendix are all up for grabs. Life finds a way.

My favourite question about the gallbladder is, ‘Will you be using a laser to get rid of my stones?’ I am not a Jedi Knight and I do not have a light sabre – well, not a real one, anyway. It is something I’d like to try but there are no lasers involved. I suspect if I used one, I might cut a hole in something I shouldn’t. Other people wonder why you can’t just pass a gallstone. ‘People manage to pee out the kidney stones don’t they?’ they ask. Unfortunately you cannot pass a gallstone unless it is very tiny. To get into the bowel, the stone must pass into the bile duct and then through a tiny valve curiously named the Sphincter of Oddi. This process can cause blood poisoning or swelling of the pancreas and is downright dangerous. This brings me to the olive oil and lemon juice drinkers. There are many recipes available claiming that if a gallstone sufferer drinks these things in sufficient quantities, the gallstones will be magically flushed out of the gallbladder. The reality is that you can drink olive oil and lemon juice by the gallon and you might as well chase it with a head of lettuce because all you are doing is making salad dressing. A vinaigrette will not shift a stone, but it will help the person spend the night on the toilet shifting a bucket-load of stool. Finally there are the true devotees of this technique who tell me that they know it worked because they have found gallstones in their poo. I find this very interesting because it means that they have actually been sorting through their own faeces in order to look for them. We even have a name for it – ‘poo sifting’. If a patient insists that they have truly produced gallstones, I will ask them to bring them along in a bottle so I can send it to the lab to prove that they are little pieces of carrot. It is always carrot.

A gallbladder attack can be so bad that some patients become the complete opposite of the ‘poo sifters’ and will actually beg to have their gallbladders removed. ‘Just do it,’ they groan, out of their minds with pain. Therein lies the genius: this simple operation can magically transform a desperate person into a serene being within hours of leaving the operating theatre. This turnaround from sick to well is a powerful thing for me and this is the appeal of removing a gallbladder. Thankfully, so many diseases that we used to see in their most advanced stages have virtually disappeared because of modern medicine. We understand a lot more about why things happen and can even prevent diseases before they occur. Gallstone trouble, however, can still be just as terrible as it was in 1420 when the problem was first described. It is incredible that a stone the size of a ballbearing can end the life of a fully grown man. Gallbladder disease is now perhaps worse than ever before, as western society gets fatter and older. So, when they eventually figure out a cure for cancer and I happily won’t have to operate for that any more, I figure I will still have gallstones and all the intriguing problems they cause to keep me busy.

Bile is the thin, golden liquid that the liver churns out 24 hours a day. It leaks out of the cells where it is made and collects in the bile ducts that form an amazing arboreal network of pipes, draining every section of the liver. Thousands of branches coalesce into larger right and left ducts that unite just outside the liver, forming the main bile duct. The bile then takes a 15-centimetre journey down this conduit before emptying into the bowel. Once there, it mixes with the food we have just eaten and becomes the detergent that breaks down the fat. If you shake a container of bile, it even froths up like soap. If bile is a type of soap, then the gallbladder is the reservoir of the soap dispenser. It stores and concentrates a little extra bile that the body keeps up its sleeve for when a fatty load of fish and chips comes along. A normal gallbladder is a delicate, almost translucent sac about the size of a Roma tomato. It is loosely attached to the undersurface of the liver by a thin layer of connective tissue. It is joined to the main bile duct by a short spiralling tube called the cystic duct. When there are stones present and a fatty meal comes along, the gallbladder tries to do its usual thing and eject its load of bile. This catapults the stones straight into the spirals of the cystic duct where they become wedged. If you can imagine what happens during childbirth, when a baby’s head tries to emerge from a vagina, it is not a big leap to figure out what will happen when a gallstone attempts to do the same thing and exit the gallbladder. The experience is one of indescribable pain. It is so bad that patients will often believe they are having a heart attack.

Why humans get gallstones is still a little bit of a mystery, but it definitely seems to have something to do with oestrogen, fat and cholesterol, and what too much of any of them will do to bile. An excess of body fat generates extra amounts of the hormone oestrogen – in both men and women. This seems to increase the amount of cholesterol in bile, making it thick and slimy like green treacle. Thick bile is a fertile environment for crystals to form in and, over time, stones seem to grow from these tiny nidi. Anything that changes the oestrogen balance in the body increases the chances of stones forming. Rapid weight loss can do it too, and a cruel side effect of doing a good thing can be a gall attack. Pregnancy is also a time where women develop stones, so as well as their bundle of joy, many women experience a bundle of pain, with their gallstones attacking them shortly after delivery.

There is another, rarer, cause of gallstones and it is just a little bit revolting. In many parts of the developing world there are parasitic worms that, similar to the movie Alien, enjoy making themselves at home inside their human hosts. They live in the bile ducts and feast on the bile and the cells shed by their benefactor. Of course, what goes in must come out and these critters evacuate their bowels and fill the bile ducts with their little droppings. These deposits harden and eventually become stones. In addition, when these creatures die their carcasses contribute to the detritus. All of this is extremely irritating to the bile ducts and results in severe scarring, continual bouts of infection, cancer, and liver failure.

Another strange thing about stones is that no one knows why some people’s gallbladders will go on the attack and why others will carry a gallbladder full of rocks around their whole lives with nary a care. Gallstones come in a spectacular array of shapes and sizes. There might be thousands of tiny little ones like grains of sand or a single stone the size of a chicken egg. Many of them are a beautiful pearlescent yellow and sharply faceted like a gemstone. Some patients even comment that they might be worthy of being fashioned into a necklace. Whatever the size, shape or number, these stones can all cause trouble – pain, jaundice, blood poisoning, inflammation of the pancreas, infection, cancer and death.

Surgically removing a gallbladder – ‘cholecystectomy’ is the technical term – is a really great operation. No two gallbladders are the same and this adds to the enjoyment. Sometimes the surgery is really easy and it is all over in under an hour, and other times it is a three-hour extravaganza and I just wish it was over. And then, just when I think I’ve done the worst one I’ve ever seen, along comes another one that is even more terrible. Since the early 1980s, the operation has been done laparoscopically, that is, via keyhole surgery through four tiny cuts in the abdominal wall. The first time it was done this way, it took more than six painful hours, but thankfully we’ve got a lot better at it and I can now get an easy one done in under 30 minutes. Separating the patient from their gallbladder with laparoscopic surgery involves inserting a series of hollow tubes or ‘ports’ through the abdominal wall. To get the first port in, we make good use of nature’s doorknob – the belly button, a very convenient place to gain access to the abdominal cavity. Before the port is inserted, it is most important that the belly button is inspected to ensure it is sparkling clean. As it turns out, some people give very little thought to umbilical hygiene and it is not uncommon to find some significant concretions nestled deep in this little orifice. Using a pair of tweezers to relieve it of its lint, cleaning the belly button can be a surgical procedure in itself.

Once a satisfactory state of cleanliness is reached, the belly button is grasped with a metal clamp and hauled upward. This lifts the abdominal wall off the bowels to avoid injuring them as a narrow tube is punctured through the skin and muscle. A gas hose is attached to this portal and carbon dioxide is pumped in, instantly inflating the tummy to around the size of a nine-month pregnancy. In their natural state, all the organs inside the abdomen are pressing against each other. Without the gas, there would be no separation and no space to operate in. The skin becomes translucent and tight as a drum, and once all the ports are in, the patient looks a little like a bloated porcupine. In keyhole surgery, all the action takes place on a TV screen. The picture is obtained by a long telescope attached to a camera that is passed through one of the portholes. Immediately, a magnified view of a rich red liver appears on several monitors scattered around the room. The gallbladder clings to the undersurface of the liver, just peeping out. It doesn’t fully reveal itself until a long slender poker is inserted into another port and the liver is gently lifted to expose the full nature of the problem. Will it be simple or difficult? You just don’t know until that very moment and the anticipation can be really exciting. If the gallbladder is translucent and soft, the nursing staff will smile because they all know that this will be a quick and easy operation. But if the gallbladder is thickened and swollen with infection, everyone will groan, knowing we will be there for the next two hours while I painstakingly scrape and scratch the gallbladder away from its attachments. I grimace because I know my arms will ache for the whole of the next day from being held aloft for so long.

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

After 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.

I can’t believe they are going to let me operate on people

Starting to operate on patients marked the beginning of a surgical way of life. Dr Smith instilled in me a work ethic of seeing my patients seven days a week and I still adhere to that to this day. He quite rightly pointed out that if I was going to have all the fun of operating on people, then I had to be totally responsible for their wellbeing 24 hours a day, no matter how tired I was. There was no way he was going to look after my patients while I was off lounging around with my friends telling them how good I thought I was. I took a lot of ribbing for doing all this extra work and missing out on the more social aspects of intern life. But I had a plan. I wanted to be a surgeon and somehow needed to fit in having a few babies along the way. It was essential that I put the rush on surgical training before my eggs withered and died. Women having children during surgical training were rare when I went through. There was no part-time training and no one I heard of had ever applied for maternity leave whilst a surgical trainee. It wasn’t really needed because there simply weren’t many women general surgeons – at least I had certainly never met one. The only female role model I was aware of was a wonderful kidney doctor called Carmel Hawley. Although she was not a surgeon, Dr Hawley had a busy and prestigious career along with a lot of children. She managed to do it all really well. I wanted to be like her and I saw all this hard work as a junior as a necessary means to attempt to hurry through surgical training to achieve my goal of surgery and motherhood. Dr Hawley showed me that there was a way.

So, following the first two years as a junior doctor, my next step was to become a surgical registrar. In order to do this, I had to compete for admission to surgical training with the Royal Australasian College of Surgeons. Once accepted I had four years to learn everything there was to know about surgery. Those years in Nambour had left me in good shape to climb up this next rung in the ladder and I began my push. Thanks to Dr Smith, I was head and shoulders above doctors two or three years older than me in terms of surgical experience. To apply for surgical training, I needed to pass a series of examinations called the Surgical Primary. These consisted of three days of written and practical examinations with hundreds of multiple choice questions. These exams were touted to be really difficult, testing all aspects of anatomy, physiology and pathology. They also cost a thousand non-refundable dollars per attempt and for me this was a real incentive to only do it once. This money was due to be paid several months prior to the exam, well before I had done enough work to think I had any shot at passing. I wrote out my cheque and stood in front of the mailbox for several minutes before I allowed my hand to release the envelope into the slot. Posting that cheque made me put my arse in gear and study enough to pass. I went straight home and did little else for the next six months other than eat, sleep, work and study.

I gave up everything except for a ration of an hour of TV a night. At the time, Andrew and I were huge fans of The X-Files. I discovered that the actress Gillian Anderson, who played Dana Scully, would be coming to Australia to promote the X-Files movie, and that she would be doing an autograph signing at a local shopping centre. To my horror, it became apparent that she would be there on the day of the written Surgical Primary examination. I was such a fan that I actually considered deferring the exa m for another six months so I could go and see her. My hopes were buoyed, however, when I found out that she would not be arriving until half an hour after the exam was over. This was my window of opportunity. I flew through that exam, checked my work once and made my exit early so I could drive like a bat out of hell across town to see Dana Scully. As it turned out, all I got was a glimpse of her red hair over the heads of 4000 other frenzied, sweating fans, but that was all I needed to be satisfied.

I had to wait three weeks to see if my celebrity addiction would cost me six months of study and a thousand dollars. Finally the day arrived; we had been instructed to call the exam hotline in the afternoon for our results. Of course I couldn’t concentrate all day and by two o’clock I couldn’t wait a moment longer. I locked myself in an office to make the call. The next few minutes would determine if I could move forward with my life. If I passed, it would show everyone that I was serious about being a surgeon, and if I failed, I would have to go back to the drawing board and do the gruelling study all over again. I dialled the number, said my name and held my breath while the secretary on the other end of the phone rifled through her pieces of paper.

Finally the words ‘Slater – pass,’ came down the line.

‘Are you sure?’ I asked, feeling warm tears of relief well up. I did it: I saw Gillian Anderson and I passed the Surgical Primary.

Now I had the exam, only a few things stood in the way of my dream of starting surgical training. There was an interview before a panel of wise surgical men, and the positive recommendations from my bosses. I was only a junior doctor from a small provincial hospital, so no one aside from Dr Smith had really ever heard of me. To improve my chances of being selected, I travelled to Brisbane to introduce myself to the power players of general surgery to at least show them my face and tell them that I was really keen on being a surgeon. My first interview was with the Chairman of the Queensland Board in General Surgery, an important person to get to know, and funnily enough it is a position that, almost 20 years later, I now occupy. It is quite strange to think that people might be as intimidated by me as I was of him that day.

‘I’d like to be a surgeon!’ I blurted out eagerly, before he even had a chance to sit down. He stared at me for what seemed like a long time, obviously thinking I was quite an idiot.

‘Let me see your résumé,’ he said finally, extending his hand to receive it. I tasted a little bit of vomit in the back of my throat. I didn’t bring a résumé. In my extreme naivety, I had failed to realise that he might need to see anything more than my smiling face.

‘I haven’t done anything to put in a résumé,’ I stammered, instantly wishing I could take the words back. The corner of his mouth lifted in a bemused smile and he continued to give me a look that is still burned in my brain. To this day I cannot talk to him without reliving that moment. He didn’t have much more to say after that and I left the room thinking my career in surgery was probably over.

That same day I also had an appointment to see Professor Russell Strong, one of the pioneers of liver transplantation in the world, i.e. not intimidating at all. I arrived ten minutes early for the interview and was greeted by his faithful secretary of many years. She did not look up from her computer as she told me to take a seat. She informed me that Professor Strong was in surgery and he would be along at some point. The first hour passed and I sat in silence.

Out of nowhere, her eyes never moving from her computer screen, the secretary eventually said, ‘A lot of girls come in here and say they want to be surgeons. Some of them start, but most of them don’t make it, you know.’

I squirmed in my chair and didn’t know what to say. She was crushing my dreams. I waited another hour. I had to pee.

The secretary looked at me this time and said, ‘Look, I don’t think he is coming, do you?’

She clearly wanted me out of there. I was reluctant to leave because what if he appeared a moment later and I wasn’t there? Was this a test? Was he waiting to see what I’d do in a tricky situation? After two and a half hours, I began to think she was right. I decided to go. My one vindication was that, years later when I returned to work at that hospital as a surgeon, Professor Strong’s secretary also became mine and we laugh together when I remind her, in a good-natured way, that some girls do become surgeons.

Having failed to gain even the most meagre advantage by getting to know the surgeons who might grant me a future, I turned my attention to preparing for the surgical interviews. That year I was competing with 35 other doctors for only eight positions. In only my second year out of medical school, I was the most junior of the applicants and the only woman applying. Despite my youth, all my after-hours work in the operating theatre meant my experience gave me a definite leg-up on the rest. That night of the interviews, Dr Smith must have also spoken up for me and told them to take a chance on the unknown girl from Nam.

Shortly after, I received my acceptance letter to commence training in general surgery and I was elated.

The life of a surgical registrar

My first year as a fully fledged surgical registrar got off to a terrific start when I was assigned to work in a hospital situated in a picturesque beachside setting. Working at a coastal hospital was a coveted posting and six months there meant living the high life in a beachfront apartment and hanging out every night with the other junior doctors in the local restaurant precinct. The hospital was two minutes from the shore and there was a spectacular view of the sparkling Pacific Ocean from every floor. The transient tourist population made every day feel like a working vacation.

My move to this new location also proved to be the beginning of a very testing time for my marriage. The rigours of surgical training would mean changing locations every six months as I toured the hospitals of Queensland. From our wedding day to the time I finished training, Andrew and I could count 12 different homes. This is what breaks many budding surgeons – living away from their family for long periods of time. Andrew and I had to live separately off and on for the entire four years I was a registrar and it was tough. He had a job working for the National Bank in Nambour – just like my father in his youth – and my move hundreds of kilometres away from him meant he had to live with my parents, eating meat and three veg with them every night while I was enjoying the nightlife with my fellow registrars. He kept smiling through it all, though, maybe because of all the whisky my mother gave him. Andrew began to sacrifice a lot for the sake of my career and it became clear to us that our marriage would not survive if we both wanted to build big careers. Andrew decided to make most of the compromises and stepped back from the bank and instead pursued his lifelong dream of becoming a commercial pilot. This job at least let him move around with me and we had great weekend trips when Andrew would fly me away in tiny rented Gazelle aeroplanes. We made it work.

I threw myself into my new role – I was now a surgical registrar, ready to heal the sick. I was scheduled to be ‘on call’ my very first night on the job. This meant that I worked a normal day and, when the sun went down, my phone began to ring. On the line would be the emergency department, calling about patients with surgical problems.

One of my calls was about a patient who had been vomiting profusely and had not moved their bowels for a number of days. I listened to their story very professionally and carefully examined their abdomen. I noted that it was as tight as a drum and that they looked quite unwell. I evaluated the x-rays and decided that the correct diagnosis was a blockage of the large bowel. The only thing left to do to confirm my stunning diagnosis was to examine inside the patient’s rectum by putting my finger up there. I pulled on a rubber glove and plunged in. I felt like I finally had used my clinical acumen when my finger confirmed what I had brilliantly suspected; there was indeed a large cancer just inside the anus. My chest puffed out with pride as I congratulated myself on being really great. I was feeling good, I was feeling special, and when a doctor feels like this, it is never actually good for anyone. Buoyed by the knowledge that I was indeed a magnificent doctor, I then decided I needed to biopsy this cancer. Now, considering I was already pretty sure about the diagnosis, a biopsy was not absolutely essential but I felt that this additional step was sure to impress my boss (who I was actually yet to meet). ‘He will think I am the best registrar ever when I prove this is a cancer with a biopsy,’ I thought. I triumphantly took the tiny biopsy and sent it away to the lab for analysis. By that time it was after midnight, so I decided I would inform my new boss about my diagnosis in the morning. This was my last job for the night, so I went home and drifted into a contented slumber.

I was awoken an hour later by a blaring pager. It was the resident ward doctor.

‘I just wanted to let you know that the patient you were just seeing is bleeding profusely from their anus,’ she said. ‘Their blood pressure is low and I am going to start giving them a blood transfusion.’

I flew back to the hospital to find my patient lying in a pool of blood. My tiny biopsy, that I had done safely many times before on other people, had inadvertently bitten through a blood vessel that wouldn’t stop bleeding. This bleeding complication can happen with any procedure, but why tonight I asked myself mournfully. With my tail firmly between my legs, I had to call my new boss in the middle of the night and let him know that on her first day as a registrar, a doctor he had never met had biopsied a patient he had no idea was in the hospital, and ask if he could come in and help her do an emergency operation. A few expletives were uttered and in he came. It was four o’clock in the morning and I was berated every minute of that three-hour operation to remove the patient’s cancer. The surgery was always going to be required at some point but it would have been preferable for it to at least be left until daylight hours. I was constantly reminded that this took the prize for the most spectacular start to a job that any registrar had ever had. I learned a golden rule of surgery that first day: never do anything that is not absolutely essential in the middle of the night, just in case there are complications. Also, never, ever feel too good about yourself because surgery has a real propensity to bring you back to earth quickly.

It took a while to redeem myself after that night but I was careful to do everything right and I worked like a dog. One of my new bosses was an amazingly experienced bowel surgeon who had become famous for the prolific amounts of work he managed to get through each day. He had such a passion for operating on the bowels that working for him was a complete and utter joy. He loved his job so much that his catch cry was to declare with gusto that it was not a good day ‘unless we have made a bag’ – a colostomy bag, that is. He had seemingly boundless energy and it was not unusual for him to be supervising three junior doctors in three different operating theatres at once. The aftermath of this meant I usually had 20 ward patients to look after at any one time. Many of them would have complicated problems with some combination of poo or pus running out of their bodies. My experience working in this unit is a big part of the reason why I enjoy operating on the most difficult of cases to this day.

The real specialty of this unit, however, was anal surgery or proctology. For such a small part of the body, the anus can have all sorts of interesting things go wrong with it. The old surgical adage goes, ‘If you don’t shit, you die,’ and part of our job was to make sure this would not apply to any of our patients. One way or another we would always manage to get them going again. I was taught a great deal about the anal challenges of patients, quite common problems as it turns out, not frequently discussed in polite company. Excess skin, warts, abscesses and incontinence – we dealt with them all. I learned that repairing bottoms could offer a surgeon the greatest of satisfactions. If you got it right, that person would think of you kindly at least once a day while they were sitting on the toilet and you could make a massive difference to their quality of life. After working in that job, I found it all so interesting that I started to think that I might want to be a bowel surgeon specialising in proctology too.

Looking back, those days as a surgical registrar were some of the best of my life, although it was hard to see it at the time. It passed me by in a haze of sleepless nights, study and stress. The greatest thing about it was that I got to behave like a specialist with the safety net of having a boss only a phone call away. It was really easy to attack surgery with all the enthusiasm of a baby Labrador because I always had someone there to guide me away from trouble and bail me out of my inevitable mistakes.

General surgery on-call days were tough. There was no such thing as ‘safe working hours’ for doctors during my training, and being awake for two consecutive days was worn like a badge of honour. The longer you could stay standing and still appear fresh, the more awesome you were. Part of the reason surgeons are so revered, I think, is that they can often continue to function after being awake for a long time, fuelled only by cups of instant coffee and a few shortbread creams. ‘Don’t upset her, she’s been up all night,’ the nurses would whisper, feeling very sorry for me at times.

The sleeplessness was a difficult but vital part of my training, because the more hours I worked, the more cases I saw and the better I became. Surgery is an apprenticeship where on-the-job training is important. If I’d seen something before, it became pretty easy to make the diagnosis when the same thing walked through the door the next time. I really worry that now junior surgeons’ work hours have been severely restricted by well-intentioned laws, as it will be difficult for them to ever get the experience they need to become really good. Surgery has to flow through your body and unless you are fully immersed in it, it will never happen. This is typically why surgeons are so cocky. We know our stuff and we can handle a crisis no matter what the situation.

I had a night on call every third day, and this would mean staying either close to or actually in the hospital overnight, so I could be immediately available when a trauma came through the door. On those on-call days, I would arrive for work at seven in the morning and I would not go home until seven the next night. I caught some sleep when I could in tiny on-call rooms that all looked the same with a noisy air-conditioner and a foam mattress on a creaky metal bed frame. This was the lot of a surgical registrar and no one thought to complain about it. It was the least I could do to repay my bosses who had to put up with assisting me while I fiddled about taking hours to do an operation that they could do in half the time. After a while I did a few things to make being on call just a little more tolerable for myself and all the other boys who had to use those call rooms. I replaced scratchy hospital sheets with soft, comforting linen. I added some art, nice lighting, a hairdryer, a TV/DVD player and a fully stocked fridge. The boys would make a donation each week and I would keep the cupboards full. They would go through ten packets of biscuits a week. It is surprising what a difference those small comforts could make when you have only had an hour of sleep.

As I began to think I might like to be a bowel surgeon, I started to plan how I would make that happen at the end of my surgical registrar training. There is a longstanding tradition in Australia that, when someone graduates as a general surgeon, they travel overseas to increase their experience. Because of Australia’s relatively small population, there is a limit to the number of cases a trainee can be exposed to. Even with the crazy hours I was working, there simply weren’t enough cases available to gain the vast experience required to go it alone as a specialist general surgeon. Working in an overseas hospital was a once in a lifetime experience, especially if I wanted to focus on just one aspect of general surgery and become a ‘Super Specialist’. Most people went to the UK but I had always been obsessed with the idea of living in the USA. I grew up on a TV diet of Sesame Street, Family Ties and The Cosby Show and I yearned to drive on the right-hand side of the road, travel across Route 66 and live the American dream. Any doctor wanting to work in the States had to sit yet another series of examinations to be eligible, so even though it was years away, I flew to Sydney to do them. This included an English test that everyone (including native English speakers) had to pass. I guess the Americans weren’t too sure about the standard of the rest of the world’s English. I nearly failed that damn test because I got bored listening to the long stories being read in a thick American accent and didn’t pay attention. I scraped through, however, and I ticked off another qualification and filed it away for later. As it turns out, it was an excellent move, as an opportunity that would change the course of my life was just around the corner.

In the poo

No book about the life of a general surgeon would be complete without a chapter discussing faeces. Dealing with poo sounds strange, I realise, but someone has to help out the people who have problems in this area. It is a part of my job I just attend to with very little fanfare. As I’ve mentioned, as a teenager considering a career in medicine, I don’t think I knew much about what doctors actually did with their day. The one thing that I did know for sure was that they all spent some time sticking their fingers up people’s bottoms. I didn’t really understand what would prompt a doctor to do this but it seemed to be important work. The thought of perhaps having to do it was very nearly a good reason not to sign up for the job. I convinced myself at the time that maybe it would be possible to have a career in medicine and avoid it completely. Little did I know that in just a few short years I’d choose a career like general surgery that listed probing the anus as a job requirement. Like most things, the first time is the hardest and once you get used to doing it, it becomes routine. Oh, and you’ll be glad to know that I did learn the reason it needed to be done.

It was pretty early on in medical school that I got the chance to do my first rectal examination or PR (per rectum) as we call it – that is, putting a gloved, well-lubricated finger in someone else’s bottom for the purpose of finding something unexpected. It is one of those things in your life that you remember exactly the moment you did it. Another surgeon who was also passionate about bowel surgery took on the role of ensuring that no student left medical school without having learned how to do a proper rectal examination. He regularly lined up a succession of wonderfully gracious volunteers who gave permission for their bottoms to be gingerly probed by the index fingers of medical students. Our teacher was always sure to let the patient know that they were contributing greatly to the advancement of medicine and he explained it to them so well that, strangely, the patients who consented to this significant invasion of their privacy didn’t seem to mind that much.

The night before I was to christen my finger in this way, I was pretty nervous and didn’t sleep well at all. How do you prepare for such a thing? I thought that trimming my fingernails definitely couldn’t hurt. Should I wash my hands before, after, or both? What would it feel like? One glove or two? What if the glove broke? These sessions were done in groups of six, and my five colleagues and I all turned up at the prescribed time and place, giggling and nudging each other like silly schoolgirls. We were brought into the room where the patient was lying under a sheet, naked from the waist down. After some preliminary introductions, our instructor asked the patient to turn on his side and pull his knees up to his chest.

‘It is important to explain to the patient that when a finger is put in their bottom they will have a desire to move their bowels. You must reassure them that this is unlikely to happen,’ he told us.

‘My goodness, is that a possibility?’ I thought, not having contemplated that messy outcome. One by one we stepped up, gloves on. The surgeon stood by with a tube of lubricating jelly ready to squeeze onto our outstretched fingers. When it was my turn, I took a deep breath, inserted a very shaky finger and probed. Once in position, I was supposed to run my finger over the back wall of the rectum and then rotate my body through 180 degrees so my finger would turn to feel the prostate gland in the front. What an unusual sensation. It was soft and warm and I was repulsed as I felt a large chunk of faeces bumping around on my finger. All the while we were being observed to make sure our technique was correct.

‘The normal prostate should be about the size of the pad of the finger. Feel the walls of the rectum, they should be smooth,’ the surgeon explained. This was followed by the old chestnut, ‘If you don’t put your finger in it, you’ll put your foot in it,’ meaning that if you avoid doing a rectal examination you will miss something vitally important, like a hidden cancer. It was a little unclear how long I was supposed to stay up there but when I thought I had got everything out of the experience that I could, I withdrew my finger. Then, the last part of the job was revealed to us. I was to carefully raise my soiled finger to eye level and closely inspect the poo that was now smeared on my glove for any sign of blood or pus. Was he kidding me?

Once the secrets of examining the anus and rectum were divulged to me, I felt that one of the great mysteries of medicine had been unlocked and I was no longer afraid. Nothing will ever change the fact that it is a truly unpleasant task for everyone involved, but it is a very important part of the examination of the human body and there are a lot of fascinating things to be discovered up there. Even after all these years, it is still exciting to see what you can discover just with an enquiring finger; this simple thing can often tell you much more than any scan.

When I was no longer a digital rectal examination novice, I was ready to progress to the more advanced techniques of examining the rectum. As a surgical registrar, it was time for things to get visual. Rigid sigmoidoscopy involves looking up someone’s bottom with a 20-centimetre long tube that is lit up along its length. This tube allows you to find things in the rectum further afield than a considerably shorter finger will reach. Traditionally the procedure is done with the patient awake and aware. Every effort is made to try and keep the apparatus hidden because if the patient sees it, they may not want to participate in what is coming next. After a lot of explanation and reassurance, the patient is placed on their side and the pointy end of the tube is slowly introduced. At this moment the patient takes a sharp breath in and a natural reflex causes them to clench their sphincter tight. I call this ‘the reticent anus’ and it is pretty understandable really. The clenching of course makes the whole thing a lot more difficult and if you don’t keep enough forward pressure on the tube, it will come flying out, requiring you to start all over again. With some gentle encouragement you can usually help the patient relax and press on.

Once the tube is in, you must bend down and put your eye up to the porthole-style window at the end of the tube. This allows you to negotiate the very straight tube up a very curvy rectum. The bowel is normally collapsed on itself making it difficult to see anything at all. To show the way, the sigmoidoscope tube has a little rubber bulb attached that literally blows air up the person’s bottom. The soft walls of the rectum billow open, allowing you to push forward, carefully dodging around any lumps of poo that get in the way.

Sigmoidoscopy can be very treacherous for the operator, as your eye and nose come perilously close to the anus. All this introduced air mixes with the poo causing a dangerous build-up of flatulence under pressure. This will eventually result in an unfortunate expulsion of material from the anus. A vital part of the job is to develop the ability to predict when this blast of particulate-filled gas might erupt. The effluent can rush toward you like the water in the aqueduct coming toward John McClane in Die Hard 3 and unless your reflexes are well developed, you will cop an eyeful. All of this must be done whilst trying to remain professional and telling the patient that everything is fine, that it really doesn’t smell at all and it is all part of a day’s work.

Every doctor has their own collection of fantastic poo stories. They usually get told when we get together over dinner at a fancy restaurant. It’s juvenile and we can get loud. We often don’t realise how crass we are being until our spouses elbow us in the ribs and we notice that all the other diners are staring at us with their mouths open. Humour is simply our way of dealing with this part of the job.

There is not an object invented that has not been inserted into an anus. If something will go close to fitting and occasionally even if it won’t, people will attempt to put it in there. This feat is usually achieved at unspeakable hours of the night and the insertee will usually attempt any and all measures to extricate the item prior to attending the hospital so as to avoid the red-faced embarrassment that will surely follow. On the other hand, there is a group of patients who get their kicks not from the act of insertion, but from the hospital staff’s reaction to what they have done. They are the ones who manage to get some seriously large objects up there. The reasons given for putting things up their bums vary widely and can be pretty funny. The most common one is blatant denial: ‘I woke up and found someone had put it up there,’ is the usual story. ‘I tripped over the cat on the way out of the shower and I happened to fall on a pool cue,’ is another.

Vibrators are pretty standard fare when it comes to insertions and to tell you the truth, it takes something a lot more creative than that to pique my interest. It’s pretty amusing, though, if it is still operating and the victim is emitting a constant low humming noise. Vibrators are usually pretty easy to retrieve. Just lube up a gloved hand and in I go. Then there was the young man who put a tube of builder’s foam up his bottom and pulled the trigger.

This is the type of gap filler that expands to mend cracks in walls. Once it fills the space, it sets hard. This crazy guy filled his entire large bowel with this expanding foam and I had to cut him open to remove it. He did manage to get a perfect cast of his colon as a souvenir of the experience. A year later he did the same thing, except this time he went up his penis and got a similar model of his bladder. A collector, I guess.

Then there was the ‘peanut guy’ who every few months would put four to five peanuts up his penis. Goodness knows what device he used to poke them up there. His particular thrill was derived from having a telescope put up his penis to remove them. After several calls, all after midnight, to tell me that he was back with his bladder full of peanuts, I would flatly refuse to leave my warm bed to go and help him.

‘Just put him in the ward and I’ll deal with it tomorrow,’ I would bark. By the time the morning came, he had usually peed them out and I wouldn’t have to lift a finger, depriving him of his pleasure. He would just deposit the nuts in a little bottle on the nurse’s desk, shrug his shoulders and tell them he was off home. ‘See you next week,’ the nurses would call out as he left.

But by far the most famous of all ‘inserters’ was the ‘butternut pumpkin man’. Yes, you read right. He was a regular attendee to the Emergency Department with a full-size butternut pumpkin up his bum. Needless to say, this took years of practice and many attempts to achieve this incredible feat and it also goes without saying that you could easily park a bus in his rectum and that he had to wear an adult diaper full-time.

One of the terrible side effects of taking narcotic drugs like heroin and morphine is severe constipation. After a while the bowels stop pushing the poo forward and the addict might only have a bowel movement every two weeks or so. A lady who was a long-term abuser of prescription pills was admitted with this very problem. She had not opened her bowels for many days and was in a desperate situation. She was so backed up, she was actually vomiting. We put her under anaesthesia so I could put my gloved fingers into her bottom and scoop out the hard rocks of poo. Those few lumps, however, were the tip of the iceberg. The only way to really get things moving in this situation is to give the patient two to three litres of salty water to drink. This results in a massive evacuation that goes on and on until the bowel is empty. It is a very unpleasant process.

Because of her drug addiction, this particular lady was very difficult to work with. She was demanding and abusive toward the nursing staff, yelling and screaming at them to get her more drugs to relieve her pain. This continual barrage of insults, not surprisingly, caused the nurses to dislike her immensely. After she finally drank the litres of salty water I had prescribed, the woman then demanded that the nurses give her a very heavy sedative to knock her out. She was sick and tired of us all and just wanted to ‘zone out’. The nurses told her that they did not think it was a good idea, but she abused them some more and insisted. ‘Fine,’ they said, ‘do what you want,’ and gave her the pills. After taking them, she stripped off her clothes and got into bed, quickly falling into a deep, drug induced sleep. An hour or so later, the bowel treatment began to take effect but this sad lady remained in her deep slumber. You can imagine what happened next.

The nurses were alerted a few hours later by loud screams and when they ran to see what was wrong, they were greeted by a wild-eyed woman wandering naked down the hall, covered from head to toe in her own faeces. Her bowels had completely emptied themselves into her bed and she had slept through the whole thing. She had turned brown. She continued to hurl abuse at the nursing staff about her dignity being compromised. They put her in the shower and hosed her down, all the while trying to stifle their laughter and remain professional. She recounted her horrible ordeal to me later on rounds. I, too, struggled to keep a straight face. Bless the nurses, they have to deal with some horrible stuff.

The smell of faeces frequently pervades the room in the course of a general surgical operation. Patients can quite naturally have a bowel movement at the start or end of a case owing to the relaxing effect that anaesthesia can have on the anal sphincter. In general surgery it is usually just a minor irritation. We can’t see it under the sterile drapes and all we have to do is put up with the smell until the end of the case and then find some excuse to be out of the room when it comes time to clean up the patient. In orthopaedic operations, however, this sort of soiling can be a really serious problem.

A patient recently told me her story of the time when she was about to undergo a hip replacement. This operation requires everything to be perfectly clean. An infected joint has disastrous consequences and must be removed immediately. As the lady was put off to sleep for her operation, her bowels discharged themselves on the operating table. Faecal matter became smeared all over the skin, exactly where the incision was to be made. The orthopaedic surgeon became hysterical at the sight of the smelly brown mess running all over his operative site.

‘Cancel the surgery,’ he shrieked.

All they could do was wake her up – sans operation – clean her up and try again another day. She told me that instead of hearing ‘Congratulations, you have a brand new hip,’ she got, ‘Well done, you did a great big poo.’ She was so embarrassed.

The call of the bile

My second year of surgical training saw me move to Brisbane, the subtropical capital of Queensland. Andrew and I moved yet again and he found yet another job as a flight instructor at a local airport. I was slated to work at one of the most famous surgical hospitals in Australia, the Princess Alexandra or ‘PA’. The whole point of working at the PA as a surgical trainee was to be exposed to the different specialties within general surgery or ‘super specialties’.

The Princess Alexandra was home to world leaders in all the specialties of general surgery but none more so than the members of the Queensland Liver Transplant Service. I had already worked at the PA for six months doing relieving jobs just before I started training as a registrar and was truly intimidated at the prospect of returning there as a registrar with considerably more responsibility. I would actually have to work closely with surgeons who were considered geniuses and I was worried that they would discover how truly stupid I often felt. I found out that my first job back at the PA would be as the registrar in the transplant unit. This would be followed by six months in Hepatobiliary where, instead of transplanting the organs, the same surgeons would cut pieces from them, ridding patients of terrible cancers.

To say that I began to hyperventilate on hearing this news would be an understatement. Of all the jobs available to a surgical trainee, these two were considered the most difficult and demanding of all general surgery rotations. The transplant rotation was often referred to as the ‘new car job’ because you worked so much overtime that after six months you could pay cash for a brand new car. I was terrified and at the same time pleased. Getting assigned to these jobs was a real honour because they were not given out to just anyone and especially not to a trainee who was thought to be struggling. Somebody, somewhere, must have thought I was doing a half decent job.

The surgeons in the transplant unit at the PA were almost like mythical creatures. Everyone I talked to spoke of them in hushed tones and there were many legendary stories about their intellect and stamina. Any problem that could not be solved by other surgeons ended up in their hands. They were constantly followed around by a troop of surgical groupies, usually transplant surgeons from overseas, who had come to train and observe their skill.

The head of the unit was Professor Russell Strong, the surgeon who I had dismally failed to meet with a couple of years before. He was Australia’s most celebrated surgeon, a Companion of St Michael and St George, a Commander of the Order of Australia and a Queenslander of the Year to name just a few of his accolades. Alongside the great American surgeon Thomas Starzl, Professor Strong was a pioneer of liver transplants and was the first person to perform a successful one in Australia. In a procedure eventually named the ‘Brisbane Technique’, he was also the first person in the world to cut an adult donor liver in half to get a piece small enough to transplant into a child. He was a bona-fide living legend, a man who never needed to say a word to command the respect of those around him. This was lucky because he rarely uttered one. However, whenever he did speak, incredible pearls of wisdom would spill out of his mouth and any person fortunate enough to be in earshot would be taught a lesson in surgery they would not easily forget.

He once shared with me how he was feeling before he did his first liver transplant for a child dying of liver failure. Thankfully, children rarely die, so child-size donor livers are uncommon. For a child to die of liver failure, however, is more common and something had to be done to bridge the shortfall and stop babies dying while they were waiting for a new liver to come along. By borrowing the techniques used to remove cancers from the liver, Professor Strong felt it would be possible to take an adult liver, split it in half and give the smaller piece to a child. There were a great many people who thought it would never work. It was seen as expensive, risky and the ethics were hotly debated. One newspaper article even compared it to the monstrous work of Dr Josef Mengele, saying that such a transplant would produce ‘stunted children’. Professor Strong was under enormous pressure to succeed.

While this storm of controversy was raging, his major concern lay with a minute detail that would have never occurred to anyone else. He was worried about what might happen after he joined the tiny blood vessels that allowed blood to run through the new liver. Over the years would these little stitches stretch and grow with the child? If they didn’t, it might mean that the baby would outgrow their liver and either die or need repeated transplants until they were an adult – a bit like needing a new pair of shoes every year. It was a complete unknown. As it turned out, everything was all right. Remarkably, the join-ups did stretch and life found a way. Australia’s first child liver transplant recipient is now in her late 20s and has two kids of her own. As a society, we owe a great deal to Russell Strong for standing firm in the face of extreme opposition to do something he knew was right. I feel humbled that I now sit in an office next to his.

Working alongside Professor Strong was Dr Daryl Wall. He was the person who took care of all the problems no one else could fix. These were broken and often institutionalised patients with volumes of hospital charts thicker than the phone book. Dr Wall was always charming and impeccably dressed in a suit and tie, even at three o’clock in the morning. Whenever I called him, he would answer with words of enthusiasm and praise for the job I was doing. His greatest gift was the ability to bring sunshine and optimism during the most desperate of times. It was likely he could find something life-affirming to say whilst amputating a leg during an earthquake. He also had the extraordinary skill of remembering and using the name of everyone he had ever met, from the cleaner to the CEO of the hospital, and everyone loved him because of it. An imaginary Dr Wall still sits on my shoulder when I am operating, guiding my hands, his surgical aphorisms sounding in my head. There is no doubt that my love for looking after complicated problems has come from him.

Professor Stephen Lynch, better known as ‘the Chairman’ for his skill in negotiating both the operating room and the maze of hospital administration, originally hailed from New South Wales. He joined Professor Strong in the earliest days of the liver transplant program at the PA and was by his side through all of the exciting ‘firsts’. By the time I started there, he was the Director of the Liver Transplant Unit. I didn’t know it at the time, but he was the man who would eventually change the course of my life. Professor Lynch was a quick and precise surgeon and watching him operate was like poetry in motion.

Finally, there was Professor Jonathan Fawcett, the newest member of the group. He was a young British surgeon, headhunted by the PA for his amazing research pedigree and giant intellect. There was literally nothing he didn’t know and he would be my ‘phone a friend’ if I ever went on the TV show Who Wants to be a Millionaire? He combined being a brilliant surgeon and dedicated researcher with the likeability of British comedian Hugh Grant. I would never have believed that we would one day become the best of friends and that I would think nothing of picking up the phone and calling him for a chat four times a day.

These awe-inspiring men aside, being a transplant registrar was a terrifying job because it was just so different to any other type of surgery I had ever done. These were long, bloody operations performed on critically ill patients who took unfamiliar medications and got bizarre infections. The catch cry in the transplant ward was ‘All bets are off’, meaning just when you think it couldn’t happen to these people – it did. Transplant medicine is a high stakes business and I was constantly worried about making an error that could cost someone their liver and ultimately their life. That feeling never goes away, even now.

Then there was the mystique that surrounded where all these spare livers and kidneys came from. It was not unusual to arrive at work in the morning and find out that a donor team had slipped out unnoticed during the night, flying to another city to retrieve organs from someone recently departed. It was always discussed in hushed tones because the secrecy regarding the origins of transplant organs was paramount in order to protect the privacy of the donor families. We would all cringe when a high profile person received a transplant because it got a lot of coverage in the press, giving a donor family the opportunity to put two and two together and figure out where their relative’s donated organ went. Of course on my first day I wasn’t really aware of this reverence for donors and made my first of many transplant faux pas.

‘Would it be possible for me to go on a harvest?’ I asked, meaning, ‘Could I attend a donor operation someday?’ I received a quick and venomous rebuke from the crotchety transplant coordinator.

‘We try not to use the word “harvest”, my dear,’ she said. ‘The families don’t like it, it sounds like we are plundering the corpse. Procurement is the politically correct term. You see, we have to show respect for the dead. Only laymen use the word harvest,’ she explained condescendingly. Of course, she made sure to deliver this dressing-down in front of several of my new transplant bosses. I was red-faced with embarrassment at my gaffe, but thankfully they just ignored me.

The transplant job was crazy – on call 24/7 for six months. The patients were unbelievably complex and needed all of my attention all of the time. I even carried my pager when I went to the toilet. These surgeons did not care how long I had been awake and I was certainly not going to complain about it because invariably they had been working many more hours than me. I really wanted to do my job well and impress them because even if I could become a fraction of the surgeons they were, I could hold my head up high. My daily routine became one of complete unpredictability, and being someone who likes a plan, I still struggle with this now. At any time, day or night, I could receive a call letting me know there was going to be a transplant and suddenly the next 24 hours of my life would be occupied.

Cruelly, the most common time to be called was late in the afternoon, just as the sun was setting and there was a glimmer of hope that I might be finishing work for the day. Intensive Care rounds were done in the morning and the patients who were more than critically ill, i.e. dead, were deemed to be that way shortly after. By the time the deceased’s family gave their consent to donate the organs and all the tests were done, it was often late in the day. Only then could things get underway and a donor team from the PA be dispatched to retrieve the organs from as far afield as the Northern Territory or even New Zealand. At the same time, the lucky person who was to receive a donated organ would be summoned by the urgent bleat of their pager. When they heard that sound, they had to drop everything, pack a bag and dash straight to the hospital. Once there, they waited on tenterhooks to hear whether or not the organ they had been counting on to save their life was going to be usable. When the word came through from the donor team that the organ was good, the recipient would tearfully kiss their family goodbye and be wheeled around to the operating theatre to begin what might be a rocky road to recovery.

My little contribution to the whole proceeding was to greet these excited and anxious recipients when they arrived at the hospital and to congratulate them on this first big step toward a new life. I also had to remind them of the grim reality that they had a one in a hundred chance of not being alive tomorrow.

About 9 pm, when most people were getting ready to settle into their beds for the night, I would be standing at the scrub sink washing my hands for what would be six to eight hours of standing perfectly still while an old liver was exchanged for a new one. I would be at the left elbow of the transplant surgeon and we would be accompanied by three of the overseas surgeons on the other side of the operating table, all jostling for the best vantage point. With our masked faces only centimetres from each other, we would all work together to remove the patient’s old liver, moving perfectly through a set of carefully choreographed manoeuvres. Professor Strong would usually operate in complete silence for the duration of the transplant. The only sounds in the room were the ping of the patient’s heart monitor and the slurp of the blood going up the suckers. The overseas doctors frequently spoke next to no English but occasionally the silence would be punctuated by one of them letting out a grunt of approval as Professor Strong put in a stitch they particularly liked.

I stood amongst them as the most inexperienced person in the room, desperately hoping no one would notice that quite often I wasn’t exactly sure what I was doing. There was no instruction forthcoming and because I didn’t want to bother anyone with stupid questions, I just had to figure out what to do by paying close attention. Occasionally Professor Strong would move my hand to where he wanted it and I would will my fingers to perform with some semblance of coordination and do whatever he asked. If I was lucky, this involved cutting a stitch or holding a thread as fine as a human hair, releasing it at just the right moment so it didn’t break. If I did snap it, Professor would scold me with a roll of his eyes and a disapproving shake of his head that clearly meant, ‘Don’t do that again, you moron.’ Most of the time, though, my job was to stand without moving as I held a sharp-edged metal blade lifting the liver up so they could see what they were doing. This was achieved by perching precariously on a tiny platform and intermittently peering over the Professor’s left shoulder to catch fleeting glimpses of the operation. There were long periods of time, though, when I couldn’t see a thing. This was the customary position for a junior assistant in liver surgery and an apprenticeship that all budding surgeons must go through. A colleague once told me that the only thing he had to look at during a marathon liver transplant was a small mole on the back of Professor Strong’s neck. After eight hours, he had stared at it for so long that he became convinced that the mole had turned into a melanoma and that the Professor should seek urgent medical attention. A different assistant standing in this position became so bored that he jumped off his box and sat down in the corner of the operating room. It took Professor Strong a few minutes to notice that he was gone. When he was discovered sitting down, Professor Strong shot the junior doctor a dangerous look.

‘I couldn’t see,’ the exasperated assistant proclaimed, realising he was in trouble.

‘No, neither can I,’ Professor Strong replied, ‘you are not doing your job any more.’ Needless to say, that doctor is now doing orthopaedics.

There were many nights when I watched the sun rise over the city through the window of Theatre 12. It was prophetic, really, because it was the start of a new day for us and symbolised the dawn of a new life for the patient as the clamps were released and warm blood surged through the new liver. Typically at around 4 am my head would begin to nod as fatigue took hold and told my body it would be all right to take a little nap. Professor Strong, accustomed to the signs of a wilting registrar, would sense this happening as my grip on the retractor would start to loosen. He would grab my arm and yell ‘Wake up!’ just before I fell face first into the wound. For some strange reason I always found singing the American national anthem quietly to myself would keep me awake. ‘Oh say can you see by the dawn’s early light, What so proudly we hailed at the twilight’s last gleaming,’ I would hum. Maybe I was dreaming that I would one day live there? It took my mind off my locked knees, rumbling stomach and the full day of regular work that stood between me and my bed. It was also around this time that the smell of bacon would come wafting into the theatre from the breakfast trolley that was supplied for all those staff involved in the transplant. This was like torture and our mouths would water at the thought of that first taste of greasy pork.

Professor Strong always displayed boundless stamina. He would finish the surgery and quietly slip away to his office to write the operation notes with his red pen. The trademark of a liver transplant patient’s chart was the Professor’s loopy crimson handwriting emblazoned over two pages, complete with complex diagrams portraying how the liver was sewn in. While he was writing, he would relax in his office for a little while, then reappear on the ward dressed in his light blue scrubs and a puffy white theatre cap, holding a styrofoam cup full of steaming coffee. He would be ready to do the morning rounds and, annoyingly, would look fresh and awake no matter how little sleep he’d had. He was never demanding, never arrogant, you would just turn around and there he would be, sitting quietly in the corner of the ward waiting for you to notice him. I only wished that I could look that good after no sleep and I was half his age.

Despite the gruelling hours, I found myself loving that transplant job. I was moved by what you could do for someone by replacing their liver. The results were powerful and immediate. These people were literally days away from dying and within two weeks they would be walking out of hospital almost as good as new. Where there was no hope, there was now plenty. Suddenly they could return to work and there were birthday parties and having children and grandchildren to look forward to. It was like there had been a stay of execution. The other thrill was the calibre of the surgery and the prowess of the surgeons and I wanted to be just like them. My aspiration to be a bowel surgeon specialising in proctology started to waver and thoughts of doing liver transplants as a career occupied my mind. I had experienced the ‘call of the bile’. Transplant jobs only came up at the PA three or four times in a lifetime. Never in a million years did I consider that I would be good enough, so I kept my feelings to myself.

My husband Andrew, however, was not so sure about my new-found career direction. On the rare occasions that he saw me in those six months, he told me in no uncertain terms that it would be over his dead body that I would do transplant as a career. We hadn’t been to a movie or out for dinner in months and whenever we tried, the night was ruined by constant phone calls. Andrew would even drive me to the hospital in the middle of the night when I was so tired that I thought I might fall asleep at the wheel. I somehow thought that I was still safe enough to look after the patient I was going to see. Andrew was definitely looking forward to seeing the back of the transplant job forever.

The night that changed the course of my life occurred in early December at the Transplant Christmas Party. Everyone was having a great time, but I was not drinking because, as usual, I was on call. Professor Lynch came over and asked me to join him at his table.

‘I hear you want to be a liver surgeon,’ he said. This hit me from left field because I hadn’t really told any of the bosses about my aspirations, just anyone else who would listen. Clearly word had filtered up. ‘We think you have been doing a good job and I’d be happy to arrange a liver transplant position for you in the USA with a view to coming back to work with us,’ he said.

My mouth was opening and closing like a fish. No words would come out. Was this really happening? To live and work in the USA was my biggest dream and I was being offered that and what sounded like a career.

‘Let me get you a drink and we’ll discuss it more,’ he was saying. ‘What do you want?’

My mind was racing, my heart beating out of my chest with excitement and it was like I had left my body and was watching the scene play out from above. All I could think was that I was on call and couldn’t drink. I felt so flustered that I could not will the name of any type of alcoholic drink to come out of my mouth.

‘Ccccoke, I’ll have a Coke,’ I eventually managed.

‘A Coke?’ Professor Lynch grinned as if my answer was a little immature. ‘Is that it?’ He laughed and with that I thought I had lost my job over an undesirable beverage choice.

Professor Lynch was always thinking ahead and that night, six years before I would start as a surgeon in the PA Transplant Unit, he was making his succession plan. Was I really being considered as a future part of this world famous team? I was just a girl from a small town who didn’t think she was very special – it just could not be true. Any training in the USA was still more than two years away so I tried not to get my hopes up. Anything could happen and besides, people say things they don’t mean all the time. But Professor Lynch was a man of his word and would do everything that he promised. I raced home and it was one in the morning when I shook Andrew awake.

‘We are going to live in the USA and I’m going to be a transplant surgeon!’ I shrieked.

‘What, when?’ he mumbled.

‘In two years!’ I exclaimed.

Andrew muttered an expletive, rolled over and went back to sleep.

Rocky Mountain High

After that momentous night, I felt my life click into gear. I am a girl who likes a plan and the thought of having my career pathway sorted brought me great comfort. All I had to do now was get through the rest of my surgical training without any problems. I operated myself silly, did all the requisite exams and after the required four years of training, qualified to become a Fellow of the Royal Australasian College of Surgeons. This meant I could now go out and independently operate on people without having to check in with a boss every time I did so. Now I was responsible for everything I did.

Professor Lynch arranged for me to spend two years training to perform liver and kidney transplants in Denver, Colorado. Andrew and I did a lot of talking, mainly consisting of me telling him that life as a transplant surgeon would definitely be better than the difficult hours I worked as a transplant registrar. (Both of us knew that this was not really true.) But, being the kind of guy he is, Andrew knew that this would make me happy and so we set the new course of our lives. We were both really excited about moving overseas and starting a new adventure. After six months spent wading through United States government red tape and filling out a stack of forms as tall as the Rocky Mountains themselves, my dream of living like an American was finally coming to fruition. Andrew and I rented out our Brisbane home, packed our lives into four suitcases and boarded a plane.

Denver is the ‘mile high city’, sitting 5280 feet above sea level. It is a majestic place that floats like a mirage on the flat desert plain that collides with the base of the imposing Rocky Mountains. From every vantage point in the city there is a glorious view of 14 000-foot, snowcapped mountains that seem to stand on the shoulders of the smaller foothills in front of them. If I was religious I would use the words ‘God’s country’ to describe the State of Colorado. Standing amongst those peaks made me want to run with open arms through a field, singing like Maria Von Trapp in The Sound of Music.

Hot and dry like a desert in summer, landlocked Denverites can find it difficult to cool off without an ocean to retreat to. In winter, the temperature dips well below zero and people head to the ski slopes or the warmth of an open fire. Because it is sunny most of the time, the snow melts to a manageable level, keeping the streets relatively passable. Snow only collects on the shaded side of the houses and trees, creating a beautiful patchwork effect. The whole of Colorado is a sporting wonderland and Denverites are very outdoorsy despite the cold. It is the State with the lowest rates of obesity in the USA – virtually everyone manages to either ski, hike, ride or climb. Because of this, predicting the weather in Denver is a very serious matter and it was vital to know what was going to happen each day before heading out. It was not uncommon to ride my bike to work in the morning in bright sunshine and emerge in the evening to find the grey snow clouds enveloping the city in a blizzard. This could turn the evening commute into a slippery nightmare and if I was caught without the necessary cold weather gear, things could get dangerous.

As well as snow, Denver’s position on the edge of Tornado Alley meant that violent storms would whip up on the plains and sweep through the city with very little warning. Thunderous sirens would sound from the rooftops of schools and everyone would take cover in their basements or in the centre of sturdy buildings. When I encountered this alarming sound for the first time, I had no idea what it was. We were quite close to the US military’s NORAD facility, so for a little while I thought it might be an air raid siren telling us that we were under attack. I looked to the skies half-expecting to see World War II bombers flying overhead. During these tornado warnings, all the patients would be moved out of their rooms, away from the windows, and into the central corridors of the building. No sooner had we done it than the threat would be over, and we would have to move them all back again. The tornado would have touched down elsewhere and even though we were safe, somewhere a random city block or two would have been flattened in a matter of seconds.

My new position in Denver was that of Solid Organ Transplant Fellow at the University of Colorado Health Sciences Centre. The transplant division at UCHSC is a small but very prestigious unit. It has some of the best long-term survival results for liver transplant anywhere in the world. It was the hospital where the father of liver transplantation, Thomas Starzl, performed the first liver transplant in the world in 1963. That first patient did not live long but Starzl was undeterred. Buoyed by the success of his kidney transplant program, he stared down a tidal wave of criticism and carried on until he had a successful outcome. The first liver transplant operation that produced a long-term survivor did not occur until some years later. After a lot of internal problems, Dr Starzl moved his transplant program to Pittsburgh in 1981 and the Denver unit temporarily fell by the wayside.

In the late 1980s it was resurrected by the current director, a formidable surgeon and Starzl acolyte named Igal Kam. As liver transplants gained widespread acceptance, Starzl was training surgeons from around the world so they could return to their home countries and start transplant programs of their own. Dr Kam was an Israeli by birth and attended medical school there. After training with Starzl he planned to return to Israel to set up their first liver transplant unit. But he soon fell in love with life in the US and after a short stint back in Israel to perform that country’s first liver transplant, he decided to return and make the US his home. Dr Kam saw an opportunity to rekindle Denver’s abandoned transplant program. This must have been a difficult time for him as a foreigner restarting a somewhat controversial and expensive service. Like all people trying to succeed in an adopted country, trust has to be earned and a reputation must be built. Over the ensuing years, Dr Kam has turned the University of Colorado Hospital Transplant Unit into a stunning success.

Professor Lynch had trained right alongside Dr Kam in Pittsburgh, and being Fellows together in Starzl’s high-pressure unit was a bonding experience. The two of them had become close friends and it was this connection that led me to Colorado. It was common practice for jobs like mine to be arranged on a word of mouth basis. This avoided the risk of taking on a trainee who turns out to be a liability to the unit. No one would dare send an underperforming surgeon to work for a friend. I just hoped that I would live up to their expectations. It was agreed that I would be given at least a year of work with the possibility of extending to two if I fitted in well.

I accepted the position knowing that I would not initially be paid for my work. A drug company was kind enough to give me a small stipend to get me started, but I would have to fund the rest of the year myself. There are not too many jobs where you reach the top of your profession but go to the bottom of the pay scale. However, it is usual that this is the arrangement for surgical fellowships and my payment was to be well trained in liver transplantation. Going without a salary involved much deliberation for Andrew and me. We had just bought a house in Australia and had a hefty mortgage to support. Our friends and parents thought we were crazy. But the chance to experience living like an American was just too good an opportunity to pass up. It was worth more to us than money; I would never have let it go. So, we got a loan and extended the limit on our credit cards and tried not to worry.

As luck would have it, the moment our feet touched US soil, the Australian dollar plummeted below 50 US cents and we found ourselves in a financial mess. Buying a pizza for dinner worked out at roughly 40 Australian dollars. After the first year in Denver, it looked pretty unlikely that Andrew and I would be able to keep our heads above water. Fortunately, I had worked hard enough to prove that I was a valuable member of the department and Dr Kam found a salary for me. This allowed us to stay an extra year and I am so grateful to him and the other surgeons in Denver who helped me out.

Two younger surgeons worked alongside Dr Kam and rounded out the team in Denver: Dr Tom Bak, a laidback local graduate trained by Dr Kam; and Dr Michael Wachs, a graduate of Harvard Medical School who did his transplant training in San Francisco under the formidable transplant surgeon Dr Nancy Asher. She was legendary in transplant circles and was one of only a handful of female transplant surgeon role models. I had heard the stories of her scrubbing out of surgery in the middle of a case to breastfeed her baby who was waiting with a nanny in the room next door. I also heard that she once handed her baby to Thomas Starzl to hold when she had to deliver an important lecture at an international meeting. This is what I wanted to be like, combining surgery and motherhood. I knew it could be done.

These three men between them were doing more than 60 liver transplants, along with 150 kidney and ten pancreas transplants each year. In addition, there were the dozens of middle-of-the-night donor surgeries that kept them working very long hours indeed. Because of the sporadic nature of transplants, there were times when they didn’t sleep for days and then there were weeks when there was ample time for a round of golf each afternoon. I was to be the first Fellow to work for them in some years and these guys were not used to having the encumbrance of someone like me who still had her training wheels firmly in place. All the surgery they did was on their own terms; there was no one to blame for any problems but themselves. Teaching junior staff adds an extra level of stress and takes a lot of effort. Not only does it slow things down, but, as I have found out now that I am a teacher, there is the deep anxiety of watching a trainee surgeon fluff around, sometimes making an operation far more difficult than it needs to be. My arrival suddenly thrust them all into this situation. It was my job to earn their trust by doing all the essential but less than glamorous tasks like ward work, donors and weekend rounds, so I could prove it was worth their time to teach me.

Andrew and I arrived in Denver in July, the middle of the US summer, the customary time to start a new job in the States. We were met at the airport by Jane Biglin, the office manager of the transplant unit and the only person we had been in contact with. Via about a hundred emails, Jane and I had managed to arrange my new life. Aside from a quick visit to Colorado about three months before, where I briefly met my future mentors, I hadn’t actually spoken at length to anyone in my new place of employment.

Over the internet we had agreed to rent a basement apartment in the cosy home of a former transplant nurse called Ann Kirby. Ann was an adventurous Irishwoman who had backpacked all over the world. When she arrived in Denver she had fallen in love with the mountains and the people and had made her life there. We became friends with Ann right from the start probably because we had the mutual bond of living far from our original homes. Her experience of settling into a new country made our transition just that little bit easier.

For us sun-loving Australians, our new subterranean apartment took a great deal of getting used to. A common feature in American homes, these basements typically had the same floor area as the house above, but buried threequarters underground. Rooms had narrow horizontal windows just beneath the ceiling that allowed just a little light to peep in whilst giving a limited view of the outside world. In winter, the snow piled up against the windows, dimming the light and casting a grey pallor over the basement rooms, making it pretty claustrophobic. In our basement there was only one entry and exit via a narrow set of stairs and I was petrified of being caught down there in a fire.

We spent that first week touring Target, Wal-Mart and various garage sales to source the very best budget furniture we could find. Before long we were watching our tiny TV on $5 lawn chairs and the day I would start as a liver transplant Fellow drew closer. Even though I was always anxious before starting any new job, this time I was more nervous than I could ever remember. Would I be good enough? This was the big league.

You want me to start at what time?

I wanted to make a good impression on my first day on the job in Denver, so I arrived at 7 am. I was used to starting work around 7.30 in Australia, so I thought that showing up half an hour early would be a pretty safe bet and would let everyone know that I was keen. I nervously approached Dr Kam’s secretary and told her who I was and what I was there for. She didn’t seem to know much about me, mainly I think because she didn’t understand my very broad Australian accent. I repeated myself, this time in my best American drawl, and what had been lost in translation finally became clear. She informed me that everyone was in surgery, that I was late, and I should get down to the operating room – or OR – as soon as possible. They had already been transplanting for an hour. She went on to to tell me that the junior doctors’ work day usually began somewhere in the vicinity of 5.30 am. Did I hear her correctly, 5.30 am? Wow, that just didn’t seem right. My heart sank, maybe this job wouldn’t be so enjoyable after all. I was ushered down to the OR to find Dr Tom Bak plugging a liver into a patient, accompanied by his favourite music – Canadian rock group Rush – playing from speakers mounted at the end of the operating table. After two years I would eventually become familiar with all the songs in their catalogue. Dr Bak did not look up from his work and without any ado told me to ‘scrub in’. I had begun my job with no fanfare.

After my morning in the OR, I finally had time to sit down and talk with Dr Kam properly for the first time. On first meeting, he was abrupt, imposing and bore more than a passing resemblance to Marlon Brando (a picture of whom hangs behind his desk). What I quickly realised was that behind the gruff exterior there was a heart of gold and one of the kindest people I had ever met. Dr Kam was renowned for his superb surgical skills, and his blistering but side-splittingly funny remarks. ‘Yous guys suck’ was a particular favourite that I like to borrow now and then when I playfully reprimand my junior staff. Operating with Dr Kam was just as daunting as it was with Professor Strong. He expected perfection and in transplant, this is not unreasonable. Dr Kam wanted every movement to be precise and done exactly as he liked it. When I operated with him, every time I moved, he would say the word ‘careful’ at least one hundred times. ‘I am being careful,’ I often thought. Just not enough for his liking, I realised. I clearly improved over time and the ‘carefuls’ became a little less frequent. It was my aim to get through a case with less than ten of them being said.

In America, everything that I knew about work was different, even the language. I misguidedly thought that we would all understand each other when it came to medical matters. It was all done in English, right? How wrong I was. Temperature was in Fahrenheit, many of the blood tests had different reference ranges, and drugs I would previously prescribe in my sleep all had different names. Even the local bacteria were foreign to me and required a whole different set of antibiotics to treat them. The nurses would call me and tell me that someone’s blood sugar level was 70 and I would have no idea what that meant. I would make small talk on the phone whilst I hurriedly looked up the answer in a book. I was grateful for my devotion to TV shows like ER for teaching me the names of drugs like Versed and Demerol. I was supposed to be in charge of the residents and suddenly I felt like an intern again. I tried my best not to let my lack of knowledge show, but I’m sure they were on to me and wondered if I would survive the year. I bought lots of medical students’ textbooks in that first month and did a fast refresher. It seemed I was a pretty good actor and before long the words ‘Run in the Neosynephrine stat’ or ‘Order a CBC and Chem7’ rolled off my tongue like I had been saying these phrases my whole life. After a few months no one seemed to be talking about the new ‘Ostralian’ girl any more.

I quickly discovered that the early start times were no mistake and that everyone did indeed front up to work at ungodly hours, shaking the patients awake to ask them how they were feeling. ‘Tired, you idiot,’ was the usual response as they cracked open one eye with disgust. This predawn medicine was a bit of a comedy because by ten in the morning we were usually being flooded with calls from the nursing staff; the patients had woken up properly by then and had had the time to consider what was really ailing them. I was used to working hard, but not quite this hard. As soon as I had assimilated enough to warrant a say in things, I rationalised these nocturnal ward rounds and persuaded everyone that a much better idea would be to all go around together at 6.30 and then head off for a team breakfast of burritos smothered with green chilli. We also came up with the brilliant team-building innovation of attaching cup holders to the chart trolley so we had somewhere to rest our supersized cups of coffee that were essential heart-starters at that hour of the morning.

There were many other differences. Scrubs are the shapeless, pyjama-style shirts and pants that surgeons wear to avoid getting blood and guts on their clothes. In Australia I was used to wearing scrubs solely in the OR. It was forbidden to wear them on the wards or to clinics, so I was used to changing clothes several times a day. In the US, though, it was standard practice to wear scrubs everywhere: on rounds, in surgery, to restaurants and to the supermarket. You simply put them on in the morning and fell asleep in them at night. If I was going to see patients on the ward, a long white coat with my name embroidered on the pocket was worn over them in an attempt to make them look a little more professional. Surgical scrubs were obtained from a vending machine. Wearing scrubs full time was a revelation to me. When they got a bit smelly, I exchanged them for a fresh set from the vending machine. I didn’t have to worry about buying nice work clothes and, best of all, there was no washing.

‘I love scrubs,’ someone once said to me as they wiped their greasy chicken-stained fingers over them. ‘It’s just like wearing a big napkin.’

Denverites are very kind and I quickly made friends. They seemed to be endlessly fascinated by Australians, especially the way we spoke. They made merciless fun of my accent and they loved the way I cursed when I got upset. The phrases ‘that just shits me to tears’, ‘what a wanker’ and ‘you’re a complete tosser’ particularly cracked them up. These insults didn’t quite have the same impact when delivered with an American accent. They couldn’t figure out the appropriate context to use them in, either, yelling out across the crowded cafeteria: ‘Hey Slater, you wanker, can you bring me some ketchup?’ It was in serious medical conversations, though, that my accent became a problem. During surgery I was often misunderstood when I asked for an artery clamp (said in Australian-speak as ‘artry’) and when I said the word melaena (meaning a sticky black poo in Australia and a girl’s name in the US) I was laughed off the ward round. I asked someone if I could nurse their baby and they nearly called child protection (to nurse a baby in the USA means to breastfeed it). Even my name was an issue. When I said it, what they heard was ‘Kellee Slider’ and they would always ask me to repeat it. My accent was distracting and it detracted from patient care. Instead of listening to what I said, everyone would listen to the way I said it and I found myself misunderstood at every turn. I soon decided that I would try to speak with an American accent when I was not at home. I thought it sounded ridiculous, but because they were not used to hearing anything else, my colleagues didn’t seem to notice. So I discarded the Australian habit of leaving letters out and pronounced absolutely every letter in each word and rolled my r’s over like a local. Again I was thankful that my years spent sitting in front of American sitcoms were finally paying off. My darling husband, with his pronounced Aussie accent, had a great deal more trouble making himself understood. He would take a pad and pencil with him and whenever he wanted to order dinner from a fast-food restaurant, he would write down ‘large pepperoni pizza’ and push the note across the counter, pretending he had a sore throat.

For someone from tropical Queensland, simply getting to work in Colorado offered new and unexpected challenges. Pretty soon after arriving, Andrew managed to get a job entering data at a pharmaceutical company. This meant he needed to take our only car. Because we were close to broke and couldn’t immediately afford a second one, I rode a bicycle the mile to work each day. With the early starts in the wintertime, it was dark and literally freezing cold. I would layer myself with thermal underwear under my bright green scrubs, add a ski jacket and wrap a scarf around my head so I could just see enough to ride. I would pedal as fast as I could down the freshly ploughed snowy streets and arrive at work just before I froze to death. If a patient was bleeding or unwell in the middle of the night, however, my trip in to the hospital would have to be faster than my bike could manage. With no undercover garage to park in, this meant digging the car out of the snowdrift that partially buried it every winter’s night. I would start it up and hop about, freezing my ass off as I waited for the engine to warm up enough to be able to drive. I would then need to take a scraper to the windshield and chip the heat-softened ice off the glass. When someone was really sick and threatening to die, there was just no time for this procedure and I would be forced to drive with my head thrust out the driver’s side window to see where I was going. I had a really good story rehearsed for the police if they ever pulled me over.

Kellee, there is a donor

Imagine you are going about your day, picking up the kids from school, stacking the dishwasher or sitting at your desk at work. Suddenly, like a bolt from the blue, you experience a headache that is so blinding you would swear you had been trodden on by an elephant. You clutch your head, a dark curtain comes down over your eyes and you collapse on the floor. That terrible pain is the last thing you remember, ever. You are discovered lying there, barely alive, and they rush you to the hospital. You are put through a CT scan and the doctors discover what everyone has feared – your brain is swollen and bleeding, the result of a weakness in a blood vessel, a ticking time bomb you’ve carried since birth and it has detonated today.

This is how many organ donors die and after this, I become involved in their stories. This kind of death will change the lives of many people.

During my time in Denver, my daily job was to remove organs from people who’d died. Donors are where junior transplant surgeons really learn to operate. We all have to do dozens of these cases to earn our stripes. Even though I had scrubbed-in to assist in many liver transplant operations by now, only after I had mastered donor surgery would I be allowed to place even one stitch in a liver transplant patient. In some countries, a junior surgeon will spend several years doing these types of jobs before they are finally considered worthy of being allowed to do a crucial part of the operation. I wanted to prove that I had what it took to be allowed to do a transplant and I resolved to keep doing donors until I fell down where I stood. Donor surgery is definitely a young person’s game, because of the time of day that they are done, so as soon as the most junior person in the team is up to speed with the operation, the task immediately falls to them. In the States, that junior person was me, and within a month of arriving in Denver, my phone rang every third night and Dr Kam’s thickly accented voice would tell me, ‘Kellee, there is a donor.’

There is a very visible side to transplants, with slick advertising campaigns depicting grateful recipients enjoying their new lives. It is very important to constantly remind people about the benefits of organ donation. Thanks to these messages, organ donation and people’s wishes are often freely discussed at dinner tables across the world. But what goes on in the actual donation operation remains a pretty mysterious thing. Many myths exist.

For the surgeon, a donor operation can be a really difficult task. When everyone else is sleeping, there are small groups of doctors and nurses hurtling around the countryside retrieving organs. Donation typically occurs in the middle of the night simply because that’s when the OR is available and it allows the actual transplant to commence in office hours when everyone else is fresh. There is nothing comfortable about doing it, either physically or technically. The procedure takes a really long time and usually involves travelling in a tiny plane in all weather conditions. It must always be done perfectly. Even a small mistake could potentially cost the life of one of the four or five patients waiting to receive the organs.

‘Doing a donor’, as we call it, is emotionally confronting for the whole surgical team. It takes a lot of resolve to cut open a dead person and take things out of them, albeit respectfully. Some cultures and religions still do not allow organ donation, and even in the West some people believe that organ retrieval from a corpse is an abhorrent concept. In our culture this seems to be largely due to a lack of education and the existence of vile stories about how donation is performed. I take a fairly pragmatic view of the whole thing. People die – it is a fact of life. They get buried in the ground or disposed of in an incinerator. The physical person is gone but their spirit will always be remembered by those who loved them. What a marvellous thing it is to be able to use these spare parts that would otherwise be wasted and thereby allow someone else an opportunity to have a happy, healthy life. If you think about it in any other way, it just does your head in.

It is a misconception that anyone who dies can donate their organs. You actually have to expire in a very special way. The brain has to die before the body in a process called, funnily enough, ‘brain death’. The patient must also die either in the hospital whilst on a breathing machine or on the way to the hospital whilst oxygen is being given and the heart is still beating. It is not possible to use the organs of someone who is found stone cold dead on the floor at home. Brain death means that the part of the brain that controls breathing must be so severely injured that there is no hope of recovery. This can occur after a stroke or a head injury caused by an accident, murder or suicide. Amazingly, as long as it has oxygen, the heart will continue pumping independent of the brain, beating under the steam of its own primitive electrical impulses. The problem is, however, that the brain controls breathing. If the damage is bad enough, the brain will halt the drive to breathe and brain dead people become completely dependent on a ventilating machine to take over this function. Within a few moments of turning the machine off, the breathing stops, the heart will become deprived of oxygen and a few minutes later it will stop beating. Almost straight away, every organ in the body begins to die; blood clots form in the tiny veins, cells burst and spew out their toxic contents. Bacteria move in and within a few minutes the body starts to rot. When you are doing a donor, the smell of decay appears pretty quickly.

Many people have told me that, ‘I’m not going to donate my organs because I’m worried that I might not really be dead.’ Trust me, testing for brain death is taken very seriously and there are multiple checks and balances to ensure you really are dead. If a patient does not pass any one of these tests, they are not brain dead and donation cannot occur. This is rock solid and is the cornerstone of donation.

Aside from the requirement to be brain dead, the number of dead people suitable to donate dwindles again because there are lots of characteristics that make people’s organs instantly unsuitable for transplanting. Donors over 65 years of age are often not optimal because – well, they are just too old. Old organs have endured the rigours of a long life and definitely have a ‘best before’ date. They don’t work as well, especially when transplanted into a very sick patient. Recently, I was standing in the queue at the driver’s licence office. The couple ahead of me were well into their 80s and both in wheelchairs. They were having a spirited argument over whether or not they should check the organ donation box on their licence application. It took all my willpower not to lean over and whisper that it would be OK if they gave it a miss. Some other donors have HIV or hepatitis B or C and are usually not suitable unless the recipient has the same virus. Just like a blood transfusion, these viruses are transplanted right along with the liver.

The organs of alcoholics, smokers or the obese can be unsuitable too because of the ravages of these abuses. Some people are too overweight to donate because fat in the liver means that it won’t work very well. People who have died of undiagnosed infections cannot be donors and, finally, any patient who has had cancer is usually unsuitable for transplant. There have been cases of recipients inadvertently receiving organs with cancer cells in them and quickly meeting the same fate as the donor after the transplant. All of these factors can make the total number of dead people who can donate very small indeed, because it is quite unlikely that young, healthy, non-drug-taking thin people will die.

For the relatives keeping vigil at a beloved family member’s bedside, making the decision to donate must be agonising. Aside from a breathing tube in the mouth, brain dead people appear to be simply asleep. They are warm, their heart is beating and their chest will rise and fall. They look peaceful and I trust they are. I’m sure that the families who are lovingly holding their hands and stroking their hair must hope that the doctors are wrong and that their eyes might suddenly flutter open. It is not possible for me to comprehend how a family makes a decision to donate at such a time. I’m sure that there is some comfort if the family knows that organ donation was something that the patient wanted to do if the unthinkable happened. Maybe the idea that a little part of their relative will live on in someone else is a big motivation. Their grief is difficult to watch and I think these families are very brave.

Once a family gives the go-ahead to donate their loved one’s organs, the Intensive Care doctor calls the organ donation agency. In the United States this is the United Network for Organ Sharing (UNOS) and in Australia it is Donate Life. In the US, this organisation is run by a board alongside the federal government and is completely separate from the transplant hospital. This is of key importance as it means that no transplant surgeon can ever be involved in decisions about which patients should be donors. Within UNOS there are ten Organ Procurement Organisations (OPOs) covering the 50 States whose job it is to distribute organs via a central computer system. When an Intensive Care Unit notifies the OPO there is a brain dead patient, a nurse from the OPO is immediately dispatched to that hospital. These specially trained nurses talk to the family and check the entire medical history of the donor. If it all looks good, the OPO nurse offers the heart, lungs, liver, kidneys, bones, pancreas, eyes and small bowel, frequently to many different transplant units. In the US, all patients listed for transplant are entered into a central database. When a donor becomes available, their vital numbers are also entered and a list of suitable recipients in the local area is produced. The transplant surgeon representing that patient is called and informed about the offer. That surgeon may accept or refuse that organ for that patient based on many medical factors – for example, the top listed patient may have an infection and not be well enough to have a transplant. If the local unit does not want to use the organ for that patient, then it is offered on to the next hospital in the area with a suitable patient and so on. Literally dozens of telephone calls are made and each donor offer can result in 12 to 24 hours of work even before the donation operation commences.

Each organ has a slightly different procedure for matching to a recipient. For livers, it is surprisingly easy. All you need is the same blood type and a reasonable size match and that’s it. It is difficult to put a big liver into a small person because it simply will not fit. Conversely, you cannot transplant the liver of a 55-kilogram woman into a 105-kilogram man – there may not be enough liver for him to survive. The only time we go outside of size criteria is for children. In order to fit, a smaller piece must be cut from a whole adult liver. The other neat thing we can do to make a rare resource stretch further is slice a liver in half in a type of two-for-one deal. This way, both an adult and child can be transplanted from one liver. This can’t be done with all donated livers, though, and for this technique to work well, only perfect livers from fit young donors will do.

The matching process for hearts and lungs is also pretty simple. Again they are allocated according to blood type and size. Only a certain sized organ can fit inside the fixed cavity of a person’s chest. Kidney matching is slightly different and more complex. Because there are two kidneys in each donor, two patients can be given the opportunity to get off dialysis. Every person who is waiting for a kidney transplant in the United States has their blood tested for a variety of special characteristics. This information is stored in the computer. When a donor kidney becomes available, it is tested for the same characteristics. This individual combination is then matched against the recipient database and occasionally a perfect match comes up. This is a little like winning the lottery for the recipient because the match makes the risk of rejection lower. The matching kidney is packed up and flown to wherever that recipient is in the country. To keep things fair, the next time there is a kidney in the state receiving a perfectly matched one, that organ is ‘paid back’ to the state that lost the kidney. A bit like, ‘I’ll give you one of mine, if you give me one of yours.’ If there is no perfect match for a kidney in the whole of the country, the kidneys go to the next closest match in the donor’s home region.

In Denver, it was my job to retrieve organs from hospitals throughout the States of Colorado and Wyoming to the north. Ideally, a liver needs to be transplanted within eight to 12 hours of it coming out of the donor and a kidney is best put in within 24 hours. Any longer than this and the organs do not work very well, so it is very important to have a reliable means of transport to get back as quickly as possible with our precious cargo. For donors in town, we circumvented Denver’s often horrendous traffic by travelling in a forbidding black Lincoln town car resplendent with sirens, lights, tinted windows and the words organ transplant team emblazoned down the side. Our driver would give us a white-knuckled ride with sirens blaring as he flew across intersections and weaved through traffic. I would remind him that we didn’t have to go so fast – the patient we were going to be operating on was already dead and we didn’t want to join them.

But the enduring image of organ donation seems to be of teams of surgeons flying all over the countryside toting their organs in beer coolers. I frequently had to climb aboard a plane and fly to all manner of tiny hospitals deep in the heart of the Rocky Mountains. Medical students always get very excited when they get the opportunity to go on one of these flying retrievals. They tell me how glamorous it all is. I suppose it is for about a minute (take-off is pretty cool) until reality soon sets in and you realise you will be awake all night, be absolutely starving, dirty with sweat and blood, with the smell of a dead person lingering in your nostrils. Doing donors in Colorado meant that I would miss a night of sleep every three days. It was gruelling work. Because most donors happened after midnight, I would try and get a few hours’ sleep before heading off to the airport. While this ‘power nap’ always sounded good in theory, it was incredibly difficult to nod off because of the anticipation of being up and working all night. My mind would race, thinking about how on earth I would pay back my sleep deficit and still fit in everything else I had to do the following day.

My initial encounter with donor surgery in Denver was of course on my first night on the job. I was attending the annual transplant ‘Cook Out’, a team-building event held for the staff in the transplant unit. Vast quantities of seafood, steak and corn on the cob were roasted on an open fire and consumed with lashings of melted butter. As often happens at these events when everyone is enjoying themselves, a telephone call came in saying that there was a donor. Someone had died of a brain haemorrhage in a hospital on the other side of the Rocky Mountains, so a trip in the Learjet was required. Because it would be my first donor in America and the first time the bosses would have an opportunity to see my work, one of them had to accompany me. They drew straws and the lucky recipient of the short one and I reluctantly left the party early to get a few hours’ sleep before we had to fly.

Unfortunately for my boss, as well as having the task of taking a donor novice through what is a complex operation, he also developed a dose of gastroenteritis that night. He spent those few hours before we left suffering violent vomiting and diarrhoea and, by the time we boarded the jet, he was not in top form. He sat slumped in the back of the plane wearing dark glasses and looking as though he might throw up at any moment. One of the donor nurses suggested that we should give him a litre of intravenous fluid to freshen him up. This is a pretty common remedy for gastro amongst doctors and considering I was eager for him to feel well enough to help me get through my first donor, I was right on board with the idea. It was decided by everyone that a great preliminary test of my abilities would be to see whether or not I could put an intravenous (IV) line in my new boss during take-off. As the plane lifted off, I plunged the needle into his arm. The blood flashed back and I slid the slender plastic tubing into his vein. Thankfully I didn’t miss or I may have been out of a job in the first week. I set up the IV and ran the restorative fluid through. It was just the ticket to revive him for a few hours and we had a very successful trip. I was a little worried about the possible implications of operating with a supervisor who looked to be in worse shape than some of the patients, but it then occurred to me that the patient we were going to operate on was already dead, so it probably didn’t matter all that much.

Our jet flew out of a small commercial airfield called Centenary. Contrary to what most people think, our aircraft was not like a ‘rock star’ jet with cute flight attendants, delicious food and in-flight movies. It was a tiny speck of a thing with five passenger seats and two pilots sitting elbow to elbow up front. There was no standing room and no toilet. Our identification was always checked by the pilots prior to boarding. This was post-9/11 America and security was tight, even on small private planes. The year before I arrived, the Denver donor team was the first plane allowed back in the sky after the total flight ban of September 11. They had a fighter jet escort so they weren’t inadvertently shot down by a twitchy US military.

We would fly in all types of weather conditions. Because of the urgency in getting the organs back to base, we could not wait for inclement weather to pass. There were many nights when we took off in blizzards or ascended turbulently through violent thunderstorms, only to emerge above the clouds and be treated to a spectacular lightning show from above. Occasionally, when we returned our plane would have to land at an alternative airport due to bad weather and we would have to get our car with its sirens to meet us and take us back to the hospital in a heartstopping ride through Denver’s snowy streets. I developed quite a fear of dying in that small plane. There have been a few tragedies where entire transplant teams have been lost when their aircraft have crashed. As the donor surgeon in charge, it was my call if, after consulting with the pilots, I felt the weather was too dangerous to head out. I would much rather let the organs go than risk the lives of my team. Because we were constantly flying over the mountains, I would always take a ski jacket, food and water on the trip. Somehow I thought it would be a terrible shame to survive a crash in the mountains only to die from hypothermia or starvation. I think I had watched the movie Alive (about the Uruguayan rugby team who crashed in the Andes and ate the dead bodies of their friends) one too many times.

We would fly to some extraordinary places on those trips, including the town of Leadville. This tiny dot of a town boasted the highest altitude airport in north America, at 9927 feet. Deep in the heart of the Rockies, it was wedged in a valley between two towering mountains, and our little plane would have to descend rapidly between the peaks. Because of the altitude, getting out of the plane was literally breathtaking. This place was so remote that there were no taxis in the middle of the night to ferry us into town. We laughed when we got our instructions to jump in an old school bus parked by the side of the landing strip and drive ourselves to the hospital.

Once we had the organs in our possession, I would haul the heavy coolers back to the operating theatre where the transplant team would be waiting for me. We would then prepare the liver for transplant and I would assist one of the bosses to sew it in. I would then often switch theatres and help sew in at least one of the kidneys into another recipient. I would have been awake, more or less, for 36 hours.

Even worse than the sleep deprivation and travel, the most awful part of donor surgery was undoubtedly the delays. From when I first heard that there was going to be a donor, it could sometimes be 24 hours before the surgery would actually commence. The donor would be kept breathing on the ventilator in the ICU while all the tests were run, family permissions sought and all the recipients called in. Donor surgery was also frequently delayed whilst waiting for relatives to fly in from around the country to say their goodbyes. The problem, albeit selfish, was that as soon as I heard about a donor, I’d rearrange the following day knowing I would have to fit in a sleep somewhere. With every small delay, I would have to change my plans again and again. So many times I would be getting in the car at two in the morning only to get a call telling me that there would be a delay of an hour or more. Not enough time to have a bit more sleep or do anything else other than just wait and watch late-night infomercials. I have bought more than my share of wondrous cleaning products over the years from watching these shows.

Then there were the delays that would break your spirit. We would arrive at a remote hospital in the middle of the night and be told that a more urgent case had just come in. Because our patient was dead, the emergency would take priority and we would be bumped for several hours. We would have to hunker down in a darkened tea room on the same 20-year-old cracked vinyl chairs that are in every hospital and listlessly drift in and out of sleep. We would then be shaken awake a few hours later and, with our eyes bleary and our tongues furry, spring into action to do a three-hour surgery. The poor old pilots would also have a long night sitting around waiting for our return. They would sit huddled in the plane or in some late-night coffee shop, trying to stay warm and awake. We were always so happy to see them when we came back to the plane because they would greet us with styrofoam boxes full of fried eggs, bacon and hash browns sourced from Denny’s restaurant – the only place open 24 hours in many American towns. Doing donors took a lot of energy and, after being awake all night, the greasier the food, the better it tasted, and we would feast like we hadn’t eaten for days.

How a donor is done

Adoctor I passed in the hall at a donor hospital once asked me, ‘Is that my patient you have there in your cooler?’ I chuckled because my strange job reminded me of the grisly scene in the movie Fargo where heavily pregnant police officer Marge Gunderson matter-of-factly says, ‘I guess that was your accomplice in the wood chipper … and it’s a beautiful day …’ It was usually late at night when we slipped into the donor hospital as discreetly as we could. We came and went via back entrances and dark alleyways just in case the family of a donor might catch us leaving with a cooler filled with organs from their relative. It was important too not to discuss a donor whilst we were taking a taxi to and from the airport in small towns because there was a fair chance that the driver might know the donor, their family or the details of the death.

Once I was up to speed with donors, Dr Kam left me to it and every case was mine to refuse. My constant companion on these frequent trips was a delightful fellow named Steve Kelly. He was not a doctor but came from a scientific background, and had become a professional surgical assistant. He was lovingly known wherever we went as ‘Dr Steve’. He had been doing donors for so long that it was impossible to tell that he wasn’t a surgeon. I was always happy he was there and he was the one who taught me how to become proficient at this very technical operation. Because he was in his late 50s and looked far more experienced than me, the nurses at the donor hospitals always spoke to him as though he was the person in charge. He was the nicest man and such a great teacher that I found it hard to correct them and rarely let on that I was actually supposed to be in charge. I would just smile, let it go and hope my actions would provide some evidence of my ability.

Organ donation is a much misunderstood procedure. People have told me that they think we do a ‘slash and grab’ to retrieve organs and that we ‘hack’ people open to plunder them of their bits and pieces. This isn’t helped of course by the wildly untrue tales of hapless tourists waking up in ice-filled baths in South American hotel rooms to find they are missing their kidneys. The reality of donor surgery could not be more different. Removing organs for transplant is a careful operation, performed in an operating theatre with an anaesthetist, surgeon, assistants and an army of nurses. It takes hours of hard slog and if it wasn’t for the dead body on the operating table at the end, the casual observer would be forgiven for thinking that we were performing any other routine surgery. The utmost reverence is paid to the deceased and even the most minor details are thoughtfully considered. Our aim is to leave the donor looking like we have not been there. I wait patiently in the tea room at the end of the case while the nurses wash the body and comb the hair. The long incision I have made is covered with a neat dressing. We cover the body completely with a clean white sheet and when we have gone, the family is able to come in and say their final goodbyes.

Despite all the respect that is paid, I still find donation a really gruesome task. I have done it hundreds of times and I think I will always feel this way. The donor team always uses the local anaesthetist and nursing staff, so in addition to your own emotions, you also have to deal with the reactions of the locals who are usually seeing this side of donation for the first time. At the smaller hospitals, many of the staff will have been involved in the patient’s care and may have formed a connection to them. It is impossible to prepare someone for the sight of a human heart removed from the chest when moments before it was still beating. Then at the end, before the wound is closed, there is the shocking appearance of a hollowed-out body devoid of its organs, when only a short time before they seemed to be a living breathing person. It can be so traumatic that I have seen theatre staff burst into tears during the procedure. I too still find it very sobering and try not to look back at the body once I have left the table. If you take the time to notice, often everyone in the theatre goes about cleaning up the room with their backs turned to the donor, trying not to think about the sad scene.

Anaesthetists can also have a really hard time because donors are the only cases where they are not there to perform their usual task of keeping the patient asleep, alive and pain-free. In donation surgery their job changes and they are there to make sure the lungs are receiving oxygen and to keep the blood pumping around the body using powerful stimulant drugs. During routine surgery, the anaesthetist is the first person to see the patient and the last one to bid them farewell when they deliver them to recovery. For donors, however, there is no recovery and the moment the heart and lungs are removed, the anaesthetist’s job is finished. The regular beat of the heart monitor that sets the tempo of the operating theatre abruptly ceases as the heart is stopped from beating by the preservation liquid running through it. There is silence in the room and instead of an operating theatre the atmosphere is more like that of a mortuary. It is completely unnatural for an anaesthetist to leave the theatre without their patient and I can tell that some have a hard time deviating from the routine. Many times they will stand firm at the head of the bed, looking a little unsure what to do next, mesmerised by the stunning sight of the organs being lifted out one by one. We thank them for being there and gently tell them they can go home if they wish.

One chap, obviously feeling odd that he had not run through his usual post-surgery checklist, asked me, ‘What was your estimated blood loss?’

I looked up quizzically, not sure that I had heard him correctly, and finally replied, ‘All of it, actually.’

He flushed with embarrassment when he realised what he’d asked. Another thing that anaesthetists do is give medication to paralyse the donor to stop them from moving. Yes, despite being dead, donors frequently move. It can really freak everyone out, me included. Donors have primitive spinal reflexes that cause them to twitch, move their hands and have erections. I just about passed out the day the anaesthetist omitted the paralysis medication and a donor’s hand twitched violently, slapping me hard on the backside.

There are usually two pairs of surgeons operating during donation surgery, one team for the heart and lungs and the other to take the liver, kidneys and pancreas. Other groups from the eye and bone bank come for the corneas and bones after the deceased has been taken to the morgue. When the donor is brought into the operating room, all activity stops while we check that the paperwork is all done and, most importantly, that the donor’s identity is correct. I don’t think that there has ever been a case of mistaken identity and it is my mission to ensure that there never will be. That would be difficult to live with.

The donor is positioned on the table in a rather unseemly pose, with their arms taped high above the head. This gives us lots of room to work. It can get pretty tight for space with the heart and liver teams working alongside each other and sometimes a sleep-deprived unfriendly rivalry results in toes being stepped on and elbows to the ribs. The body is opened via a long cut from the neck to the pubic bone and a noisy power saw is used to slice the breast bone up the centre. A metal frame is inserted into the gap and the chest is slowly cranked open. The heart is then fully on display, beating steadily in its sac. This is a showstopping sight and, exposed like this, the heart makes a soft slapping sound as it pounds away. At the same time, one of the chest surgeons passes a telescope through the nose and into the lungs to ensure the windpipe is clear and that the lungs are healthy. They are looking for cancer and infections that might render the lungs unsuitable to use. From time to time they even find some surprising things down there. One donor I went to met his end by crashing his Harley Davidson into a tree whilst riding to the Sturgis Motor Cycle Rally in Wyoming. Down his windpipe we found the piece of gum that he had been chewing at the moment of impact. He had inhaled it and it was wedged hard and fast. It was probably what killed him. Life can hinge on the smallest things.

Once the chest is cracked, it is my turn to spring into action. The abdomen is also propped open with a metal frame that fully displays the liver and bowels. A careful inspection is made of all the organs to determine if they are usable. Hopefully, there will be a smooth, rich red liver with sharply angled edges. A bad liver is one that contains too much fat that accumulates in little bubbles throughout the cells. These livers have rounded edges and are so fragile that they can bruise and split like a piece of overripe fruit if they are not handled gently. We call them pumpkins because of their golden colour when the blood is drained out of them. Sadly, fatty livers are all too frequently found as the waistlines of the western world expand, fuelled by our fast food diets. The fat damages the inner workings of the liver cells and causes liver disease. If a liver contains more than 40 per cent fat, it may not work very well and a very sick liver transplant recipient can have a slow and painful death if they receive one. A skilled donor surgeon must eyeball the liver and take all of this into account, literally deciding right there at two o’clock in the morning whether a recipient will live or die that day.

Once the two teams of surgeons decide that all the organs are good, we get down to the business of carefully dissecting their blood supplies out of the surrounding fat and breaking down all their connections to the body. The liver has a very complex blood supply and is different in every patient. The blood vessels to the liver have to be taken with as much length as possible so there are lots of options when it comes time to sew them into the recipient. Everything is detached as much as possible while the donor’s blood is still circulating. When both the chest and abdominal surgeons are ready, the anaesthetist gives a massive dose of a blood thinning medication called heparin that renders the blood as thin as water. This allows us to wash all the blood out of the body and replace it with the preservative fluid that makes transplant possible. This fluid is pumped in via tubes inserted into the major blood vessels in the donor’s abdomen and chest. This liquid is ice-cold and surprisingly sticky. It is called UW (University of Wisconsin) solution and contains a complex combination of salts and preservatives that prevent the cells in the organs from bursting when they are stored at a low temperature.

When everything is in place and both teams are ready, someone cries out ‘Cross-clamp!’ Then it is on for young and old as the clock is ticking. Up to this point, it has been a careful and considered surgery. Now it is all about speed. We move like Edward Scissorhands, chop, chop, chop. This is the trickiest part – to move fast without cutting something you shouldn’t. Our success is measured by the time it takes to get the organs into their new owners, because from this moment everything is dying. It all happens at once: the aorta, a hosepipe-sized artery carrying blood from the heart to the legs via the abdomen, is clamped; the inferior vena cava, the massive vein carrying blood from the legs to the heart, is severed and the donor is exsanguinated. Five litres of blood floods into the body cavities. At the same time, the hanging bags of preservation solution are run through, full speed. The blood in the veins is replaced by the ice-cold fluid and almost instantly the deep red colour of the liver fades to beige, the heart stops beating and the only noise in the room is the sound of blood being removed by the suckers.

The heart and lungs are lifted out of the body first. The heart surgeons cut the blood vessels that suspend them in the chest. Just before the windpipe is divided, the anaesthetist delivers several final puffs of air via the breathing bag in order to blow the lungs up to their full capacity. This stops the delicate air sacs from getting glued together during transport. The two lungs and heart are then lifted out of the chest, like fully inflated balloons. This is a clumsy block of tissue. Imagine trying to manipulate two wet pillows tenuously connected in the middle by a wobbly heart. It requires two hands to clutch the jiggly parcel and carry the organs to a waiting sterile table, wrap them carefully in three layers of plastic bags and bury them in ice. It is then my turn to free the liver from its last few attachments as fast as I can and place it into its own bags. Like the lungs, the kidneys are also delivered as a pair, but are separated into right and left once they are out of the body. They are bagged separately, the left one being the more favoured by transplant surgeons as its naturally longer blood vessels make it a little easier to transplant. Then we are done and I stitch the skin wound closed, gather the labelled and bagged organs, and hit the road.

In case you were wondering, yes, I have gone close to seeing an organ dropped on the floor. We were returning back to the University Hospital in Denver one night when we opened the trunk of the car and the cooler fell out, spilling ice and bags of organs all over the pavement. Luckily there were no breakages of the bags of organs; even though they were shaken, they were buffered from the impact by the fluid surrounding them. We hurriedly scooped them all up and stuffed them back in the cooler before anyone could see what had happened. They worked just fine.

When I returned to home base, the next hour was spent preparing the liver for transplant in a procedure called ‘the back table’. This is absolutely critical, because the moment the liver or kidney is lifted out of the ice by the transplant surgeon, everything has to be ready to sew it straight in. It is vital to get blood flowing through the organs again as fast as possible because the moment they start to warm up, they begin to decay. On the back table, any extra tissue and fat from the donor is trimmed off the blood vessels until they look a lot like glistening tubes of calamari. If the vessels are too short, they are made longer with spare arteries taken from the donor’s arms or legs. There are always a few little holes made in these blood vessels during the course of the donation surgery and these must be painstakingly repaired with fine blue nylon stitches. It is very easy to miss one or two of these holes when the organs are cold like this and they become pretty obvious once the organ is transplanted. Blood pours out of them and they have to be rapidly repaired at a time in the transplant when a lot of things are happening all at once. This bleeding can cause a great deal of chaos and the repair of these holes is usually accompanied by a little good-natured cursing of the backtable surgeon, especially if they have already gone home to bed and are not in the room to defend themselves.

Because every donor has slightly different anatomy, it is relatively easy to make a mistake when you take the liver out in the controlled cutting frenzy at the end of the donor operation. Any unrecognised error can sentence a recipient to months of problems after their transplant and may even result in death. The back table is the place where these potential problems are identified and sorted out. When I was learning, I certainly made my share of errors, inadvertently cutting the wrong thing at the wrong time. I would cop a mouthful from my bosses if I cut something I shouldn’t and would have to spend an extra hour on the back table, painstakingly sewing the severed ends of my blunder back together. Another boss, having made a few mistakes of his own, was more generous and would say, ‘That’s why stitches were invented.’

We have found a new liver for you

Can you imagine what it must be like to sit at home waiting for a telephone call that has the potential to save your life? Can you also imagine what it must be like to know that the call may never come and your life will just dwindle away? This is the daily reality for a patient on the liver transplant waiting list. When the telephone rings to say that there is a suitable liver available, I expect it must feel like escaping the hangman’s noose. Some patients will wait for more than two years for their reprieve to come. Some are so close to the end that they are in hospital when that offer of a precious organ finally arrives. One man was so near death that when I told him that we had found a new liver for him, he thought I was an angel sent from heaven to comfort him on his way to the pearly gates. Sadly, some patients will never get that wonderful call to come to the hospital to receive their new organ and they will die waiting.

Liver transplant is never a walk in the park for any patient. They will be on anti-rejection drugs for the rest of their days and these have side effects that can make life difficult sometimes.

A new liver also doesn’t always mean that everything will be all right. I tell people that transplant surgery is a lot like riding a roller coaster – there will be lots of ups and downs. Some will not even make it out of the gates, dying of complications in the first few weeks or months before they ever get to enjoy the benefits a new liver can bring. For a rare few, their new organ will not work at all and they will need to be urgently re-listed for a second liver that may not materialise in time. For the rest, some may have to endure multiple operations and painful tests; some may have their liver disease return; and, over time, some will even get cancers as the anti-rejection drugs reduce their ability to fight off deadly tumours. For all these reasons, a patient has to be really close to death to go on the waiting list for a liver transplant. Their chances of being alive in one year need to be higher with a new liver than with their old one.

The most common reason for someone to need a liver transplant is because they have cirrhosis. For many people, the word cirrhosis conjures up the image of a red-nosed alcoholic perched on a bar stool with the top of their butt peeping out of their shorts. But really, alcohol is only one of the causes and cirrhosis is simply the term doctors use to describe irreversible scarring of the liver. Cirrhosis and liver failure can be the result of anything that damages the liver: fat, viruses, immune diseases or genetic defects account for most cases. There is not a single person from any walk of life that it cannot touch and cirrhosis can occur at any age from newborn babies to 90-year-old great-grandmothers.

The liver has a huge job to do and it influences the function of every other system in the body. There is no machine that can duplicate its actions and so, unlike a kidney patient who can be sustained for a while with dialysis, there is no temporary solution to replace it should it fail. The liver makes protein to strengthen muscles and molecules that help the blood to clot. It makes bile to help us absorb our food. The liver removes all sorts of toxic products of digestion as well as breaking down many types of medications and drugs. It deactivates the ammonia produced by the bowel into a form that can be passed easily in the urine. It makes and stores sugar, vitamin A, D, B12, iron and copper and it regulates the cholesterol level in the blood. It even makes a hormone that controls blood pressure and, in a foetus, it makes blood. So, it is really pretty important and when a patient has cirrhosis, all these systems will slowly fail and the body will fall apart.

We are all born with far more liver than we need and in fact I can easily remove 70 per cent of a healthy person’s liver and they will notice no difference at all. The remaining section will rapidly grow and within six weeks the liver will be back to its normal size. When someone has cirrhosis, the liver cells that have been repeatedly injured over a number of years will eventually die and become replaced by hard scars. This happens very quietly, in the background, and quite unbeknown to the victim. A fighter until the very end, the liver continually tries to repair itself, forming little nodules of new and hopeful liver cells among the sea of scar tissue. As it does this, its appearance changes from being smooth and glossy to shrunken and knobbly.

It is only when the liver has dwindled to around a quarter of its former self that signs begin to appear that something is seriously wrong. These symptoms make a lot of sense if you can understand what is happening inside the liver during this process of scarring. The thousands of blood vessels that run through the liver are trapped in the scar tissue and become convoluted and squashed. The resistance to blood flow increases so much that the blood will eventually move in reverse. When this happens, the blood that usually gets back to the heart via the liver must find another way. Normally insignificant veins that meander through the abdomen will expand and become conduits for massive volumes of blood. These varicose veins are paper-thin, under explosive pressure, and they coat all surfaces of the bowel in an intricate purple spider web. These little veins are simply not designed to carry so much blood and there are consequences. These can be as minor as spontaneous nose bleeds or catastrophic when the presence of liver disease can announce itself in a most spectacular way. When the fragile walls of these veins are exposed to acid in the stomach, they can rupture and blood will pour out of the jagged tears. Because the stomach can hold several litres of liquid, the bleeding can continue unabated until the amount is sufficient to make its presence felt by a voluminous vomit of bright red blood. A bleed like this can put on an extraordinary display. In the most extreme case I have ever seen, we were taking a patient to the operating theatre to have her liver transplant. We were in the elevator when, without warning, she told us that she needed to vomit. We all stood aghast as she left everything in that elevator, including us, dripping in blood. It looked like a grisly murder scene. We rushed her into the theatre where, luckily for her, the new liver was standing by. As the anaesthetist squeezed bags of donated blood into her veins, we stopped the bleeding by transplanting the liver into her. This instantly dropped the pressure in the veins feeding the bleeding in her stomach, because blood was now flowing through the new liver in its natural direction. That lady was very fortunate that day, because very few people will survive a bleed like this.

More often, the onset of liver disease is far more subtle but no less deadly. There is a reason that blood goes through the liver to get to the heart. This blood is rich in toxic waste, a product of the digestion of the food we eat, and the liver does a terrific job of stopping us from being poisoned by it. The poisons enter the liver cells and get taken apart, shielding our body from their harmful effects. But because the blood is bypassing the liver in patients with cirrhosis, these poisons are let loose into the body’s general circulation and have terrible consequences. The afflicted person’s complexion will slowly change and big spider veins will appear on their face and chest. Their skin will dry out and turn brown. The whites of their eyes become an alien shade of yellow as their level of jaundice deepens. The person’s faculties gradually slow as the level of ammonia (the same stuff that is used to clean drains) rises. Victims of cirrhosis develop a peculiar smell as the deadly ammonia is blown out on their breath. They become fatigued and cannot get through a day of work without having to take a nap. Eventually there is outright confusion, followed by coma and death.

Because the liver can no longer make protein, the blood becomes thin. Water will leak out of the blood vessels making the skin swollen and boggy. The abdominal cavity fills with litres of fluid as the liver literally weeps and the sufferer appears to be nine months pregnant. This can happen so slowly that the patient might only seek help when they notice they can no longer see the television over their swollen tummy. This fluid can also run into the scrotum and patients have to take to a wheelchair when they can no longer carry around the weight of their own balls. Their belly button will protrude with the pressure of the fluid and the skin covering it will thin out until it ruptures. Then, a steady stream of clear yellow liquid will dribble out through the hole in a continuous stream. All they can do is catch it in a plastic bag. A liver with cirrhosis will no longer break down oestrogen and men will take on some female characteristics. They grow small breasts, lose their body hair and their testicles shrivel up.

As if all of this is not enough, in one final and fatal blow, cirrhosis is fertile soil for cultivating cancer. Deadly tumours develop and, like invaders, will just keep on coming as long as the damaged cells are there. These cancers are particularly aggressive and spread their tentacles into major blood vessels, growing toward the heart and lungs. Because they love to invade big blood vessels, these tumours are notorious for rupturing, usually resulting in the patient bleeding to death.

Dying of cirrhosis is torturous and cruelly takes many years to kill its victim. When these people are as close to death as they can get, it is my job to swoop in and save their lives. It is a really cool thing to do.

Donor livers for transplant are a very precious commodity. In Australia on average there are only about 200 that become available each year. That is 200 lives we can save. In an ideal world, it would be fantastic to transplant a liver into everyone who might get some benefit from one. At the moment though, because there are so few livers on offer, we have to be very careful about who we choose to receive one. We must select the patients who have a very good chance of having a successful recovery. If more donor livers were available, we could push the limits of transplant to try and help those people who have more difficult problems to cure. These are the patients who are suffering from cancers like bowel and breast that have spread to the liver. They will usually die from their disease, but a small number of them might have a slight chance of recovery if they had a liver transplant. Even a ten per cent chance of a cure is better than none. Most patients with cancer, however, will die faster with a transplant than with no treatment at all because of the anti-rejection drugs they must take. Keeping cancer at bay relies on an immune system that works, so for most people on these drugs, cancer can return quickly after the operation. So, transplant is not for everyone.

It is our onerous task to find the people who transplant is good for. Patients must be sick enough to need a transplant, but not too sick in order to survive the operation. It is a delicate balance to get right. In Australia, liver failure is caused by many things but the most common are the hepatitis C virus (frequently acquired from sharing drug injecting needles in the distant past) or drinking too much alcohol. More recently, being overweight seems to be contributing to liver failure, too. Sadly, liver failure will often make its victim pay for their silly teenage mistakes 20 years after they have well and truly overcome their addiction demons. For a minority, however, addiction is never far away and sometimes the only thing that has stopped them drinking or taking drugs is the fact that their livers are so bad that they are too sick to lift a glass to their lips any more. These patients who have not dealt with their problems are often the ones who will fall off the wagon within a few months of their transplant.

It is addiction and all its attendant social issues that make the selection of patients for transplant very tricky. It is something we take very seriously and we try our very best to try and identify the patients who might relapse. A formidable panel of doctors, nurses and social workers assess all patients for transplant. Such is the number of tests and interviews these patients have to go through I often wonder if actually undergoing the liver transplant might be less stressful. When all the tests are done, the patient is brought before us and they tell us how liver failure is affecting their lives. We carefully consider each potential recipient for many hours with their medical background, their sobriety and their family support structure all being factored in. After transplant, the most important thing is that there are caring family members willing to look after the recipient when they go home. Without all these boxes checked, we do not go ahead. But, even with all the tests done, in the end we have to take a leap of faith and trust that the person will do their very best to look after the liver they might be given. Happily, most of them do. They realise that they have been granted the rare gift of a second chance to live and do everything we ask of them even though it is difficult and even painful at times. Many of them will even become avid crusaders for organ donation and do everything in their power to repay their debt of gratitude by living a healthy, happy and productive life.

No matter how many tests we run, it is impossible to always get the selection of patients for transplant right. As a doctor (and a human), it is difficult not to be affected when someone is sitting in front of you begging for their life, knowing you have the potential to save it. The vast majority of the time, we give people the benefit of the doubt. When we say no to someone wanting a new liver because they are at very high risk of going back to drugs or alcohol, it is impossible not to feel gutted. Deciding whether someone will live or die is a truly terrible thing to have to do but I try to remember that the precious organ needs to go to the person who needs it most and will look after it the best. It still doesn’t make it any easier. Humans are fallible creatures and no matter how hard we try there is still a small number of people that get through the selection process and will return to drinking or drug taking after transplant for one reason or another.

There have been some world-famous examples of this publicised in the media over the years. These are the most difficult patients for any transplant unit to deal with and when it happens we feel disappointed to our core. The power of addiction is so strong that it causes these patients to somehow block out the memory of what it felt like to be so close to death and the journey that took them there in the first place. There are even rare people who are never able to quit their poison and carry on a series of complex deceptions throughout the transplant work up process. A man I spoke to who continued to actively use drugs the entire time told me, ‘Doc, wouldn’t you lie to you to save your own life?’

But there was one patient who took the prize for the worst relapse we have ever seen. This chap was ready for discharge from hospital ten days after his liver transplant, for a long past addiction to alcohol. He was sick of eating the hospital food and, despite being sober for years, he thought it would constitute sound judgment to go to the pub and have a counter meal of fish and chips washed down with a beer instead of going straight home. We don’t know whether it was his new medications or something else that impaired his judgment, but one beer quickly turned into five and less than one hour later, he was returned by ambulance to the Emergency Department. He had got into a drunken bar brawl and ended up with a broken arm. As one of my colleagues succinctly put it, ‘Today, the Liver Transplant Unit has reached a new low.’

When these events occur, it is really demoralising for everyone on the team who spends their lives helping these people. We feel as though we have failed the donor family who has chosen to give such a precious gift. I try and remember the 99.9 per cent of people who do the right thing and love their new liver by living a great life.

How to do a liver transplant

After I had been in Denver a few months and had spent many hours assisting Dr Kam, he became confident enough of my abilities to take me through my first liver transplant as the primary surgeon. I was thrilled. This was followed a few months later by my first solo transplant, that is, without one of the bosses scrubbed. This was a big day and I was every bit as nervous and excited as I was with my first appendix. I didn’t even know it was going to happen until I was well into it. Dr Kam sat in the corner of the OR preparing the new liver for transplant while I started the operation with the surgical registrar. Of course my first brilliant manoeuvre was to make an inadvertent hole in a major blood vessel and it was difficult to mask the sound of the blood rocketing up the suckers and the flurry of activity as I forcefully requested the required stitch to patch the hole.

‘Kelleeeeeee, everything going OK?’ Dr Kam asked, looking up from his work in the corner.

‘Yes, Dr Kam, no problems,’ I said, sewing up my hole as quickly as possible, trying to keep my racing heart under a hundred. I did not want him to have to take over to get me out of trouble. This was part of being a grown-up surgeon. With a few quick stitches and the tying of a knot, everything came under control and Dr Kam turned back to what he was doing. Things then proceeded in an orderly fashion and after a while Dr Kam announced that he would be going upstairs for a while.

‘I am on my phone,’ he instructed. ‘Call if you need help.’ With that, he left the OR and everyone turned to look at me. This had not happened before. I beamed behind my mask and then just felt anxious as I realised the trust he was placing in me. I would not let him down. When I successfully put the last stitch in and tucked the patient into the Intensive Care Unit, I dropped into Dr Kam’s office to tell him I had finished.

‘Everything OK?’ he enquired.

‘Yes, thank you for letting me do it,’ I said, secretly so chuffed with myself. I found out later that everyone had shared my excitement at my first solo case from the moment Dr Kam arrived at the office. In the American system, trainee surgeons are rarely left alone and I knew that this was a nod of confidence in my skills and especially my ability to call for help if I needed it. In surgery, trust is everything.

When a liver transplant goes well, I experience a high that any drug in existence would be hard pressed to provide. This rush will last long after I get home and I am usually so wound up that I have trouble falling asleep as I replay every single stitch and every gush of blood over again in my mind. I revel in the precision of this operation, where one mistake or error of judgment can mean the case will end with fatal results. I feel so proud of what I have done that it is difficult to stop my heart bursting out of my chest. It is an interesting sensation, knowing that you have taken someone who could have been dead tomorrow and helped to give them the possibility of returning to a relatively normal life. It is their life in your hands and it is an awesome responsibility. I still can’t believe they let me do it.

Of course, right along with the big highs come the lowest of lows. As I’ve mentioned, not everyone survives a liver transplant. Some die in the months after the operation, but an unfortunate few do not make it off the operating table alive. Surgery has a way of keeping you humble and just when you think you are pretty awesome, a complication will happen to keep your ego well in check. It all becomes very real when you have two litres of someone’s blood soaking through your gown onto your underpants and have to change before going out to the waiting room to ruin the lives of a hopeful family.

Actually doing a liver transplant can feel a lot like running a marathon. There are moments of breathlessness, fatigue, extreme focus – it can be physically torturous. The wear and tear on a transplant surgeon’s body can be so significant that many find the physical demands impossible to deal with after a certain age. Almost every transplant surgeon retires with a bad back and arthritic knees. Transplant can also be dangerous work for all of my surgical staff. Many of the recipients have hepatitis B, C or HIV and sometimes all three. In an operation that often involves using hundreds of stitching needles, a stab to the hand with one of them can mean contracting a disease that will end your career and possibly your life.

Then there is the incredibly uncomfortable outfit I need to suit up in each time I do a transplant. For a start, I don scrubs, a plastic apron and a long-sleeved gown with gloves. My head is adorned with a complex arrangement comprising a surgical mask, heavy black glasses with microscopic lenses protruding from them, and finally a tight headband carrying a light, that after a few hours begins to feel like a crown of thorns. Sweat runs in a constant trickle down my back under the layers of plastic that protect me from the blood, and by the end of the operation I am dripping wet and the patient’s congealed blood is pooling in my shoes.

Because the liver is tucked all the way up and under the ribs on the right-hand side of the patient, I need to contort my body into a half sideways pose, facing toward the patient’s head, quickly turning from side to side to get the right angle to place a stitch. It is a most unnatural way to stand for the long hours that it takes to do the surgery. One moment I am on my tippy toes, in a dominating position over the liver in order to lift it up, and the next I am almost kneeling on the ground so I can look under it and release it from its deepest attachments. ‘Doctor, your dick is not stuck to the operating table,’ one of my bosses would yell at me, meaning to keep moving my ass so as I could get in the right position to place a stitch as accurately as possible. Then there are the bladder issues. During a transplant it is not unusual to go for six hours or more without taking a pee. It is like my body goes into a kind of crisis mode when I am concentrating so intensely. All non-essential systems temporarily shut down and the urine simply does not get made. It can’t be good for you.

The only reason that surgeons get away with cutting into people’s flesh is that the normal functions of the body help to repair the damage we have inflicted. Healthy people have blood that clots and wounds that heal and the liver plays a crucial role in this process. So much so, that if a patient in the final stages of cirrhosis undergoes any sort of operation other than a transplant, the few liver cells they have left will not be able to meet the demands of surgery. They will simply give up the fight and the patient will perish. Aside from the body’s own healing ability, two other things ensure that we have a live patient at the end of a liver transplant operation – a beautiful healthy donor liver and a big team of people who include specialist anaesthetists and nurses. The anaesthetists are charged with the responsibility of keeping the patient alive while I am doing things that would otherwise kill them. Cutting a knobbly, diseased liver out of a person can be a real blood bath and without the folks at the top end doing their thing, the operating theatre would quickly become a crime scene rather than a place of salvation.

The anaesthetists begin their work on the patient a couple of hours before I even show up. Two of them work together to constantly make fine adjustments in response to the numbers they see on their monitors. They render the recipient unconscious with a white liquid injected into a vein called Propofol. Yes, that is the same drug that reportedly killed the singer Michael Jackson and which he used to help him sleep at night. The difference in the operating theatre is that when the receiver of the Propofol inevitably stops breathing, the anaesthetist is there to help them out by inserting a breathing tube down their throat. Plastic tubes the size of drinking straws are plunged into the major veins of the neck, arms and groin so bags of blood and fluorescent yellow clotting serum can be given as quickly as a litre in 30 seconds if necessary. The patient can manage to lose blood that fast if I make a big hole in a blood vessel. The anaesthetist will also use powerful drugs to constrict the blood vessels of the recipient’s legs and arms during moments of copious blood loss. This causes blood to be diverted to the heart and brain to make sure they are not deprived of oxygen. A quarter of the room is filled with their equipment, all there to keep the patient going. If it wasn’t for the patient in the middle of it all you would be forgiven for thinking we were there to launch the space shuttle.

After all this preparation, it is my turn to get to work. I yell out, ‘All right to start?’ If there are no objections, I make a sizeable incision in the patient, about four centimetres beneath the ribs extending from one side of the abdomen to the other. Professor Lynch always says, ‘Unless the anaesthetist at the top of the operating table can see every stitch going in, then the cut is too small.’ The incision is often called a Mercedes Benz because it is shaped like the luxury car’s trademark symbol and is very fitting – expensive car, expensive operation. As soon as the skin and underlying muscle layers are breached, litres of clear amber fluid called ascites will gush out of the patient’s abdomen, spilling onto the floor. I do my best to try and capture it with two powerful suckers and the two-litre capacity plastic bags attached to the sides of the table, but nonetheless a great deal of it inevitably ends up on and in my shoes.

With the fluid evacuated, the soon-to-be-defunct liver comes into view. A healthy liver is smooth and shiny. A liver with cirrhosis, however, is a shrivelled, lumpy little thing with much the same profile as a giant walnut. To give me enough room to perform the transplant, I set up an elaborate metal frame which is clamped to either side of the operating table and supports a semi-circular arch. This arch rises about a foot above the patient’s chest. Clawlike metal blades are positioned under the patient’s ribs on both sides and with a grunt and a groan I haul the chest upwards, hooking the blades onto the frame. The liver is tucked high up under the ribs, almost in the chest, so without this medieval-looking device I would not be able to see a thing. Exposure is everything in surgery and if you can’t see, you can’t stitch. Surprisingly, this retractor doesn’t hurt the patient at all and it also just so happens that the frame is a very convenient place for everyone in the surgical team to rest their elbows. The only drawback of this retractor is that it has a big metal knob, anchoring it to the side of the table. This bolt presses uncomfortably into my groin for the entire case, reminding me that surgery is painful for everyone.

When the view is optimal, the next task is to cut out the failing liver. This is done quickly and in such a way that everything is set up to put the new one in. As soon as the liver came out of the donor, the clock began to tick. A short ‘bucket time’ is crucial to a transplant’s success and blood must be flowing through the new liver inside 12 hours of its removal from the donor for the best result. Getting the old liver out is not as easy as it might sound. The massive varicose veins that surround the liver and coat every surface of the abdomen explode with even the slightest touch, and because these patients have blood that does not clot, the haemorrhage can be so ferocious that much of the ‘taking out’ part of the transplant is frequently done underwater in a sea of blood. The more I stitch, the more the patient will bleed. Even the normally innocuous holes that I make with my tiny needles will ooze uncontrollably. Just making the skin incision in people with cirrhosis can result in losing half a litre of blood. All of this lost blood is salvaged by a special machine that recirculates it back into the patient, cutting down on the need to impose on the blood bank – a type of recycling, if you will.

To remove a liver, it must be freed from all its attachments. Just as I would do to the ‘new’ liver on the back table, I need to strip all the superfluous tissue off the blood vessels going to the old liver in order to gain as much length as possible. I need to fashion something to stitch the new one on to. To understand this better, a quick lesson in liver anatomy is required. For such a big organ (approximately one and a half kilos depending on the size of the person), the liver has very little in the way of attachments to the body. Aside from a few flimsy ligaments, the only things that really hold it in place are its blood vessels.

The liver is unique because it has two separate blood supplies. The first is the hepatic artery that brings blood brimming with oxygen straight from the lungs via the heart. The bile ducts are the main beneficiary of this blood and it is for this reason that the hepatic artery is the Achilles heel of liver transplantation. If the blood stops flowing in the hepatic artery at any point after the surgery, the liver may not survive. The fragile bile ducts will die and liquefy, forming infected lakes of bile within the liver. These pools will quickly fill with pus and the patient will begin to rot from the inside out. Unless they are re-transplanted with a fresh liver, it is possible the patient will die.

The second blood supply to the liver is the impressive but delicate portal vein. The size of a garden hose, the portal vein drains blood from the bowels, stomach and spleen. It gives the liver cells the first pickings of the nutrients, fats and toxins produced by the gut. Then there are the imposing hepatic veins. Like everything in surgery, what goes in must come out and the main hepatic veins are how the blood comes out of the liver. These are the three stout tributaries that return the blood from the liver almost directly into the heart. Make a hole in one of these babies and you will really know you are alive because shortly after, the patient may not be. These hepatic veins are the most significant support structures for the liver and, incredibly, only a single row of tiny stitches between these veins is all that is required to keep the new liver in place. More than a few times I have had patients refusing to get out of bed the day after a transplant for fear that their new liver will fall out of position. I am happy to reassure them that this doesn’t ever happen and we have never had to retrieve a fallen liver out of anyone’s pelvis.

Once all the blood vessels are stripped clean of their fat and sinew, a very cool thing happens. I can actually put my hand under the right side of the liver and the whole thing can be rotated from side to side on its central axis to get a good look underneath. This manoeuvre will reveal the final impediment to freeing the liver – the short hepatic veins.

Not to be confused with the three main hepatic veins, these are the smallest but most perilous vessels of them all. There are around ten to twenty of these short, fat little buggers emerging straight out of the back of the liver and going directly into the body’s grandest vein, the inferior vena cava. Only a few millimetres long, they can prove to be very treacherous. Detaching them involves an hour of stooping down low in order to get a view deep under the liver where they live. There is only a sliver of space to operate in. Fine silk threads must be passed around every last one of these veins to securely tie them off forever, as the new liver does not need them to get by.

Because the liver is being lifted up and tilted to one side, these veins are placed under tremendous tension and they tear with alarming regularity. They are completely unforgiving, and within seconds a tiny tear can expand into a gaping hole in the inferior vena cava. In a large vein, a negative pressure is created when the patient breathes in. When there is a hole in said vein, this negative pressure causes the blood to suck back for a brief moment, similar to the way an ocean pulls back just before a tsunami hits. There is a horrible moment when I will be treated to a rare glimpse of the glistening insides of a great vein moments before the ensuing tidal wave of blood floods the operating field and obliterates the view completely. Moments in surgery like this definitely justify the use of some emergency language. ‘Christ alive,’ is one I have heard as the blood begins to pour out. ‘Holy fuck’ or some equally profane reference to the sexual act is another one that easily rolls off the tongue. No one ever seems to mind, because there are times in surgery when only the word ‘fuck’ will do.

When there is bleeding like this flowing from the vena cava, deep under the liver, it is time to cut your losses and abandon any further careful dissection by placing large metal clamps across the mighty vessel to stem the tide.

‘Liver’s coming out!’ I cry. ‘Mark the time,’ as I cut away the last few strands of tissue holding the diseased organ in place. Using two hands, the old liver is scooped out of the abdomen and plopped unceremoniously into a waiting dish. It makes an extraordinary sucking sound as it releases itself from its bed, as if making one final protest. Turning back to the patient, I am faced with the surreal sight of a vast hole where the liver used to be.

As the old liver is coming out, the new liver, ensconced in its protective plastic bags, is taken out of the cooler and brought onto the operating table. It is carried with reverence across the room because this is the moment when there is a real chance it might end up on the floor. It has never happened to me, but I imagine if it does, I would just have to wash it off and use it regardless. What other choice would there be? I hope I never have to find out. Ice-cold salty water is hooked up to a tube inserted into the portal vein of the new liver and poured though at full speed to keep the liver cool and to flush out all the preservation solution. If this is not done, when the blood is allowed to flow through the liver again, the preservation solution goes directly into the recipient’s bloodstream. This liquid contains a huge load of potassium and when that hits the heart, it can cause it to stop. Heart stoppage is definitely not desirable in the middle of a transplant, so it is best avoided by taking the time to flush the liver.

When everyone is ready, the new liver is lifted out of its bag and shoehorned into its new home. It is then a race to sew the blood vessels back together again. This typically takes anywhere between 13 and 22 minutes and yes, we do compete with each other for the best times. The first to be joined up are the main hepatic veins, sewn almost directly onto the heart down a deep and narrow hole with thread not much thicker than a human hair. The new liver is still cold and pale and this seems vastly out of place next to the warm, pulsating tissues that surround it. There is no talking during this part of the operation, just tremendous focus. I am in the zone. I am lent a hand by my assistants who, for the time it takes, must contort themselves into unnatural positions holding metal retractors at just the right angles so I can get the optimal view. Knots are tied down with gloved fingers, pushed into the depths with just the right amount of tension so as not to break the thread. As I do this I pretend that I am Luke Skywalker using ‘The Force’ and close my eyes as I feel the tension in the thread of the stitch rather than see it. With the hepatic veins complete, the next step is to join up the portal vein. This will bring most of the blood into the liver. It is easy to twist this vein or to make it too long, so a great deal of judgment must be used to cut it to just the right length. Too long and the vein will kink and clot, too short and it will snap like an overstretched rubberband.

When these two join-ups are complete, it is time to release the clamps and witness a miraculous sight. The cold, pale liver instantly fills with blood and life begins again. Like slapping a newborn baby on the bottom to stimulate its breathing, I give the new liver a loving rub to massage the blood right out to its edges. The liver once again becomes warm, as the blood rushes in and returns it to its familiar rich red colour. I often wonder if the new liver was able to speak at this point, whether it would let out a big sigh and say, ‘Damn you all, I thought I was dead and I could finally have a rest. Now you want me to go to work for someone else?’ The reperfusion causes the liver to swell and become about 30 per cent bigger, easily expanding to fill the space where the old one used to be. This is the point where you hope the size match between the donor and recipient has been estimated correctly. If the liver is too big, it will proudly bulge out of the abdomen like an unfurling spinnaker on a sailing ship. When this occurs, the liver becomes virtually impossible to move around and makes stopping the bleeding behind it very difficult.

The moments after blood rushes through the new liver are very dangerous for the patient and they can become massively unstable as there is usually another wave of rapid blood loss. The anaesthetists hover expectantly at the top of the table, poised to correct any drop in blood pressure or slowing of the pulse. This is the time during the transplant that the patient is most likely to die. The new liver takes some time to start working and the blood, still affected by the ravages of cirrhosis, will take a while to clot. Little holes in all the blood vessels begin to open up one after another with the changes in pressure, and each one needs to be attended to with fast precise stitches. I roll the liver back and forth to locate these holes, yelling out, ‘Stitch, stitch, stitch,’ as I hold out my hand waiting for the nurse to slap the next instrument loaded with needle and thread into the palm of my hand. I don’t take my eyes off the action for a second. As each stitch is put in and tied, the scrub nurse sprays my hands with water so the knots tie down smoothly and won’t snag on my blood-caked gloves. The tails of my stitches are trimmed off and as I finish with each one, I flick them backward onto the floor, not because I am messy, but so the ends do not get wrapped around my fingers, wasting a vital second as I tie the next knot. At the end of the operation, there is a mountain of fine blue nylon thread on the floor, mixed with congealed blood. It sticks to the bottom of my shoes and the nurses get grumpy when I forget and trek the gooey mess all over the floor.

Once the bleeding has settled down, my attention turns to the hepatic artery. Now the pace of the operation slows considerably. Joining this artery together is a painstaking job that must be performed with technical perfection. I keep saying that life hinges on small things and this is the case when it comes to this blood vessel. The serpentine hepatic artery is a three-layered structure and sloppy technique can cause these layers to split apart, rendering it useless. Peering down my microscope glasses, I place each stitch, not touching the delicate vessel with anything other than the tip of my needle. I pierce the wall of the artery at a perfect right angle and it takes about 20 stitches, placed at an exactly equal distance apart, to put it together. When the clamps holding back the blood are released, the artery wriggles to life and hopefully will stand erect with the pressure of the pulse. Then, there will be yet another wave of bleeding as tiny holes upstream of the artery start to bleed. More ‘Stitch, stitch, stitch!’ About this time the liver will be starting to work a little. Clots are produced and slowly the bleeding will ease. The transplant liver usually has its gallbladder still attached, but not for long as I whip it off. The last thing a transplant patient needs is an attack of gallstones. The final step is to connect up the bile duct that will deliver bile from the new liver into the bowel, and we all relax a little.

That’s it, case done – new liver, new life. I take some time to have a final look around and make sure there is no more bleeding to stop. When everything seems calm, I wearily close the layers of the abdominal wall and skin over the patient’s brand new organ. Only then do I lift my head and step back from the table. With a stiff neck and locked knees I stumble off to pee as my brain suddenly realises that I haven’t attended to that for a while. The silence in the room gives way to happy chatter. We all know we have done a good thing that day.

Born in the USA

Winter was nearly over in our second year in Denver when the city received a once-in-one-hundred-years blizzard. Eight feet of snow fell in one night. We woke to a winter wonderland of fresh powder right up to the rooftops. Cars left on the street had become white mounds, and there was no clear indication where the road was. The snow ploughs could not cope with clearing the highways, let alone suburban streets, so no one could get to work that week. The nurses who were already on shift that first night had to stay in the hospital for days until the roads were clear enough for them to travel home. I was the only one in the medical team who lived close to the hospital, but even walking there over the mountains of snow seemed impossible. When I tried to step out the front door, I sank up to my waist in soft powder. There were fallen tree branches everywhere and power lines had been torn down by the sheer weight of the snow.

I was four months pregnant. Perhaps not thinking clearly, I had the brilliant idea of strapping on my skis and travelling cross-country to work. It took me a while to get there in my gestational state, breathing heavily in the mountain air. I shuffled rather than skied but I made it to the hospital to do the rounds and make sure the patients were safe. This embodied my attitude to my pregnancies: I just kept going.

I was 32 years old at this point and, after arriving in the States, I quite suddenly developed an overwhelming desire to start a family. Even though I had always wanted to have a baby one day, it had never really occurred to me to actively try. In fact, Andrew and I had spent all of our 20s taking measures to avoid the possibility, and starting a family still seemed like something that only grown-ups did. I fancifully wondered if it might just happen serendipitously one day and the decision would be made for me. But this was unlikely – I am simply too much of a planner ever to allow an egg and sperm to meet in an accidental way. There had never seemed to be a ‘right time’ before now. Medical school was a time of social awakening, with days spent doing nothing but studying and partying. Then, surgical training was one endless 36-hour shift and countless exams had me shackled to a desk whenever I was not working. My time was not my own and I had nothing more to give. I had had bosses regularly telling me that I had to be in the operating theatre on a Sunday at 10 pm with no notice. There was scarcely enough time to see Andrew, let alone having a tiny baby to vie for my attention.

Now, with ten years of happy marriage under our belt and the critical part of my training behind me, the time to reproduce suddenly seemed right. I became painfully aware of my biological clock ticking away and I assured Andrew that we would be able to manage. The other thing that cemented the plan was that having a baby in the USA meant he or she would be born an American citizen. I was in love with the idea of belonging to this amazing country in some small way and if I couldn’t be an American, making one was the next best thing. Of course, I had a number of fears. Because I had seen almost no female surgeons juggle both a family and a career, I was very concerned whether I would find it impossible. What if I had to walk away from all that training? It was all well and good to think I could deliver a baby and then waltz back into work a few weeks later, but when the time came, would I actually be able to leave my precious bundle in the care of someone else? I was also worried about the physical aspects of the pregnancy. Would I be able to keep up the pace of being a transplanter while I was pregnant? What if I got sick and was put on months of bed rest? How would my pregnant belly fit at the operating table? Would I vomit into my surgical mask if morning sickness took hold?

It is in a doctor’s nature to imagine the worst-case scenario and I thought of all the bad stuff. Where most women chose their birth hospital based on its well-appointed rooms and the availability of birth balls and spa tubs, I chose mine because their Intensive Care Unit was excellent.

I thought it would be a good idea to go and see Dr Kam before we started trying to conceive. It was important for me to have him on board with the pregnancy plan in case I became sick. I breathed a sigh of relief when he seemed excited and genuinely supportive. He was thrilled that we would be producing an American baby. He was a relatively new American citizen himself and he understood how proud we would be. So Andrew and I launched headlong into adding to our family and, to our surprise, two weeks later I peed on a pregnancy test stick and a little plus sign appeared in the window. I burst into tears and then really started to panic. I hadn’t expected it to happen quite so fast.

The morning sickness kicked in right away and I spent the first three months trying to keep my lunch down. The tiredness was extreme. I was used to sleep deprivation but this was something else. Because of my fatigue, it became increasingly difficult to try and keep things a secret at work. Everyone guessed what was happening when they found me asleep on a pile of charts in the office. During the second trimester the nausea abated, and my pregnancy progressed along with very few problems and I was able to work as I always did. In fact, working was really good because when I was operating, the concentration took my mind off how much my expanding body was hurting. The most difficult thing was to convince Drs Kam, Wachs and Bak that I didn’t need special treatment and I could still handle being awake for two days, flying on planes and managing a busy service. It seemed that Drs Wachs and Bak were being nagged by their wives that they were working me too hard and how unreasonable it was to make a pregnant woman fly around the countryside in the middle of the night. ‘Pregnancy is not a disease,’ I would insist.

One of the things I loved about Americans was their generous hearts and the transplant team opened theirs widely and rallied around to make sure Andrew and I had everything we needed for a new baby. We were a long way from home and any help from our families. My pregnancy had injected a lot of excitement into the department and because I was always at work, everyone got to feel the baby kicking and watched my bump grow. They all looked forward to being surrogate uncles and aunts to our little person. We knew we were having a girl, and I felt very loved and humbled when the transplant nurses threw me a pink-themed baby shower to celebrate. I came away from that party with cribs, prams, rocking chairs and diapers – enough to furnish a nursery, feed a baby and keep her bottom (and everything else) clean for the first two years. I had to hire a truck to get it home. All that stuff has gone on to serve our four children well. They were generous beyond words.

Pregnancy did pose a few unexpected issues. I was quite a bit more emotional than usual. Dealing with donors was already psychologically confronting, even without the hormones. I usually got through the adult donors just fine. I was careful to not look at their faces and just concentrated on the job at hand, thinking only about the people they were helping. It was a totally different story when it came to teenage and child donors. These little people had usually died in a terribly sad way, through accidents, gunshot wounds or drownings. To cut their small bodies open and retrieve their organs was too much for me to bear. Even now, it makes me very uncomfortable. I cannot help but imagine the unbearable grief that the parents of these kids must go through.

When I was 24 weeks pregnant I was asked to perform donation surgery on a young woman who had become brain dead while delivering her own baby. Unlike Australia, in the USA it was quite common for the deceased’s family to want to meet with the donor team just before we wheeled their loved one away to the operating theatre. These would be the final moments they would spend together and it was always an emotionally charged meeting. There would be tearful goodbyes and loving embraces. I hated to see these farewells, not because I am cold-hearted but quite the opposite – it was just too raw. These meetings ruined my carefully cultivated disconnect with the donor, the shield that I established to get through the day. This particular donor had died of pre-eclampsia (high blood pressure during pregnancy) and her baby had been delivered by caesarean section shortly after. The baby had miraculously been born alive and was perfectly healthy.

The woman’s courageous family wanted to donate her organs and her husband asked if he could meet my team before we took her away. I didn’t want to do it but found it difficult to refuse. I was already holding back tears simply having heard the story and felt myself well up even before I got to her room. I walked in to find the lady’s husband cradling his beautiful newborn daughter in his arms. He was sitting next to his dead wife, telling her how lovely their baby was. I could see the pain etched on his face, unable to comprehend the job that lay ahead of him over the next few days, weeks and years. He was dealing with the cruel dichotomy of the pain of losing his wife and the joy of raising this delightful bundle. Life had changed forever for him.

‘Please look after her for me,’ he said quietly, looking up at me. I thanked him for his incredible strength and the unbelievable gift of his wife’s organs under the circumstances. As I extended my hand to shake his, it turned into a hug. I admired his new daughter.

‘What’s her name?’ I asked him.

‘Sydney,’ he replied, and at that I completely lost control of myself. Sydney was the name I had chosen for my unborn baby. I felt my bottom lip quiver and my throat close up and I let out an audible sob. Tears poured down my face and I found myself in the unusual position of being comforted by him. He held me in a long embrace that I think we both needed and we cried together. I was so upset that they called the hospital chaplain to try and calm me down. I eventually had to collect myself and perform the donation surgery. I am not religious in any way, but I do believe that life gives you signs and I felt that the fact that that baby was called Sydney was an ominous one. I changed my mind about using the name and it was probably for the best, especially for a kid who was eventually going to be an Australian.

I didn’t miss a day of work during my pregnancy, and when I was only two months away from delivery, I had the biggest week of my surgical life. Transplant is either boom or bust. Some weeks you do nothing and in others there is no end in sight to the work. That day began with the usual donor call and it did not stop for a week. Just as we finished one transplant, we were called about another and then another. In all, we did six donors in five days. That is, six livers and twelve kidneys. Every donor takes about six hours; a liver transplant, between four and six; and a kidney about two. You do the math. I ran on pure adrenaline and put my heavily pregnant self through almost all of those operations in one way or another and did not go home in between. My back ached and my haemorrhoids throbbed. My growing foetus felt so heavy that when I stood up, I thought she might just fall out. Each evening Andrew delivered a bag of clean underwear and scrubs to the hospital. He was worried, but he left me to it, knowing that there was no way to talk me into going home while everyone else was continuing to work. My only rest came in half-hour blocks, when the chief resident and I took turns to close our eyes on well-worn mattresses in the call room. We sent the junior residents out for food and they would deposit brown paper bags filled with cold fries and cheesy burgers next to our beds to eat when we awoke. Along with the food, they provided updates about the condition of the various transplanted patients. Someone would ask my opinion about a patient’s results and through a blanket of fatigue I hoped I responded with the right answer. At the end of the week, they were all still alive, so I guess I did. There were so many patients that none of us was really clear about who had which organ. To avoid mix ups, we resolved this problem by assigning each patient a number corresponding to the order in which they were transplanted instead of using their names – impersonal but effective. It was just crazy and at the end I think I slept for two days. But, because we were all in it together there was a special camaraderie that developed and at the end of that run, we couldn’t believe what we had achieved.

Good health favoured me for my pregnancy and I was able to work right up until the day my beautiful girl was born. I had worried needlessly about how I would fit at the operating table. I just seemed to accommodate it, using the little bit of room at the side of the patient’s belly to wedge my bump. The main side effect of late pregnancy was a resurgence of the overwhelming exhaustion. As I neared the end, I would find myself staring longingly at the patients in their beds, wishing I could change places with them so I could lie down just for a minute. My tired mind was envious that they could just lie there and not be woken every few hours in the night by a pager going berserk.

My other big problem was swollen legs. There were days when I couldn’t wear shoes because the hours spent standing at the operating table would result in my ankles almost doubling in size. Extremely tight stockings – the kind you wear when you are a patient in the hospital – became essential for me to get through the day. Of course wearing these stockings, along with the layers of gowns, masks, glasses and headlights that are part of being a surgeon, would frequently cause me to overheat. I was always burning up and sweat continuously ran down my back, often distracting me from the job at hand. They could never get the air conditioning in the room cold enough for me. Our innovative theatre technician, Anthony Adams, came up with a fantastic solution to my cooling issues. He rigged two hoses up to a fan that blew cold air. While I was standing in position at the operating table, he would feed a hose up each leg of my pants and secure it at my ankles with duct tape. It was like having my own private air conditioning system. My pants would billow out and I was comforted by the very pleasant breeze. It wasn’t long before everyone at the operating table wanted to try it.

At 38 weeks, like all expectant mums, I was really over the whole thing and couldn’t wait to see my baby. I was almost at breaking point and I didn’t know how much longer I could go on working at the usual pace. I was too proud to tell anyone about this, of course. Whenever they asked, I said everything was fine, but whenever I saw my obstetrician I offered her a financial incentive to put me out of my misery. A moment of utter disappointment came in that second-last week when I thought it might be time. I was pottering away on the back table in the corner of the operating theatre, preparing a liver for transplant. When you are working on the liver, it sits in a silver bowl filled with slushy ice to keep it cold and well preserved. I suddenly felt liquid running down my leg and it stopped me operating instantly. I was more than a little paranoid about my membranes rupturing because my friend had recently broken hers in the middle of a busy supermarket and had to limp back to the car leaving a trail of bloody fluid in her wake. ‘This is it!’ I thought excitedly. ‘My water has broken, time to stop work and lie down.’ To my dismay, it was only the melted ice from the liver dish spilling over the edge of the table onto my crotch and down my leg. Realising that’s all it was, I forlornly turned back to continue my work on the liver and had to wait another two weeks for my daughter to make her grand entrance.

It was my goal through the whole pregnancy to work right up until the day I had the baby. What I didn’t know, however, was that the last week of pregnancy would be like wading through quicksand whilst peering through a thick fog. Everything was heavy, my brain slowed down, and all I could think of was how much I wanted it to be over. Even small tasks seemed a massive imposition. In addition, because I had worked so far into my pregnancy, I also had to endure many unhelpful comments from people who thought they were being really funny:

‘Haven’t you had that baby yet?’

‘Gee, you really are huge, are you sure it’s not twins?’

I wanted to scratch their eyes out. At 40 weeks and one day pregnant I was doing what I hoped would be my final liver transplant before I gave birth. Towards the end of the operation I felt increasingly uncomfortable. There was an unusual rhythmic tightening in my belly. It wasn’t too painful, so I put it down to the usual Braxton Hicks contractions that I had been having over the preceding weeks. I kept stitching and putting the final finishing touches to the transplant. I felt absolutely dreadful and as the pains got worse, for some reason I tried to talk myself out of the idea that I was probably in early labour. I was a tough girl and I was going to finish the job. I got through it and so did the patient, by the way. I scrubbed out and called Andrew.

‘I feel awful,’ I told him. ‘Come and get me.’ Andrew took one look at me and drove me straight to my obstetrician. She confirmed I was indeed in very early labour and that I should go home because delivery was still a while off. She was right because it was another 36 hours of pain before they used a pair of shiny cold forceps to pull my baby girl out by her colossal head. We named her Abigail, after Abigail Adams, an influential American woman who was the wife of one United States president and mother of another. Because the labour took so long, there was a great deal of anticipation and impatience among all the transplant secretaries and nurses. They were standing just outside the door as Abigail crowned and it didn’t take them long to get sick of waiting and burst into the room, followed shortly after by my bosses who had decided to include me in their daily ward rounds.

‘Don’t mind me,’ I said, my legs still up in stirrups. They didn’t seem to notice as they all took turns holding our brand new American.

Do you think I could have a piece of your liver?

Around the world there are thousands of people who give away parts of themselves so others may have a chance to live a better life. This is called living donation. These people voluntarily put themselves in harm’s way. They are selfless, brave and just incredible.

None more so than a quiet, unassuming man I met one day. His entire family were recent immigrants and understood little in the way of English. It turned out that they had a family member who was very ill, his liver was failing so badly that he was being considered for a liver transplant.

During the course of his medical work up, an interpreter mentioned to the family that living donation – that is, a relative giving up part of their liver for transplant – was an option. They were given the necessary written information so that it could be explained to the rest of the family to see if there was anyone interested in volunteering. They went away to think about this and talk among themselves. The patient and his entire extended family returned to the clinic a week later and informed us through the interpreter that a potential donor had indeed been found. The crowd parted and from the back of the group a man was pushed, almost shoved, forward. He stumbled a little and looked very nervous.

‘Our cousin will be the donor,’ the family patriarch proclaimed.

We smiled and thanked him, letting him know that it was a very generous thing he was contemplating. We began the arduous medical work up required for donation. As things progressed, we noticed that this man was far more uneasy than the usual donor. He seemed to be filled with dread.

During a private moment away from the rest of his family, we asked him, ‘Is there something bothering you? You know you can always pull out of this at any time.’

‘No, no, I am ready to die. I am ready to make this sacrifice for my dear cousin,’ he replied stoically through his interpreter.

‘It is quite unlikely you will die, you know,’ we told him, slightly puzzled as to why he would say such a thing.

A strange look crossed his face. ‘What do you mean? Of course I will die,’ he said.

Then it hit us – this courageous man thought that he was going to be killed so his cousin could have his liver. Everything had been lost in translation. For some reason, the family had decided that this poor guy should be the one to make the big sacrifice. You can imagine his shock when he was told that not only could he be a good cousin and donate his liver, but he could stay alive too! I’ve never seen someone so relieved. Eventually we all began to smile cautiously, followed by laughter when we realised what had happened. This story serves to illustrate just one of the potential pitfalls that can arise in the lead-up to this complicated procedure.

Aside from learning how to do a standard liver transplant, an important objective of my time in Denver was to learn the process for getting someone through one of these ‘right lobe adult living donor liver transplants’ – a long name for an even longer operation. This technique has gained acceptance around the world because of the demand for organs in countries where the donation rate is low.

Pioneering surgeons knew from cancer surgery that they could remove 70 per cent of a person’s liver and not only would they survive, but they could still live a normal life. So it was a natural progression to think that they could remove half the liver from a healthy person to transplant into someone dying from liver failure. The halved liver does an extraordinary thing and grows bigger. It does this so quickly that within six weeks of the surgery it has reached its full potential again. Compared to living donor kidney transplant, however, the risks for liver donors are considerably higher. Unlike the kidneys that have completely separate blood supplies, the liver receives its blood from single blood vessels that split into two just before they enter the liver. This means that removing a kidney poses very little risk of damage to the other one. With the liver, the risk of damage to the remaining half in a living donor is very real. The stakes are high.

Professor Strong and his partner Professor Tat Ong had taken livers from deceased donors, cutting them in half for use in two recipients. Spurred on by the success of transplanting these ‘half livers’, in 1987 they reported one of the first transplants exploiting this splitting technique, using a donated section of liver from a living person. This pioneering operation was first performed in Brisbane, Australia, between a parent and their child.

Of course, with living donation there is the possibility of ending up with two dead patients at the end of it all, and one of them didn’t even need an operation in the first place. But in this first instance, because it was a parent making a sacrifice for their child, the risk seemed acceptable and there were many parents who were willing to leap at the chance to rescue their child from a slow miserable death. The medical community also agreed with adult-to-child donation because the operation for the donor was relatively low-risk because it only involved removing a reasonably small section from the left side of the liver. By doing this, it avoided going near the important blood vessels that supply the rest of the liver, minimising the chance that the remaining section would be damaged. Encouraged by the good results the technique achieved in children, it was only a matter of time before the concept was adapted for transplants between adults.

Adults are bigger than children, so for an adult-to-adult living donor liver transplant, a larger section of liver is required. Adult living donor transplant continues to be mired in controversy because the very idea of subjecting a healthy person to this type of risk is difficult for people to accept. The decision for any transplant unit to do living donation is never taken lightly and we only do it when there are no other options. To procure this bigger piece, it is necessary to remove the right half of the liver from the donor. This is a far more technically demanding operation than taking a section from the left-hand side of the liver for transplanting from an adult to a child, and there is a higher chance that the section of liver remaining in the donor may be in jeopardy. Transplants do not always turn out for the best.

The cold hard numbers report that for adult living donation, one in one hundred living donors will die during or after the removal of the right half of their liver. These donors might end up literally giving their life in an attempt to save another. There are risks for the recipient, too. Sometimes a donated liver just doesn’t work – the blood vessels might clot or the donor might reject it. Some livers must be urgently removed within days of the transplant and suddenly the recipient can be fighting for their life again. One in ten recipients, in fact, will not be alive one year after the transplant. The donor might go through all this pain for nothing. This can leave a donor feeling devastated.

Being a live donor must be a sensation like nothing else imaginable. There is only a select group of people around the world who can tell you how they really feel on that morning just before they are wheeled through the doors of the operating room. I’m sure they don’t sleep the night before, knowing that tomorrow they are going to be cut open to give away a quite important part of their body. They have been through dozens of medical and psychological tests and the work up has been an arduous rollercoaster ride. With each test might come the news that the whole thing will be called off. I’m sure some feel incredibly relieved when this does happen, no matter how much they want to help – now they can bow out without terrible guilt.

For those who have been declared perfectly healthy and are willing, the day finally arrives. They have been very brave and strong up until that point but when they cross the threshold into the operating theatre, all of their bravado disappears. Donor and recipient lie side by side on narrow stretchers in the pre-surgery area, knowing that in a few hours they will be linked together for all time. Many will clutch each other’s hands as tightly as possible until the last moment when they are taken to their respective theatres. One, the very picture of good health, the absolute antithesis of the other who is gaunt, yellow and dying. This is a very uncomfortable scene to watch. The best words I can use to describe the donor’s demeanour are ‘white with fear’. They look like a person who is about to face their executioner. The sense of pride about the amazing thing they are doing seems to desert them at that moment and I’ve seen grown men shake and cry like babies. Families too are profoundly affected as they are torn in two directions: on the one hand this is the moment that life can begin again for the person dying of liver failure. For the other there is a real chance of dying healthy. No one knows how to feel. Should they be happy or sad? The confusion on all faces is obvious.

We do our best to reassure everyone that things will be fine. But any surgeon involved in donor surgery has also had little sleep the night before. It is hard not to worry about operating on these donors. A rule of surgery is ‘first do no harm’, and this is exactly the opposite of what we are doing to these donors. Everything has to go perfectly. The moves are rehearsed in our minds over and over. Every eventuality must be predicted and no detail left unaccounted for. The stress of this can be very difficult to handle and no matter how many cases you do, it never goes away.

For a while after the operation, life is not easy for the donor. They are very glum as they struggle with their pain. They find it hard to get out of bed and even coughing or taking a walk is not easy – all the things they previously took for granted. I’m sure that some might think, at least for a short time, that donating a part of their liver may have been the single biggest mistake of their lives. It is not difficult to figure out why. They had had nothing wrong with them and we have inflicted pain and suffering. Aside from doing a generous thing, they have no real reason to be in this situation.

The recipients of the transplant, however, are usually quite the opposite. They have every reason to feel better. In the space of a few hours they are no longer dying and, when the operation has gone well, they are typically up and around within a few days, suffering very little pain and looking forward to their new life. The large doses of immune suppressing drugs we give them can even make them euphoric. It can be a difficult time for donors to see the recipient flourishing when they are feeling so low. There is an old saying that ‘time heals all wounds’ and this is so true for these donors. Eventually, as the pain disappears and their wound fades, they begin to realise what they have done and feel the immense satisfaction of seeing the recipient start their life over again. So powerful is this feeling of pride that some donors even ask if they have enough liver left to do it again. They can’t, of course, it is a once in a lifetime gig.

Love you Lynn

During my time in the States my life was touched by some amazing patients; a patient in his 70s who returned to his demanding job within three weeks of his transplant; a snowboarder who won an Olympic medal shortly after his; and hundreds of people who were kind enough to allow an Australian girl to look after them for a little while. But the most remarkable patient I have had the privilege to care for was a lady called Lynn. She was a 32-year-old woman who came from a small town in Colorado. I met her for the first time just a few hours before the operation that would threaten her life and eventually save it. I couldn’t know it at the time, but the first time I took her hand would mark the beginning of the strongest bond I would ever form with a patient, and the most hours I would ever spend looking after any one person.

Lynn was a happy and energetic single mum raising two small girls. She worked very hard managing her family’s business, trying to give her kids a good life. Lynn’s world came crashing down when, out of the blue, she got a pain under her ribs. She went to her doctor and got a scan that, horrifyingly, revealed dozens of abnormal spots in her liver. Lynn had an unusual cancer called haemangioendothelioma. This tumour is so rare that there are only a few hundred cases reported around the world, ever. The cancer spreads from the liver to other parts of the body and after a few years it is generally fatal. There are very few cancers that can be treated well with a liver transplant but fortunately haemangioendothelioma is one of them. The catch is that patients with this type of cancer must wait a long time for a transplant because they do not have liver failure. The system that allocates organs for transplant heavily favours those whose livers have cirrhosis and don’t work any more over those whose livers are killing them from cancer. The transplant doctor looking after a cancer patient can apply to a board to give the person extra points, bumping them up the list, but cancer patients still wait too long for a second chance at life to come along. Meanwhile, every minute of the day the cancer is growing and spreading throughout their body – time is of the essence.

Lynn’s tumours grew and it became apparent that she would not get a liver transplant from a deceased donor any time soon. Out of nowhere, one of Lynn’s friends came forward and volunteered to donate the right half of her liver to Lynn.

Lynn’s donor also had small children. She knew the risk she was taking, but would not be deterred from helping her friend. She went through the weeks of rigorous medical tests and was deemed suitable to donate. It was then full steam ahead toward the day that Lynn’s life might begin again.

Lynn and her donor both had big extended families. When the day of the operation came, the families were all there at the hospital, keeping vigil, pacing around the waiting room. They prayed and drank endless cups of coffee, waiting for any word that things would be all right. I cannot imagine how it must have felt for those families, knowing their two girls’ lives were in the hands of strangers. There was such a crowd of well-wishers, we could actually hear them all talking while we were in the operating room.

The surgery to remove the right half of the liver from Lynn’s donor finished first and went very well. A few hours later we put the last few stitches into Lynn. Tired, but pleased, we strode out to the waiting room to tell the expectant families that things were OK. To our surprise, we were mobbed by Lynn’s mum and dad giving us joyful hugs as the rest of the family erupted in a raucous outburst of relief. We were even treated to a Mexican wave. The shouts of approval went on for what seemed like five minutes. Little did they know that this was just the first of hundreds of nights that they would spend in that dreary waiting room.

Both Lynn and her donor spent the first night in Intensive Care, and by the following day they were back on the general transplant ward in beds side by side. Lynn’s donor did really well and went home after a week without a problem. Lynn’s path to recovery was not to be so straightforward. It would be exactly one year before she would walk out of the hospital again, in many ways in much worse shape than when she entered it.

In the middle of that first night after her transplant, Lynn started to bleed from her bowel. Blood came pouring out of her backside and she endured a torturous night sitting in an adult diaper passing sticky black poo. This is not an uncommon problem because bleeding and liver transplant go hand in hand. In the first 24 hours after the operation, the blood is very thin and does not coagulate well. A normal liver continually manufactures molecules that allow the blood to clot, but when there is a new one this process takes a few days to kick in at full capacity. How fast the blood clots is a good way of telling if a new liver is working. Bleeding from the bowel like this usually stops by itself and as long as the patient is supported with blood transfusions, everything usually turns out fine. Even when you re-operate on these patients, the bleeding has usually stopped by the time you get in there.

Lynn’s bleeding didn’t stop. The next morning, after sitting by her bed all night pouring blood and clotting products into her veins, it became obvious that she needed to return to the operating room. We opened her abdomen again and stopped the bleeding from the bowel.

We hoped that this would be the end of the problems, just a small setback. But within a few days, Lynn became unwell again. This time she developed severe back pain, and blood tests revealed that she had one of the most terrible conditions a human can endure – pancreatitis. This is a problem you would not wish on your worst enemy. One of the very first things every doctor is taught in medical school is ‘Don’t mess with the pancreas.’ The pancreas is a gland shaped roughly like a fish that makes insulin, to control the sugar levels in the blood, and a corrosive alkaline juice that digests food and anything else it gets hold of. When the pancreas becomes inflamed, it spews forth a tidal wave of intensely alkaline juice that causes a ferocious and unstoppable chemical reaction. This normally innocuous little organ begins to digest itself and the fat surrounding the kidneys and bowels. The body will literally eat itself. All manner of poisons are released into the bloodstream leading to a cascade of devastating events. The lungs fill with fluid, the liver falters, the kidneys fail and the stomach becomes paralysed, filling with litres of bile and acid. Once started, nothing can be done to stop the carnage. This is pancreatitis.

In its severest form, pancreatitis kills one in three people and the rest spend six months or more recovering in hospital, and these are the numbers for those who were previously healthy. Lynn was starting way behind the eight ball by the very fact that she had just come out of a liver transplant for cancer, a potentially lethal problem all by itself. She only had half a liver and she was on powerful drugs to suppress her immune system so she would not reject it. This posed a massive problem, as these drugs also stop the body from fighting infections and slow healing down to a snail’s pace. Lynn was in grave danger.

She became increasingly unwell and we quickly needed to put her into an induced coma that she would not awaken from for six months. During this time, every orifice of her body was filled with a tube and her every function was controlled by a machine. A ventilator took her breaths for her and a dialysis machine washed her blood to get rid of her waste when her kidneys failed. The fat that surrounded Lynn’s pancreas began to liquefy and, like a stagnant swamp, bacteria multiplied unchecked in the foul broth this created.

Lynn’s chances of surviving this battle were near enough to zero, but battle she did. I saw her struggle and it profoundly affected me. I had cared for plenty of critically ill people before but there was something about Lynn that made me try harder than I ever had. I decided I was going to fight alongside her for as long as it took. Many nights I sat by her bed in the Intensive Care Unit, making small adjustments to her care: balancing the fluids going in and coming out, giving her blood, analysing her blood tests, adjusting the ventilator and changing her drugs. It was minute-to-minute work and I did it because I was determined that this lovely woman who did nothing wrong would survive. Maybe it was because Lynn and I were about the same age, or perhaps I could not bear the thought of her children growing up without her. I was pregnant during most of her stay, so these feelings were amplified. Whatever it was, I had a strong resolve deep in my core that I would not let her die.

I lost count of the number of times I called Lynn’s parents and her partner to tell them that tonight would be the night when we would lose her. They would come up to the hospital (if they weren’t already there) and hold an all-night vigil. Somehow, she always made it through to the next morning. Her kidneys, bowels and pancreas did not work. Her lungs were waterlogged – the little sacs that usually contain air were filled with fluid and she was literally drowning. For more than a week she had only 50 per cent of the oxygen in her blood that a human requires to live. I became fearful that we were only keeping a body alive and that Lynn’s brain would not make a meaningful recovery. There was a real chance we were working so hard to save someone who would never walk or talk again. I worried every day that Lynn’s family would have to take home a brain-injured invalid who would require 24-hour care. But every time we considered taking away her life support, she would make some tiny improvement that would convince us otherwise. There was always a sign that she was still fighting, so I didn’t give up.

When doctors look after critically ill patients, it is really easy for us to lose sight of the fact that there is a family whose lives are also profoundly affected by their loved one’s illness. Lynn’s mother and partner essentially moved into the hospital that year to be by her side and to take part in critical daily discussions about her care. Patients like Lynn undergo literally hundreds of procedures. Each one needs careful discussion regarding the pros and cons and written consent has to be given. Lynn’s family stood by and attended to these things with love and care. Suddenly their work and their personal interests had to be put on hold as they gave us their undivided attention. They had begun to live a strange transient life, sleeping in hotel rooms and on mattresses on the floor of the hospital. In many ways, I formed a closer bond with Lynn’s family than I did with her, at least initially, as we made difficult decisions together. It makes all the difference in the world to be dealing with a family who are understanding and patient and Lynn’s family were amazing.

We opened Lynn’s abdomen more than 15 times that year to scoop out handfuls of foul, grey, digested fat. The smell was so bad it would make me gag. It was like there was a dead animal inside her. When an abdomen is opened and closed so many times, the muscles rip and will not hold stitches. The edges of the surgical wound retreat and the skin of the abdominal wall dies back. There was not enough tissue to cover Lynn’s bowels and they protruded grotesquely out of her abdomen. All we could do was protect them with a plastic bag and leave her abdomen gaping open when she returned to the Intensive Care Unit. With the loss of the protective barrier of the abdominal wall, eventually holes formed in Lynn’s bowels and litres of faeces ran uncontrollably onto her skin. The corrosive fluid burned it until it was red raw. She lived in this torturous state for months.

Every patient with severe pancreatitis develops multiple infections of the chest, urine and blood. In someone like Lynn who had undergone a transplant, these infections were so severe at different times that we decided to stop her anti-rejection medication completely to give her body a chance to help itself. Within a few days, the inevitable happened and her body rejected her new liver. She became deeply jaundiced – her eyes an alien shade of fluorescent yellow. Her blood became as thin as water, her hair fell out and she stopped making the vital proteins that she needed to keep fighting and healing. We would treat her infections with the most aggressive antibiotics available and at the final hour, swoop in and rescue her rejection with medications so powerful that they can eventually cause cancer. Three times, we did this. It was unheard of, but still Lynn survived.

One evening, the pancreatitis ate away the artery to Lynn’s spleen and it ruptured in the wee hours of the morning. Again, I got a call from the ICU to tell me that she was in trouble and rushed in to find her bleeding to death. Her blood pressure was dangerously low and she required dozens of bags of blood. Again we operated to remove her spleen and called her family to tell them it was likely she would die. Again, she didn’t. Around this time I was spending four to five hours each day at Lynn’s bedside, caring for every facet of her being.

After six months on the breathing machine in an induced coma, one day, for no apparent reason, Lynn started getting better. With each passing day, her vital signs normalised and she began to move around on the ventilator, giving us subtle signs that she was alive. An eye would attempt to flutter open or a finger would move a little. There was less and less daily drama. I dared to hope that Lynn’s brain may have survived all the insults. When you look after someone who can’t talk back to you for hundreds of days, you quickly run out of things to say. You aren’t even sure if they can hear you. I would prattle on to Lynn in a one-way conversation about how my pregnancy was progressing and the different things I had done and seen that day. I would let her know that her kids were doing great and, up to this point, there had been not even a flicker of recognition.

Each morning we would begin our rounds in the ICU. I walked in one day and greeted Lynn with a ‘Good morning’ and began to tell her about the weather and the news of the day as I read her latest set of blood tests. I announced that Arnold Schwarzenegger had just been elected governor of California. This statement made her eyes fly open with surprise and resulted in me reeling backward in shock. Could I have been mistaken? Did she really just respond to what I had said? It was like a scene from a movie. The night nurse came in and said it was true. Lynn had woken up in the night and was even writing messages. It was like a switch had been turned on and she was back. Lynn continued her rapid improvement over the next few hours and it was quickly obvious that her mental faculties were still well intact. She demanded a big pad of paper and wrote volumes of notes, telling us all the messages and gripes she had not been able to express over the last six months as she drifted in and out of consciousness. A lot of the notes were about spiders – the morphine we had been giving her for pain had been torturing her brain with horrific hallucinations about spiders crawling over her.

The morning that Lynn woke up, I kept the delicious news to myself. Every day at 11 am, the big transplant ward round with all the transplant surgeons came into the ICU to see her. For the last six months we had all stood solemnly at the foot of her bed and discussed ‘Lynn’s body’ in a cold, matter-of-fact way. We discussed numbers, ventilator settings and medications. We had all naturally lost sight of who was lying in the bed. It was the only way for us to cope with something so awful. On this momentous day, the nurses had done what was left of Lynn’s hair and sat her upright in the bed. She still had a breathing tube protruding from a hole in her neck but was more than ready to greet everyone on the round and give them a lovely surprise. They came into the room and a smiling Lynn gave them the thumbs up. They could barely speak as they crowded around the bed to say hello. I wiped away tears. This was the moment that made all those hours of work worthwhile.

Lynn then began the long process of recovery and spent another month in Intensive Care. I had to go and have my baby just after she had made this big step forward. Everyone was under strict instructions from me not to allow anything to happen to her while I was away. She was still in a precarious state and could easily take a step backwards. Five days after Abigail was born, I took her into Intensive Care to show her off to Lynn. This was a big priority for me because we had gone through the whole pregnancy together. It made her day to see this little person I had been discussing with her during our long nights together in the ICU. I was a little worried about all the bacteria in that place, so I stood at Lynn’s door and held my tiny daughter aloft so she could admire her.

After several more difficult surgeries and many months of rehabilitation we managed to close Lynn’s abdomen and stop the holes in her bowel from leaking. For a while there during her recovery, Lynn had the unique opportunity to watch the food she ate reappear out of the holes in her bowel a few minutes later. It is extraordinary what a human body can endure. One year and one day after her transplant, she left the hospital. This happened to coincide with my last day of work in the US and we had a huge farewell party together.

Lynn and I are still close and talk regularly. She is now back living a relatively normal life with just a few annoying long-term problems with hernias and numb feet due to the hours spent motionless in Intensive Care. She cherishes every day and has seen her daughters grow up, finish school and get married. Her transplanted liver is working well and she has no signs of her original cancer.

There is a final, incredible twist to this tale. Sadly Lynn’s relationship with her partner at that time did not weather the stress of her illness. They parted on good terms. A short time later, though, Lynn met a lovely man who made her happy and they were married. During her time in the hospital, Lynn had developed a friendship with one of her nurses and they had kept in touch after she went home. It just so happens that this nurse had battled kidney failure for many years. She had already endured two kidney transplants and now she was back on dialysis waiting for a third. She had been waiting a long time for another chance at life and was getting sicker. There were no donors on the horizon. Incredibly, Lynn’s new husband asked if he could give one of his kidneys to Lynn’s friend the nurse. He was so grateful to have met Lynn and realised that he never would have if it wasn’t for someone giving her a piece of their liver. He wanted to show his appreciation by helping someone in the same way. Amazingly, he was a match and gave his kidney to Lynn’s friend. It has been a huge success and both ladies are living their lives and enjoying every extra day they have. I am humbled to know them. They are fighters who have looked death in the face and said, ‘I’m not ready yet.’

Transplant Mom

Six weeks after my beautiful daughter emerged, it was time for me to start back at work. Americans take extreme pride in their jobs – they live to work and their enthusiasm easily rubbed off on me. With most working mothers only stopping for a short time to bond with their newborns, I felt like I had to get back to it quickly too. No one seemed to bat an eyelid when I kissed my daughter goodbye and picked up my job again like I had never left. Those six weeks at home with Abigail were blissful. There is no doubt that being a new mother is tough, but for someone like me who was used to going without sleep, getting up at 3 am to feed a baby rather than driving in to deal with a bleeding liver transplant patient was sheer heaven.

Because Andrew had to continue working just to keep food on the table, we made the decision to hire a babysitter to look after Abigail during the day. Even though it was difficult heading back to work so quickly, I was careful not to lose sight of the bigger picture. My sole reason for being in the States was to become a transplant surgeon and I did not want to be away from it for too long. As much as I wanted to stare at my lovely little baby all day long, I reminded myself that I was doing this for the three of us. It wasn’t about being a superwoman, it was about keeping a commitment I had made to my job and achieving my goals of being a working mother. Instead of a ‘soccer mom’ I became a ‘transplant mom’. I hoped my passion would rub off and set an example for my daughter that everything was achievable with drive and good planning.

I was more than a little emotional when I went back, though, suffering with the baby blues. Every morning when I left the house I would sob, knowing that it would be hours before I saw Abigail again. I tried my best not to let my sadness show at work but I struggled, and for a while I’m sure they all thought I had lost my mind. Going back to work so early did very little for my self-esteem, either. I looked and felt absolutely wretched. Not to go into too much detail but I was either leaking breast milk, bleeding or peeing my pants every time I coughed. I was literally covered in protective padding just to get through the day dry. To add to my discomfort, unlike gorgeous celebrities, after six weeks I had most definitely not returned to my ‘pre-baby body’ and had to endure several well-intentioned questions about when my baby was due. This did not improve my mood.

Just like my pregnancy, starting back at work as a new mum presented all sorts of interesting practical difficulties. Breastfeeding has never been easy for me, but in my quest not to miss out on any important aspects of mothering, I was determined to give it a go. In those first few weeks it was a real problem. I would be operating away and I would gradually become aware of an uncomfortable wetness running down my abdomen. My squirming always drew the attention of my male assistants in particular, and when they discovered what was happening, they would delight in mimicking the sound of a baby crying to ensure my let-down was even more prolific. This was more than any breast pad could cope with and I would grin and bear it whilst milk leaked through my bra and onto the front of my scrubs in ever expanding circles. I smelled like a rancid milk bottle by the end of the case by which time a shower and change of clothes were definitely in order.

On-demand feeding meant having a freezer full of little packages of breast milk, so when I was away from the house, Andrew could just thaw them out and satisfy our hungry girl. I made good friends with my breast pump; in fact, at every spare moment I was attached to this device. As though they had ‘transplant moms’ in mind, some ingenious person invented a double-barrelled battery powered pump complete with a freezer storage compartment and picture of my child (to aid let-down) all housed in a discreet black leather handbag. That bag went everywhere with me, allowing me to pump on the run and do my job at the same time. I had it down to a fine art and I could procure a whole feed in under ten minutes in a process not dissimilar to milking a cow. Because I needed to do this every three hours or so, I had to pump in some odd places and at some unusual hours of the day. I did it perched on the edge of toilet seats during short breaks in operations. I did it in the back of the aeroplane on the way to a donor, throwing a blanket over myself to hide the confronting sight of a pair of engorged boobs hooked up to the device. The chug, chug, chug sound of the machine was difficult to ignore, though, even with the sound of the jet engines roaring, and my three male colleagues sitting opposite me in the plane didn’t know where to look while I was attending to milking time. I can’t imagine why!

Whenever possible I would take a leaf out of Dr Nancy Asher’s book. She was the San Francisco transplant surgeon who also took motherhood in her stride. Whilst I didn’t have the financial means to have a full-time nanny waiting outside the operating room with my hungry baby, I would take Abigail to work with me on the weekends when I knew I could give her some time. She became a regular fixture around the wards, strapped to my chest in a baby sling, loving every minute of the attention she got wherever we went. The patients were visibly cheered up by her visits and the sight of a smiling infant made them forget their troubles for a moment. She was a great baby, just happy to come along for the ride. She would usually be taken from me the moment I got to the ward and passed around between the nurses and patients. She would sometimes disappear for an hour or so but I would only have to look for the big crowd of admirers to find her. A few months old and she was already a social butterfly.

Before we knew it, our two years of living like Americans were coming to an end. We would have loved to have stayed and made our life there. Denver was a happy place to work and raise a child, with plenty of fresh air, activity and optimistic people. Sadly, unless I could be of value to the US and do something like win a Nobel Prize, my work visa stipulated that I had to return home. Dr Kam, my generous boss, hosted a huge farewell party for us and it was very hard to say goodbye to those kind people who had given so much support to Andrew and me as we started our family so far from home. It was with a heavy heart that we boarded the plane back to Australia with considerably more luggage than when we arrived. It marked the end of an amazing chapter in our lives but, as much as I wanted to stay, I was content to be returning to Australia holding Abigail in my arms. It was like taking my own little piece of America with me. I received a treasured letter from the White House when she was born. It read:

Welcome. The day you were born will always be a special day. Your birth has brought great joy to your family and your life symbolises the promise of tomorrow.

We wish you a happy and healthy life that is full of love.

May God bless you and may God bless America.

Signed George Bush and Laura Bush

As a finale to our stay, Andrew and I took our little family on a traditional American road trip, taking in at least 25 of the 50 States. After six relaxing weeks, our previously trusty car’s transmission deposited itself in several pieces on a road in rural Mississippi, directly in front of a prison work gang. Despite feeling for a moment like we were the social workers in the movie Mississippi Burning, the prisoners were just delightful and stayed with us until a Baptist minister with ‘I honk for Jesus’ painted on his car window gave us a lift into town. From there, we sold what was left of our crippled car and headed for home. God Bless America indeed, we loved every minute and will forever hold you in our hearts.

During my time in Colorado, I was involved with 120 liver and 180 kidney transplants. It was a fantastic grounding and I hoped on my return to Brisbane to get a job where I could build on my experience. True to his word again, Professor Lynch had arranged yet another post for me as Fellow, this time at my alma mater, the Princess Alexandra Hospital. This would give me two years to perfect the other aspects of hepatobiliary surgery aside from transplant – including liver resections, where different sections of the liver are removed, taking enough to clear a cancer but leaving sufficient liver for the patient to survive. Learning to remove sections of the pancreas was also on my ‘to do’ list. Only after I had mastered the other operations that could be performed on these organs, in addition to my transplant experience, would I have any hope of handling all the problems the liver and pancreas could throw at me. Only then might I have the right to call myself a hepatobiliary surgeon who was good enough to work at the Princess Alexandra Hospital.

A fully fledged surgeon at last

On our return to Australia, Andrew and I set about adding to our family. Madeleine Shelby, named after Coloradan and former US Secretary of State, Madeleine Albright, was followed eighteen months later by Priscilla Dana – named of course for the wife of the King (aka Elvis Presley) and my hero from The X-Files, Dana Scully. Three girls in three years, what were we thinking? We were thinking that we could have everything and we were right, we could – satisfying jobs and a lovely family. I wasn’t getting any younger, so we had to get on with it.

Again I worked right up until the day of the girls’ births and, not wanting to be away for long, I was back at work again within two months. The reality of our lives was that I was the main breadwinner and I had to keep food on the table. For both Madeleine and Priscilla I needed to have a caesarean section to deliver them safely. For me, having surgery was so much better than the traumatic labour I had had when I pushed Abigail out.

Obviously I feel very at home in an operating theatre, so getting to watch surgery where my own child was being born was a wonderful thing. It was calm and controlled, like all good surgery should be. I was treated to the unusual sight of watching my own operation and Andrew was fascinated too, commenting helpfully that he could see my bowels. I’m sure my obstetrician was more than a little nervous, having to operate on a fellow surgeon. The scrub nurse kept looking over the drapes, reassuring me that things were going well and the stitching was very neat.

After Priscilla’s birth, my return to work came a little earlier than expected. Three weeks after she emerged, I was in the midst of the deep power sleep of a breastfeeding mother. The phone rudely interrupted my slumber. I forced one eye open and peered at the red numbers on the bedside clock.

‘Why is the phone ringing at 2 am?’ I thought. ‘Has someone died? Are they calling about a patient?’ I reached for the phone and on the other end was one of the surgeons from the PA.

‘Kel, so sorry to call but I thought you might be awake feeding the baby or something,’ he said a little sheepishly.

‘No, actually, new mothers do sleep sometimes,’ I replied groggily. ‘But what’s wrong?’ I knew Priscilla would be awake any minute now wanting a feed, so I reluctantly swung my legs over the side of the bed.

‘Ah, yes, well, anyway,’ he continued on the other end of the phone. ‘I was wondering if you could help us out of a bind tomorrow. We have two transplants on, you see, and there is no one to do the pancreas cancer case. Do you think that there would be any way that you could come in and at least start the case off until I finish the transplant?’ he pleaded.

‘What?’ I said, thinking I might still be dreaming. ‘I just had surgery myself.’ Was he really asking me to do this? ‘This sounds a lot like I am on call, it’s a bit unreasonable,’ I said, quite awake now.

‘We’d be really grateful.’ He was trying flattery now. ‘Think of the story you’d have to tell.’

Well, that was it, I had to take up the challenge and yes, I am now telling the story. He sounded so desperate and I felt terribly sorry for the cancer patient who would get cancelled if I couldn’t pull myself together to be there. I hung up, still in a slight state of shock.

‘Who was that?’ Andrew asked, now wide awake too.

‘No one,’ I said, too afraid to admit what I’d agreed to. I left it until the next morning to tell him. He wasn’t happy, but knew he couldn’t stop me. I padded up my boobs, fixed up my neglected hair, took some painkillers and in I went. Of course as usual, the transplants took far longer than anticipated and my colleague never did make it in to take over from me. I had to do the whole case from start to finish, with a really junior assistant to boot. I was hurting by the end. Three weeks post partum, three weeks, I still remind him regularly.

‘Well, you did it, didn’t you?’ he shoots back with a grin.

I was on my game though; that patient had a terrible cancer and is still going strong five years later.

After returning from the States, it would be another two years until my dream job at the PA would come up – that of fully fledged surgeon in the Queensland Liver Transplant Service. I bided my time learning everything I could about taking out sections of the liver and pancreas, mainly for cancer. Even though it seemed I had the big job in the bag, given I was the only applicant and the only person in Australia even remotely qualified for it, bureaucracy dictated that I had to have an interview. I was 25 weeks pregnant with Priscilla at the time and I thought I would be facing a room full of strangers from administration and human resources. I decided I would wear a long trench coat to the interview (it was the height of summer) to hide my expanding belly. Despite it being totally illegal, my gestating brain was worried that they wouldn’t want to employ a pregnant lady to do a job like this and have her disappear on maternity leave soon after. When I got into the interview, however, the panel was filled with the faces of the surgeons I had worked with for the last ten years. I immediately relaxed and was ready for the first question. To my surprise, someone asked with a big grin, ‘So, just how many children do you think you might have?’

I smiled back at the tongue-in-cheek question and said, ‘You can’t ask me that, next question.’

‘We are just worried about how you are going to do it all,’ he said.

‘I’ve managed to do it all so far,’ I shot back as I took my trench coat off with an air of confidence – I obviously didn’t need it any more.

The day after the interview I found out that I got the job: I was now Hepatobiliary and Liver Transplant Surgeon. After almost nine years and thousands of hours of training, I achieved something I would never have imagined. This is where you will find me today.

Give me the gun, this liver’s coming out

I got an unusual email one day. The subject line read urgent, please help, my child is dying! I dismissed it as another scam trying to get money out of me, but just as I was about to hit delete, my secretary rang and told me I must urgently call the international telephone number in the email. An Australian family had been holidaying in Argentina and they were frantic: their 11-year-old daughter had been enjoying a day of skiing when she had slipped and slammed straight into the pylon of a ski lift, splitting her liver in half in the process. The little girl was fighting for her life in a small hospital close to the ski resort. The general surgeon on the scene had opened her abdomen and found that she was bleeding to death from her ruptured liver. He closed her again after wrapping her torn liver in gauze bandages in the hope that it would stem the tide. It was not working and the family had been told to expect the worst. Now they were appealing to me from the other side of the world for help. Goodness knows how they got my name. They were in a foreign country and felt very alone. Surely there was more that could be done?

‘Could she have a transplant?’ they wrote.

‘No, she can’t, it won’t work, there is not time to find a donor,’ I thought to myself, but there was more that could be done. I had to act fast. Serendipitously, it just so happened that we had a surgeon training with us in Brisbane who was originally from Argentina. With his contacts we were able to get hold of a specialist liver surgeon in Buenos Aires, who phoned the small hospital where the girl was being treated. He coached the desperate surgeon through another operation, and this was all he needed to do to stabilise the girl enough to transfer her to the capital for further care. I received daily updates from the parents over the internet, and I let them know what they could expect and reassured them that everything the Argentinean surgeons were doing was right. After at least two more big operations to remove sections of her injured liver, the little girl was well enough to travel home and I finally got to meet this patient who was my longest distance consultation ever. Such is the nature of managing liver injuries sometimes.

The Princess Alexandra Hospital is a tertiary referral centre. This is a long-winded way of saying that we look after some really complicated stuff. For patients with liver trauma, we are their final outpost. Patients come to us from all over the place and they are frequently one step away from death. I am fortunate to have every resource that exists in the world at my disposal, the best of everyone and everything, and this enables me (for the most part) to begin to mend these broken people. Some of the most challenging cases I look after are the victims of serious accidents who have had their liver split in two by sheer force of impact. These can be scary procedures.

Some liver injuries are simply untreatable – these are the ones where the violence of the accident literally rips the liver from its blood vessels and the victim bleeds to death at the scene. Even if this kind of accident happened at the front door of my hospital, there is absolutely nothing I can do about it. That person will be lost. For most people with liver injuries, though, the progression toward death occurs a little more slowly and there is actually time to help them. The best way I can describe what happens to a liver during trauma is to think of it as a juicy plum. It has a pretty tough skin, but it is soft and vulnerable on the inside. When it gets squashed, the skin of the liver can stay deceptively intact, hiding the bruises within. The liver is well protected from minor trauma by the ribs, which act a lot like a suit of armour. When there is a severe blow to the chest, though, it is the ribs that often do the damage as they fracture and splinter, spearing straight into the depths of the liver.

Within the liver there are sizeable arteries and veins radiating through its soft insides, just like the spokes of a wheel. These vessels channel litres of blood at a staggering rate. What makes dealing with liver injuries difficult is that all the biggest blood vessels happen to be in the deepest part of the liver. This means that when there is a tear in the liver, the most frightening bleeding will come from the base of a deep crevasse, like a river flowing through the deepest part of a canyon. The weight of the liver splitting and falling apart causes any tear in these big blood vessels to be held open, and massive blood loss ensues. Sometimes all that is needed to stem the bleeding is to simply push the edges of the shattered liver together and roughly return it to its natural position. This closes the holes in the veins and everything calms down, at least temporarily. This buys valuable time for the anaesthetist to give more blood and stabilise the patient. Occasionally, pushing the liver together like this is even enough to solve the problem completely. Multiple gauze pads are packed around the liver to hold it in its rightful position and the patient is returned to the Intensive Care Unit. By the following day, if the bleeding has stopped, the packs can be removed and the body will heal itself. Packing a liver is something that any general surgeon is trained to do.

Sometimes, though, packing does not fix the problem and the bleeding doesn’t stop. The tears in the blood vessels are just too big and every time the pressure on the liver is released, the holes at the bottom of the cracked tissue open up again. Blood will well up instantly, like a sink overflowing, and the surgical suckers can’t keep the field dry for long enough for me to get even a glimpse of anything to stitch. Pulling the liver apart has the additional effect of tearing these blood vessels even further. This is a terrible situation to be in for both the patient and the surgeon. With each drop of blood lost from the ripped liver, the patient makes less and less clot, catapulting them into a death spiral that quickly becomes difficult to reverse. The only solution to this problem is to cut away the damaged section of liver in order to see what is actually bleeding. Suddenly all the holes in the blood vessels will come into view, allowing the opportunity to stitch them closed.

This sort of liver surgery is usually well outside the repertoire of most general surgeons. Even on a good day, they are unfamiliar with the complex operations on the liver, let alone in a trauma situation when they are faced with a patient who is bleeding to death right before their eyes. Where I live in Queensland, more often than not the kind of accidents that damage the liver happen in the most remote places, where the nearest surgeon is far from specialist colleagues like me who can lend a hand. It is a very lonely feeling. From time to time I will get a call from a surgeon in just this situation. They will be standing in the operating theatre holding a shattered liver together with their gloved hands. If they release the pressure even for a few seconds, blood will pour out at an alarming rate. They are literally holding a life in their hands. These patients cannot be packed up with gauze pads and transferred by plane, ambulance or any other method, so I have to go to them. One of the good things about being part of a transplant unit is that I am used to travelling at very short notice. Within half an hour I can gather up a few special gadgets that I use to make liver surgery easier, cancel the rest of the day and hit the road. Occasionally I am lucky enough to get a police escort and sometimes they give me the go-ahead to drive just a little faster than the speed limit allows. On the way, I have a little time to ponder what the scene will be like when I get there. I rehearse what I’ll have to do and how I’ll do it. With every passing moment I half expect to get a call saying, ‘Thank you for coming but the patient is dead, you can turn around and go home.’ No matter how hard I try to stay calm as I drive along, by the time I arrive my adrenaline is pumping and I am pretty keyed up. Security will meet me at the front entrance and rush me up to the theatre where everyone is waiting for me. When I walk in, all eyes are on me to take control of the situation and fix the problem. I know that everyone is thinking, ‘What is so good about this woman that she can do something that we can’t?’

I once worked for a very wise surgeon who taught me how to face the peril in these high-pressure situations. When I was a junior registrar, I was alone one time and trying to fix bleeding that I could not control. I was being assisted by a very inexperienced resident, and every time I took my finger off the haemorrhaging vessel, they just couldn’t put the sucker in the right place to allow me enough of a view to get my stitch in. I just didn’t think I could fix it without extra help. The problem was, that help was in his home about 15 kilometres away. I called this surgical boss, whining to him that I was having problems and I didn’t know what else to try. I asked him if he would drive in as quickly as he could to help me out. He knew from long experience that if I couldn’t get myself out of the predicament right there and then, by the time he came in I would have lost the patient. In his most soothing tone, he gave me the following advice.

‘Doctor, I want you to step outside and take a deep breath,’ he instructed. ‘Then I want you to imagine you have a red bandana. Take that bandana and tie it round your head. Then, I want you to pretend you are John Rambo and get back in there.’ He hung up the phone.

I was momentarily stunned – I guess he wasn’t coming then. Apparently I was to be the only member of the cavalry that night. I regrouped and focused my inner Rambo and did exactly what he told me. I learned that sometimes there is no one to call for help, sometimes you have to trust your own abilities and just fix the problem. So now, whenever I am the person called upon to save the day, I get my red bandana out and tie it tight around my head.

Fixing one of these complex liver injuries is such a unique procedure that we have developed a special name for it. When we say it, everyone at our hospital knows what we are talking about: ‘chk-chk boom’. The phrase entered the vernacular after it featured in a YouTube video of a young woman telling a story about someone getting shot, and how the gun ‘went chk-chk boom’.

Shortly after this video had been in the news, I received a call regarding an elderly gentleman who was in deep trouble. He had fallen off a ladder and ruptured his liver. He was bleeding to death, his liver blown apart by the impact of the fall. He had already been operated on in a smaller hospital and the surgeons had done their very best to stabilise him. He was steady enough to transfer via helicopter to the PA, so the surgeons packed a large number of gauze pads around the injured liver and sent him down. During the flight, the packs loosened and his liver began to bleed once more. By the time he arrived he was fighting for his life again. I had no option but to take him straight to the operating theatre and attempt to remove the damaged piece of liver so I could see what was bleeding.

As it so happened, I was the only liver surgeon in town that day. My colleagues were all on vacation or at meetings. Liver surgery is a team sport. We need each other to do these big cases. It is always a nervous time when a liver surgeon is left alone in town, because Murphy’s Law usually dictates that there will be some sort of disaster requiring you to be in two places at once. Sure enough it happened that day: I was operating at Greenslopes Private Hospital when the call about this patient and his bleeding liver came through. I was immediately uptight because I knew I had a waiting room full of patients in my private rooms who had driven from all over the countryside to see me that afternoon. Now this chap was on his way, everything else would have to wait. I finished the operation I was doing as fast as I could and jumped in the car to get back to the PA. Just as I was calculating how much time it would take for me to finish the emergency liver operation and maybe see the waiting patients afterwards, I received yet another phone call. This time, it was the Royal Children’s Hospital. One of the kids who had undergone a liver transplant the week before was showing signs of bleeding into their abdomen. I now had a critical situation on my hands. There were two patients, in two different hospitals, both of them needing my urgent attention. I was the only member of the cavalry in town. I had to make a decision: which patient would die first without me?

I swung my car towards the Children’s Hospital to check on the child. Once I’d seen them, I decided the elderly man was sicker and gave some orders to the junior staff at the kid’s hospital to stabilise the child while I dealt with the man. I drove like a bat out of hell back to the PA. On the way, I donned my imaginary red bandana in preparation for removing half of the man’s liver as fast as I could and getting back to the Children’s hospital to make that patient safe, too.

Routine surgery to remove a section of liver is a painstaking process involving carefully cutting and tying hundreds of tiny blood vessels and bile ducts. Great care is taken to lose only a few hundred millilitres of blood in a very calm and controlled manner. In trauma, however, the pressure is on to get the job done quickly. Removing the section of damaged liver in this situation is best described as a precision slash and grab. Not only do I have to be fast but I must be accurate. The correct piece of tissue has to be removed and one wrong cut can damage the blood vessels that supply the only remaining piece of liver. To do this, I form a 3-D mental picture of the internal structure of the liver and do the job by feel and not by sight. In trauma, what is usually visible, is flooded by a litre of blood. Everyone in the operating theatre has to be on their game. There are literally only minutes to make things right before the anaesthetist won’t be able to keep up with the blood loss any more and the patient will die. To do a trauma liver resection I use a device that looks a little like a pump-action shotgun to literally ‘staple’ the damaged liver from its remaining attachments. This instrument is a little over a foot long with a staple cartridge at its end. It works by jamming the jaws of the staple gun into the liver tissue, clamping it shut and firing. When the trigger is pulled the gun fires six rows of staples. This is followed by a sharp blade that slices the tissue in between the rows of staples, leaving the liver separated and blood vessels neatly sealed. This stops much of the bleeding and as more and more of the liver is cut away, the bleeding that is not quietened with the gun can be dealt with by stitches. When a surgeon is in the pressure cooker situation of a trauma, it can be really easy to get carried away with the stapler and go too far. One too many pulls of the trigger can mean the difference between a live patient and a phone call to the coroner. Firing this gun makes me feel that just for a moment I am Clint Eastwood in Dirty Harry, discharging my Magnum .44 into a bad guy over and over. After each firing, I press the release button and the gun springs open, the cartridge spent. I hold my breath as I wait to see if that load has done its job and that the release of the trigger is not followed by a tidal wave of haemorrhage.

With a bleeding child at another hospital and the man’s life slipping away in front of me, I knew that I would have to staple this liver out even faster than usual. I called for two guns, so I could have one after another with no pause for reloading. I fired at will and without looking away from the liver, threw each empty gun back to the nurse to reload with a new staple cartridge (by loudly shouting ‘Reload!’ for best effect). She kept them coming and I blazed away until the offending segment of liver flopped free into my hand. At one point I even had a gun in each hand, blasting away, adding to the sense of Wild West action. I closed my eyes for a moment, trying to slow my heart rate down because I could feel my pulse surging in my ears. ‘Please let there be some sort of functioning liver left at the end,’ I thought. I opened my eyes again and peered into the gaping hole that used to contain the right half of the liver. Lo and behold, the remaining section of liver looked pink and the bleeding wasn’t too bad. The gun and I had done our job and we had a patient who was in with a chance. I left my registrar to clean up and close while I jumped back in the car and sped to the Children’s to deal with the next bleeder. Happily the child had stabilised by the time I arrived and I was able to take them to theatre and deal with their bleeding in a more orderly fashion.

Because I had two patients on the go, that elderly man’s liver was always going to have to come out fast. It all happened with such haste that later it prompted someone to ask how I managed to get it all done. The YouTube video popped into my head. ‘Chk-chk boom,’ was my reply, and from that day a liver resection for trauma was renamed. Now if I tell the nursing staff that we will be doing a ‘chk-chk boom’ procedure, they know exactly what to prepare for.

We will not let your daughter die

While taking out a section of liver in a hurry represents the pinnacle of a liver surgeon’s skills, I am nothing without my team, especially my anaesthetist. Dr Rebekah Ferris is one of my best friends, and I’ve known her since we were junior doctors. She also happens to be one of the best anaesthetists I know; the person at the head of the patient who I rely on implicitly. Without her, I couldn’t do what I do and have a live patient at the end of the operation.

Rebekah’s brilliant work was no more evident than on the day I received a call to go urgently to the Intensive Care Unit at the PA to see a patient who had been transferred by helicopter from another hospital. Her name was Krystal. I had simply been told there was a patient who was bleeding. I arrived at her bedside to find a beautiful woman lying in an induced coma, breathing with the aid of a ventilator. Her hair was braided, she had been bathed and her bedclothes were neatly tucked under her chin. She looked totally serene and her appearance betrayed the utter devastation that was taking place inside her abdomen. In the usual bland and clinical way that doctors do, the Intensive Care registrar began to fill me in on her history.

‘This is a 23-year-old lady who developed sudden abdominal pain whilst at home and collapsed on arrival at the hospital. She underwent emergency surgery and was found to have a bleeding liver. They packed her liver with gauze but they don’t know why it ruptured,’ he said in a robotic monotone.

They didn’t know why her liver had ruptured, but I had a pretty good idea. It was an even bet that this was going to be a ruptured adenoma; a rare but deadly tumour that grows in the livers of young women. It was the only logical reason why a liver would rupture in a person who hasn’t been in an accident. These non-cancerous tumours grow quickly when they are fuelled by an excess of the hormone oestrogen, causing them to rupture in the process. Without urgent attention, a bleed from an adenoma is frequently fatal.

Whilst the Intensive Care doctor was in the middle of his dissertation, Rebekah bounced into the room, full of her usual enthusiasm. She always has her finger on the pulse of what is going on around the hospital and that day was no exception.

‘I heard you had someone bleeding and thought you might want to bring them around to theatre straight away,’ she said. ‘I tracked you with my iPhone and saw that you were already around here. I’m available to put her to sleep and I have a team of nurses ready to go.’

We both ignored the ICU registrar who was still talking and instead turned our attention to Krystal’s family, who were gathered around her bed. I thought they looked even more distraught than usual for a family in this situation. Something was clearly amiss. A good-looking man, who I presumed was Krystal’s partner, was holding her hand, and her mother and father were hovering nearby, dabbing their tear-filled eyes.

‘Everything will be all right, you know,’ I said reassuringly, even though I wasn’t sure yet that it would be. ‘I know you are worried but we’ll take good care of her and we will get her through.’

They all exchanged strange looks and Krystal’s mother began to sob loudly. There was definitely something more going on here.

‘We’re still in shock about the baby,’ Krystal’s partner stammered.

‘What baby? What are you talking about?’ I asked, a little bewildered. Then I felt the hairs on the back of my neck stand up as things began to become very clear to me.

‘Our baby, our little girl …’ he said. ‘She died.’

‘What? When?’ I demanded.

‘Today,’ he sobbed.

I felt the blood drain out of my face and my stomach twist into knots as the true horror of what had just happened to this family hit home. I didn’t want it to be true.

Her partner started to tell me about the events of that day. Yesterday, Krystal had been nine months pregnant with her first child. She had chosen not to find out the baby’s sex ahead of time but had always longed for a girl. As much as she secretly wished for a daughter, she had talked herself into a boy because she didn’t want to be disappointed. She woke up that morning – the day the baby was due – and had started packing her bag for the hospital. Krystal was happily adding some finishing touches to her baby’s nursery when, out of nowhere, she felt an incredible pain rip through the right side of her abdomen and into her shoulder. It brought her to her knees and as she called out for her partner, Krystal knew that something was very wrong. He rushed her to the small country hospital close to their home. While Krystal drifted in and out of consciousness, they sat in that hospital waiting room for a couple of hours before anyone realised that this was not labour pain.

‘She was just so pale,’ her partner kept saying. ‘I didn’t know what to do, no one was helping us.’

Because she was young and fit, Krystal’s normal blood pressure and pulse gave no indication of the catastrophe taking place inside her, inches away from her unborn child.

When the doctor at the small hospital realised that things were very serious, he bundled her into an ambulance and she was driven at full speed to a larger district hospital. By this time, Krystal and her baby were near death. Adenomas are so rare, occurring in only one in a million women, that no one suspected what was going on. It is not a diagnosis that anyone apart from a liver surgeon would easily think of. Everyone was misled by the pregnancy, believing that it all had something to do with the baby. By the time she had reached the next hospital, Krystal’s heart had stopped because there was almost no blood left in her veins. The doctors worked furiously to get her back. Before she lost consciousness, Krystal had sensed that her baby was not doing well, yelling to her partner through the excruciating pain that she had not felt it move for a long time. She later told me that she knew her baby had died.

The doctors managed to get her heart started again and rushed her into the operating theatre. They delivered Krystal’s lifeless baby girl via emergency C-section. After that sad moment, and just when they thought things might stabilise, the real problem finally revealed itself. Litres of blood gushed out of the wound and it was clearly not coming from her uterus. The surgeon rapidly extended the incision upward from her low caesarean wound in a sweeping cut from pubis to breast. This lay her completely open and there it was – a gaping crater in the centre of her liver. Krystal’s life ebbed away as she tried to follow her daughter and the anaesthetists struggled to keep up by pouring bag after bag of blood into her veins. The surgeon pushed the liver’s ragged edges back together, bolstered by dozens of gauze packs to try and restore it to its natural position. This manoeuvre slowed the bleeding enough to stabilise her and he closed her up, stuffed tight with packs, and put her on the helicopter that would bring her to me. The packs would only hold her for so long and Krystal was continuing to bleed to death as we stood in front of her.

Rebekah and I absorbed this story and stared incredulously at this loving family who had just lost a muchwanted baby daughter and granddaughter before they had even met her. Now they faced the prospect of losing the baby’s mother, all on the same day. I found it all a little difficult to process. I was truly speechless (and that doesn’t happen often). It took a few moments before I could open my mouth to say something, but all that came out of me though was a big sniffle and then a sob. I tried to keep myself in check, tried to remain professional, but of course I couldn’t and the tears came streaming down my face. Rebekah followed suit and we were all crying right along with the family.

‘We will not let your daughter die, that is not happening today,’ Rebekah managed to say to Krystal’s family. ‘We will take her to theatre now, fix her up and bring her right back to you.’

Rebekah and I literally scooped her up and pushed her bed around to the operating theatre ourselves. We were in charge of her now and we would not stop until she was out of danger. We called through to theatre on the way and told them to expect us shortly and to get ready for major blood loss. It would be a ‘chk-chk boom’ case. Our team was on fire that day and when they heard the story of what had happened to this young woman they were even more efficient than usual. Everyone was desperate for Krystal to live. Fortunately the nurses were ready with my staple gun because the bleeding was truly horrendous. I had that ruptured section of liver in the bucket in no time flat but this only did half the job. As the torn blood vessels retracted deep into the remaining half of the liver, the blood loss continued. It gushed out so fast that it actually made a noise. This is what we call ‘audible bleeding’ and it meant that Krystal was in mortal danger. When someone has received dozens of bags of blood, their body will run out of the little molecules that the body needs to make blood clot. It all happens so fast that there is no time for the liver to make any more. There was nothing I could do. Just like plugging holes in the dyke, every time I put a stitch in one place, blood spurted out from somewhere else. I kept repeating to myself quietly, ‘I’ll just keep stitching until Rebekah tells me she is dead.’ Many people say that when they have a near-death experience their life flashes before their eyes. As I stood over her, it was Krystal’s life flashing before my eyes. As her blood rushed between my fingers I thought, ‘The next few minutes will determine the rest of this woman’s life.’ I pictured her family waiting outside and I imagined myself walking out to tell them that the person they loved most in the world had died.

The signs of a patient’s deterioration during an operation can be very subtle and Rebekah has developed a way of telling when things are not going well. She calls her sixth sense, the ‘sounds of my surgeon’. She pays very close attention to the noises I make and watches the way I move when I am under pressure. Anaesthetists can’t always see what I am doing in the abdomen, but after years of watching my body language, Rebekah can pick up the subtle changes in my posture that occur when I feel like I am seconds from disaster. She notices how my head leans forward to almost touch my assistant as we both focus our attention on a critical part of the operation. She listens to my little grunts of exertion and watches how I rock back and forth slightly when I am tense. She hears the suckers working overtime to mop up a sudden rush of blood.

Rebekah’s senses were in top form that day and she knew that I had done all I could. It was now up to her. While I held my hand hard on the ragged surface of the remaining section of liver, exerting as much pressure as I dared, Rebekah darted about at the top of the operating table with syringes of drugs in one hand and the telephone in the other. She was constantly talking to the blood bank letting them know what she needed – more blood, more clotting products, more everything. Send them around now, now, now. She was a picture of calm efficiency, issuing precise orders to the three nurses who were diligently carrying out her every request. Every time there was a new wave of blood loss, Krystal’s blood pressure would plummet to dangerously low levels and Rebekah would respond, injecting powerful drugs to make it rise again, making a little more blood flow to her brain, keeping her alive. Rebekah watched my struggle and when it became obvious I could do no more with stitches, she sent me to sit in the doctor’s lounge for ten minutes while she continued to pour the clotting factors in, trying to get the balance right in order to make the blood clot. We call this a ‘haemostatic pause’. Eventually, after dozens of stitches and fifty bags of blood, the bleeding slowed and the cut edge of the liver suddenly became dry. Rebekah told me things were steady and it was time to close up. The room looked like a war zone, with pools of blood on the floor and empty bags of fluid and blood products littered everywhere.

With the job done, we returned Krystal to the Intensive Care Unit, and after a few days this lovely woman’s eyes fluttered open and she started breathing for herself. When she became conscious enough to understand what had happened, Krystal still had the breathing tube down her throat. She knew that her baby had died even before we told her, but there was one important question that she urgently wanted answered. Tethered to the ventilator, she furiously waved her hands to demand a pencil and paper so she could write her question down. She wanted to know the sex of her baby.

Krystal has since told me that when her partner let her know that the baby was her much longed-for girl, she rolled her eyes and felt the painful irony:

‘Of course it was a bloody girl! Of course!’ she said with anguish.

Her milk came in several days later as a cruel reminder of what could have been. She left hospital a few weeks after the ordeal began and she still comes to see me from time to time. Krystal has survived all this and has got on with her life with more courage than I thought was possible. Seeing her face – seeing her get on with her life – reminds me why I sacrifice so much of my life to do this job. It was many people working as a team that saved her that day and I never let my surgeon’s ego forget that without them, none of it would be possible.

Buy a bra, save a child

I believe that life hinges on the smallest things and nothing was more certain this day. I had finished my operating list early, all my paperwork was done, and things were winding down as I prepared to head off for a mid-winter vacation in Fiji with my family the following week.

I had bought a few resort outfits and decided at the last minute that I needed a strapless bra to wear with one of them. I was beginning to feel relaxed. It was Thursday afternoon – one day to go until no phones, no emails and no dying patients.

There are almost no spare moments in my life and an opportunity to get to the shops alone is a delicious treat. I seized the opportunity and snuck out of work early to my local department store. With a selection of bras in hand, I headed off to the fitting rooms to try them on. As I stood in the change room cubicle, topless and grappling with the hooks on a bra, I heard a high-pitched scream coming from somewhere outside. It sounded like quite a commotion.

I paused for a moment and listened carefully. I have become cautious about rushing into situations where there may be danger. I had almost got myself into difficulties a few years before when I leapt without thinking into a flooded creek to help out a cyclist who had fallen in. I had learned from this, and from countless emergencies in the course of my job, that first appearances may be deceiving. I now take care to hang back for a minute or two until I can take stock of a situation. It is not that uncommon for people to faint or fall over at the shopping centre, and as I stood there I thought to myself that this was probably all it was. There are usually plenty of people around to help. I lingered in the dressing room in my semi-naked state and wondered if it was worth the effort of putting my clothes back on to go and see what was happening.

The woman’s screams become louder. ‘Help, help me!’ she pleaded. A ‘code blue’ announcement came over the loudspeaker and then I knew it was serious. Who knew there even was a code blue procedure at a department store? What did it mean? I heard the woman scream, ‘My baby’s dying!’ It was the visceral cry of someone who was going through something very bad.

That was enough for me. I was now compelled to get involved and I began to pull my clothes on as fast as I could. As I left the change room, still optimistically clutching my bras, I could see a crowd of people gathered a short distance away. There were store managers and security guards buzzing around the periphery, barking commands into their walkie-talkies. ‘Call an ambulance,’ I heard one say. I pushed my way through the throng and was confronted by the sight of a chubby toddler with a mane of curly blonde hair lying lifeless on the parquetry floor. Her skin was a deep shade of blue.

I announced to no one in particular, ‘I am a doctor. Do you need some help?’ The woman I had heard calling out was red-faced and frantic.

‘She’s choking, she’s choking on a cracker,’ she yelled.

This was all the information I needed and I knew exactly what was going on and what I had to do. Without waiting for permission I sprang into action. The bras were flung sideways as I sank to my knees and hoisted the little girl up by her ankles. Her hair dragged on the floor as I slapped her vigorously between the shoulderblades with the palm of my hand in an attempt to dislodge whatever was blocking her windpipe. No response. She remained as limp as a ragdoll. I commanded a burly man standing nearby to keep holding the little girl upside down so I was free to pummel her even harder. I could hear her mother babbling incoherently into her mobile phone a few feet away. On the other end of the line was her husband, working more than 100 kilometres away from the horror of this unfolding scene.

‘She’s dying, our baby is dead,’ she cried. I could only imagine how helpless and wretched this poor man must be feeling as he listened on the other end of the line.

I realised my efforts weren’t having any effect and time slowed down. The words, No one is going to die in the underwear section, kept running through my head. I am not going to let this happen. I was keenly aware that there was now a very big crowd watching my every move, stunned at what they were witnessing. I could feel them willing me to make this right. How could a trip to the shops lead to my holding a dying baby in my arms? Twenty precious seconds later, I knew I had to try something different. The toddler’s colour was fast becoming a shade of deep violet that belongs only to the dead. I flipped her back onto the ground and laid her out flat. I put my finger in her mouth and probed around, trying to feel the soft, macerated cracker obstructing her airway. Her chest was not moving and her eyes were wide open, staring lifelessly toward the ceiling. I knew that shortly it would be all over and she would be irreversibly brain damaged.

I weighed up the options for my next move. If something is lodged in the main windpipe, it can be impossible to remove it without surgical instruments. This is always the problem for a Good Samaritan – while you might have the skills, you don’t have the equipment to do what you need to do. When someone is choking, unless you can blow air past the blockage, the victim will die. Foreign objects often lodge fairly high in the windpipe and the only option if they won’t budge is to try to make a cut in the neck and insert a makeshift tube into the windpipe below the obstruction. Doing this type of emergency tracheotomy in a hospital, to an adult, with all the available technology, can be difficult enough, let alone on the floor of a department store with a robust, no-neck toddler. I had previously heard of a tracheotomy being done on a person who had choked in a restaurant. They used a kitchen knife and a drinking straw to make an airway to deliver lifesaving oxygen. I had given some thought to how I might do this, if I was ever faced with that situation. I wondered if I should send someone to the kitchenware department to get me a knife. I had a pen in my bag that I could pull the ink tube out of to use as a temporary breathing tube. I also wondered how this huge crowd of onlookers would react if I took a knife to this little girl’s throat. What if it didn’t work? I’m not sure they would understand what I was trying to do and I wondered if I even might find myself arrested.

Given it was at least two minutes since this baby drew a breath, I figured that I didn’t have enough time to get a knife. I had to do something else. I knew that the little girl’s heart was still beating because I could feel her strong pulse beneath my fingers. It was only her lungs that had stopped working, collapsed beneath the blockage. The priority was to get oxygen to her brain. I thought if I gave mouth-to-mouth resuscitation, I might be able to blow enough air past the blockage to get her going again. It was a risk, because doing this might push the cracker further down her windpipe, making a tracheotomy impossible. The other possibility was that I could blow the cracker all the way down into one lung, meaning that only one would be affected and the other might work enough to buy the time needed to get her to hospital.

I decided that this was the only practical choice and worth the gamble. I threw her little head back and it hit the wooden floor with a loud clunk. Her mother was looking on in horror as I got in position to start mouth-to-mouth. Now it was really life or death. I stared into the baby’s eyes, willing this to work, and then pressed my lips to her open mouth, pinched her nose and blew. You are not going to die today, I said to myself as I blew. Strangely enough, after all the resuscitations I had attended over the years in the hospital, this was the first time I had ever given actual mouth-to-mouth or ‘the kiss of life’. In the hospital there are masks and tubes to do this job. As I clamped my mouth over hers, this very close interaction with a complete stranger was an unusual sensation.

I continued on for what seemed like an hour but was probably only twenty seconds. I pulled back for a moment as I thought I felt a whimper escape the baby’s lips. I couldn’t quite believe it and kept going with the mouth-to-mouth for another few breaths. A nurse had arrived by that point and touched my arm.

‘She’s started to breathe,’ she said kindly, ‘you can stop now.’

Her touch was enough to break my intense concentration and I paused for a moment to evaluate the situation. I was pretty pumped up, feeling like a mother lion protecting her cub. I quickly realised, though, that things might be OK as the little girl’s deathly pallor turned rapidly to a healthy pink. I cradled this beautiful girl in my arms and watched the life flow back into her face. She started to bellow and that was the best sound I have ever heard. Some of the bystanders watching were clearly overwhelmed and, feeling helpless, rushed in to comfort and quiet her.

‘Please, just let her cry,’ I said. ‘When someone is crying it means they are breathing.’ I carefully handed her back to her stunned mother, who rocked her back and forth and kissed her head, not quite allowing herself to believe what she had just seen. A minute too late the ambulance arrived and whisked mother and daughter off to hospital to be checked out. All I had time to do was ask the girl’s name and wish them well. It was a little bit like a dream and I too found it hard to comprehend what had just happened.

When it was over, I started to shake as the adrenaline took effect. I began to walk away, not sure what else to do, my legs feeling a little wobbly. The dazed staff thanked me and took down my name and number. I walked outside the store and collapsed in a chair at the closest coffee shop I could find. It really hit me then and took me about half an hour before I was composed enough to even contemplate driving home. A kindly bystander who had witnessed what had happened bought me a cup of coffee. As I sat there, I realised that I didn’t get my bra. Could I really go back to the store and buy it after everything that had happened? I decided there was no reason not to, so I went back in. There were still a few staff members milling around and reliving the events. They had retrieved the bras I had tossed aside and they were sitting on the counter.

‘We thought you might be back,’ one said, smiling. ‘They are all yours, on the house.’

As soon as I got home, I was surprised to find TV and radio stations calling to get the story. Less than an hour after the whole thing happened, I was doing a live radio interview. Friends were calling all evening and asking whether it was true that I resuscitated a child at the shops wearing only a bra! The next morning, in the middle of my operating list, ABC radio called and asked me to go live on air with presenter Madonna King and tell the story. The only thing I knew about the mum and daughter at that stage was the little girl’s first name. She had been taken to hospital so quickly, I didn’t even know if she was OK. Madonna King put out a call for the girl’s mum to ring in if she was listening. She was, and I finally got to ask if her daughter was all right. We all ended up sobbing on the radio together as Madonna King recounted the events. The lovely mother said that I would never know how grateful she was. But of course I knew. I was a mum, so I could imagine exactly how thankful she felt.

A few days later I got to meet all the family, including the poor helpless dad who had been on the other end of that frantic phone call. What beautiful people they were, and I am privileged to have been involved in their lives in such a way. I am so glad I could get their little girl back for them. My husband and I had been trying for another baby for three years at that time with no success. The very next month our dreams came true and I fell pregnant with our much longed-for son. I do wonder if it was fate rewarding me for keeping that gorgeous soul alive. I’d like to think so.

Transplanting babies

It was a very unusual thing, to have my fingers inside the abdomen of a tiny baby. At a mere 3.1 kilograms, he was one of the smallest people to have received a liver transplant in Australia and I was there that day, assisting Professor Jonathan Fawcett, the head of the paediatric transplant program. When I walked into the operating theatre to start the case that morning, the first thing that hit me was the heat. Liver transplant theatres for babies must be 30 degrees so that our precious charges don’t lose too much body heat when their tummies are laid open. The more they cool down, the more blood they lose. We swelter like it’s a summer’s day, made worse by the layers of gowns we wear. But it is not about us, is it?

The second thing that struck me was the person on the operating table, or the little there was of them. Almost hidden by the vast amounts of anaesthetic equipment and tubes was a scrap of a thing. Once we covered him up with our surgical drapes there was an area the size of the palm of my hand to operate on. I had to continually remind myself that this baby’s head was where an adult patient’s chest usually is and to not squash him with my resting elbow. The anaesthetists were on to our habits of absent-minded squishing when we are caught up in the heat of the case, and circumvented the problem by suspending a wide metal frame over the baby’s head.

It seemed very wrong to make a cut in that innocent child, but we did because if he didn’t get a new liver, he would be dead within days. He was born with liver failure, through no one’s fault, just a cruel quirk of nature. We worked for hours to remove his tiny liver and when it finally came out, it was so small that it was a little perplexing that it had taken us so long. We were very careful about our blood loss. An adult can bleed a litre and not really miss it. For a baby this small, though, a litre was several blood volumes and every drop counted. He had blood vessels so minuscule that I could barely see them even with my magnifying glasses, and they had to be joined together by a plastic surgeon with the aid of a powerful microscope. So meticulous was this work, those six minuscule stitches to join the artery together took an hour and a half.

Getting the right donor liver for these tiny babies is another challenge. Thankfully, there are almost never donors this small. To get the right-sized piece, we must cut a segment from an adult liver. For these really tiny babies, however, even the smallest piece of liver is usually too big for their little tummies. Once his brand-new piece of liver had blood running through it, it doubled in size and in this tiny bub it protruded from his abdomen, reminding me of a triangular sail of the Sydney Opera House. There was no hope of closing the wound over the bulging liver at the end of the operation, and any attempt to do so would have squashed the liver, pushing it up into the baby’s chest so hard that he would have been unable to breathe by himself. The solution was simple, albeit a little confronting. At the end of the transplant, we left his abdomen gaping open, protecting the new liver with a simple piece of plastic sheeting sewn around the edges of the wound. We slathered the plastic with a thick coating of antiseptic cream, rather like icing a cake, and the little boy was carefully delivered to the Intensive Care Unit in an induced coma.

Over the next week or so an amazing metamorphosis took place. The liver began to shrink until it fitted. We took the baby back to the operating theatre every second day, slowly pulling his abdomen together over the rapidly shrinking liver. After a couple of weeks, everything was back where it should be. The little boy was woken up and his parents got to hold a baby who was not yellow.

Interestingly, apart from these super-small babies, the operation to give a child a new liver is not as different from doing an adult transplant as you might think. Clearly children are much smaller, but fortunately for us, their abdomens are disproportionately large. The liver is one of the biggest organs a baby has and its bulk gives them their cute ‘pot belly’. So despite the blood vessels and bile ducts being a whole lot smaller, there is usually a reasonable amount of room to work in. The other difference in paediatric transplants is that they are definitely more emotional for me to do. Most of these kids have been sick their whole lives and have endured many painful experiences. When I see their little bodies lying there helpless on the operating table with IV lines in every limb and monitors covering almost every part of their body, I just want to give them a hug instead of potentially causing them more pain. These kids have fear in their eyes as the anaesthetic mask is clamped over their faces and they drift off to sleep. How could they possibly understand why all of this is happening to them? Most of the kids I transplant are the same age as my own children and it is hard to not imagine myself in their parents’ place, pacing the corridors while they wait to hear if things have worked out. I feel a heavy burden of responsibility to return their baby to them in better shape than before.

What is really extraordinary about these plucky little kids is their endless resilience; they seem to take the whole transplant ordeal in their stride. The hospital has usually become a very familiar place to them because most are so sick that they have seldom had the chance to go home. A few are born in the hospital and have never known any other home. Because they are cared for by dozens of different people in the course of their young lives, they are usually friendly, outgoing kids who keep us laughing with their antics. I used to think that a small child would find it difficult to cope with having myriad tubes and wires attached to them for any period of time. You would think that they would pull them out. This is usually not the case, though, and these children seem to accept this as their reality as they sit and play with tubes up their noses and IV lines in their necks, stuffing potato chips into their mouth despite them.

The Queensland Paediatric Transplant Service has hundreds of liver transplant kids who have grown successfully into adulthood. Most of them go on to live exceptionally normal lives, only needing to take one or two tablets a day to stave off rejection. Many visit us only once a year, mainly to say hello and to remind us why our job is so great. These former transplant babies now have jobs, kids of their own and, best of all, quality of life. One of them, transplanted as a young child, now in his late teens, even has the ambition to go to medical school so he can become a liver transplant surgeon too. These are the triumphs that could never have been made possible if it wasn’t for the work of Professor Strong and many other pioneers of liver transplantation.

While transplanting the tiny babies is amazing, there is no paediatric transplant I will remember more vividly than the nine-year-old boy born with a very rare genetic problem. His disease causes a pigment called bilirubin to build up in the blood. Bilirubin is the brown substance that is normally disposed of by the bowel and it is what gives the faeces its colour. This genetic disease alters the way the body processes bilirubin, causing it to build up in the bloodstream. Shortly after a victim is born with this illness, the bilirubin levels become dangerously high and the baby’s eyes will turn an alien shade of yellow. If left untreated, they will rapidly become brain damaged. If it is diagnosed early enough, the brain damage can be put on hold for a while with an unusual treatment. Kids with this disease must lie under hot blue lights for more than ten hours a day. The light converts the harmful bilirubin into a molecule that can be safely passed in the urine. Of course, this treatment severely restricts their lifestyle and in the long term becomes less and less effective and the jaundice will return.

This little boy we were treating had been living his life under the lights for nine long years. To get enough exposure to the blue light, he needed to be semi-naked most of the time. He was sick of being called ‘devil eyes’ by his classmates and all he wished for was to go to sleep at night in the dark and feel a pair of pyjamas on his skin.

He was healthy in every other way and it was a terrible existence for everyone in his life. His family could never go anywhere because they could never be far away from the lights that were keeping him alive. His devoted parents had to work hard to make sure this active boy, who wanted nothing more than to be outside with his friends, spent the right number of hours per day under those lights. The little boy was becoming more and more jaundiced as the light treatment began to fail. His disease could be completely cured with a liver transplant, so when his quality of life became intolerable, the boy’s family made the difficult decision to move to Brisbane and wait for a liver to become available.

He waited a long time for the ‘right’ liver to come along and when it finally did, I removed his faulty liver and replaced it with the new one. Everything seemed to go really well and I felt confident as we wheeled him back to the Intensive Care Unit around midnight. Just as I got home and drifted into an exhausted sleep, I received a call from the doctor in Intensive Care. They told me that the little boy was not doing well, his liver tests were highly abnormal and his blood was showing no signs of clotting. His blood pressure was dangerously low and they were concerned that if we didn’t take some drastic action he would soon be dead. I was pulling on my clothes and getting back in the car even before I got off the phone.

I knew straight away that this might be the most dreaded of liver transplant complications: ‘primary nonfunction’. This means that there is something intrinsically and unpredictably wrong with the donor liver and that it has no hope of ever working in its new owner. Fortunately it is a very rare event and this was the first time I had ever actually had a patient experience it.

When I arrived at the hospital the little boy was already back on the operating table waiting for me to open him up again. I had to do this because sometimes there is a relatively simple problem with the blood vessels that might be an alternative explanation for what was happening. When I got my first glimpse of that liver, though, I knew that it couldn’t be saved and that the situation for this little boy was dire. The liver was mottled and instead of the normal red colour, it had turned to black. My blood vessel hookups were all working well and blood was flowing normally into the liver and out the other side. The only explanation was that the liver cells themselves had inexplicably failed. Leaving this dying liver in the little boy’s abdomen was not an option. To do this would mean his system would be irreversibly poisoned. Professor Fawcett and I made the agonising decision to take out the new liver and send out an urgent SOS around Australia for another one to be found as quickly as possible. This meant that the next donor liver with the right blood group to become available belonged to this little boy and we would have to rely on sheer chance alone to see if one came along in time.

The operating theatre fell silent as I removed that dead liver and slipped it quietly into a waiting bowl. I closed my eyes and wished it wasn’t true. I don’t ever remember feeling so helpless. I closed his abdomen over the space where his liver should be. It was a very unnatural thing to do to a living person and the reality was if a liver did not become available soon, he wouldn’t be living for long. A human can be without their liver for a day or so before all the intensive care in the world can no longer keep them going. All we could do was hope.

I walked slowly and with dread back to Intensive Care knowing that I would have to tell this little boy’s family that everything was not all right. That room was cold and unwelcoming as I told them that their son’s new liver had been removed. Their eyes widened with disbelief when I explained that we did not have another one to put in him, and this had left their son fighting for his life with only a matter of hours left.

‘My baby,’ his mother cried out. My heart skipped a beat. She appeared deep in thought for a moment obviously trying to search for a solution to this diabolical problem.

‘What about his old liver?’ she said. ‘Can you put it back in to keep him going for a while?’

It was a good thought, actually. His old liver had absolutely nothing wrong with it to look at and it would have been perfect if it hadn’t already been preserved in formaldehyde for examination in the pathology laboratory. I was so desperate that for a second I actually considered getting it back and washing it off. Instead, I gently explained that it wouldn’t work and we’d have to wait. If a liver became available he was still in with a chance.

Unbelievably, within a few minutes of my conversation with his family, a transplant unit in another state called to say they were working up a donor who might be suitable for our boy. We eagerly accepted their offer. Of course, there is always a catch. The donor was not brain dead but had no hope of recovery.

We call these Donors after Cardiac Death or DCDs. This means that instead of taking the organs while the patient is still on the ventilator with oxygen circulating in their blood, the patient’s heart must stop beating and they must die in the more traditional way before the organs can be removed. Australia had only just begun taking livers from these types of donors and they are used sparingly. Sometimes the livers from DCDs do not work very well because the tissues are deprived of oxygen for a longer period of time while waiting for the heart to stop beating. We had not tried a DCD liver in a situation like this, but in absence of a better offer, we had no choice. There was not a moment to lose.

The second difficulty was that the donor was an adult and the liver would need to be cut down to fit. This takes a lot of time, so instead of making us fly down to do the donor surgery, a kindly local transplant surgeon sprang into action. In record time, a new piece of liver was on its way to us on a specially chartered jet. As soon as we got the word that the plane was about to land, we took our dying patient around to theatre and re-opened his abdomen. Everything had to be ready to sew that new liver in the moment it arrived. The police picked it up for us at the airport and sped that precious cooler through Brisbane’s peak hour traffic with their sirens blaring. We were all scrubbed and ready and within 20 minutes of that liver arriving, having only been out of its old owner for about four hours, we released the clamps on the blood vessels and it pulsed back to life. That was as close to death as any person can get.

After more than a month spent in the hospital recovering from this closest of calls, that little boy is back at home, finally getting to do all the things that healthy kids take for granted like running on the beach and playing football with his friends. I hope I never again have to close a patient without their liver where it should be.

You have three months to live

I sat on the edge of the bed, trying to hold back my tears as I held his hand. This man had been in and out of my life for four years now. I knew him well. I called his wife and kids by name and I knew how hard he had fought his cancer. We had gone through a lot together. I had stood over him for hours, working to remove half his pancreas, his bile ducts and part of his stomach that were all riddled with cancer. I had done this on Christmas Eve, no less. I had sent him to the chemotherapy doctors so they could fill his body with their poisonous cocktails to help him have a better chance at beating his terrible cancer. Then, a couple of years later, I had sat in front of him as he presented me with his latest scans. I tried to keep my face emotionless as I immediately saw his cancer was back and it was everywhere. I sent him once again to have more chemo. He lived another year, bravely fighting while his appetite slipped away until he was skin and bones. There were days that he was in terrible pain but still he fought.

Now I sat with him on what would be his last day on earth. I knew it and so did he. We were alone; his family had gone to have a break from their 24-hour vigil. It is hard to know what to say to someone on their last day. You can’t exactly talk about the future. There is nothing to look forward to. We talked about his kids and mine for a while and I told him a few funny stories from my day, just like I always had. It came time for me to leave. I said goodbye, knowing it would be for the last time, there would be no more ‘see you tomorrows’ and I felt my hot tears well up. I embraced him so he wouldn’t see them and he whispered ‘Thank you for everything’ in my ear. He was so weak that even the effort of the hug seemed to drain a little more life out of him. I left the room and just made it to the doctor’s desk before I broke into a sob. Another person that I couldn’t save and I took it very personally. It ripped my heart out.

Almost every day, I get to see people on the worst day of their lives. It is my job to tell them that everything is not going to be all right and let them know how their life will end. I think I would rather do a thousand rectal examinations than have to do this and I feel sick to my stomach every time it comes around. It is something they never really prepared me for in medical school. I take my role of giving bad news very seriously and I consider myself privileged to be a witness to the dignity that people manage to muster after they hear the worst news imaginable. I have dreams sometimes about the day it will be my turn to sit in that chair and have some doctor that I have just met tell me it’s time for my life to come to an end.

‘I’m sorry,’ they’ll say, ‘there’s nothing we can do.’

What will I do on that day? Will I cry? Will I punch a wall? I don’t know and no one does until it happens to them. Most people just sit there and take it with quiet grace and I am not sure how they manage to stay in control.

Telling someone they are going to die is as uncomfortable, poignant and gut-wrenching as you would imagine. Seeing the pain on people’s faces can be unbearable. You might think I would become hardened to it over time, but I don’t believe that will ever be the case. I certainly hope it won’t, anyway. After a while, some doctors find breaking bad news to be an almost impossible task and will do anything to avoid it. It seems to break them and I wonder if one day it will break me too. It takes a toll. At the end of the day I meet with my colleagues and we have a debrief about how many people we’ve given ‘the death talk’ to that day. Amongst ourselves, when no one is listening, we call it ‘putting on the black hat’ or ‘telling people not to start any long books or make any new friends’. Humour, especially black humour, is usually our way of softening it. Laughter and tears seem to be two emotions that are not very far apart. It is our way of coping with the darkness and to some it may seem callous. Even our husbands and wives don’t really understand.

It has taken me a long time to figure out how to break bad news in a way that might come even remotely close to being acceptable – if it is possible to use the words ‘acceptable’ and ‘you’re going to die’ in the same sentence. It has to be done with compassion and kindness but most of all with honesty. This is the greatest skill that a doctor has to learn and I still think I have room to improve. Nothing can be held back and things should never be made out to be better than they are. Because terminal cancer is the most significant news that someone will ever be told, the way it is done will never be forgotten by the patient or their family. I believe I have done my job as well as I can when I am so sad that I am crying right along with everyone else. As well as being compassionate, it is also my duty to be a rock for the patient. People feel utterly helpless and vulnerable at that moment and have no idea what to do next. It is my job to take everything in hand and make sure I navigate them through the confusing maze of medical procedures in a difficult health system that has no real empathy for anyone.

There are a few courses around that teach doctors how to give bad news, but for the most part it is learnt on the job by watching other people do it. Just as I have seen my mentors do it with great empathy, I have also watched others stumble through it appallingly. I have seen surgeons take phone calls part way through the death talk and I’ve heard them tell people that they have years to live when they simply do not. But nothing I have seen compares to the night we had worked on a young car accident victim in the operating theatre for an hour or so.

It became apparent that his injuries were so bad that we were losing the battle for his life and we reluctantly stopped our attempts to revive him. After a short time, we watched forlornly as the heartbeat monitor turned into a flat line with our hands still in his abdomen. I followed my boss (whose speciality meant that he did not have to deal with this type of death very often) solemnly toward the visitor room where there were 20 or so family members anxiously waiting to hear news of their relative’s condition.

The surgeon began to tell them about how their boy was terribly injured and that we had attempted multiple procedures and manoeuvres to stabilise him. He went on in an emotionless monotone for about five minutes, regaling them with technical medical jargon: ‘We packed his liver, resected his spleen, evoked the massive transfusion protocol …’ The family leaned closer and closer in hopeful anticipation, obviously concluding from this long dissertation that there was a reasonable chance that everything was all right. Then, out of nowhere, the surgeon ended with ‘… and then he died.’

The words just hung there in the air and a look of astonishment crossed the face of everyone in that room. There was exactly five seconds of stunned silence before pandemonium erupted. The women began to make a primordial sound, a type of guttural keening, as they collapsed to the floor. The men swore – the noise was extraordinary. I looked on at the scene, feeling terrible for this family and bemused when my boss just kept prattling on, not knowing how else to comfort them.

‘We did everything we could,’ he said to no one in particular as they huddled together on the floor, rocking and moaning.

I touched him on the arm and said, ‘I don’t think they are listening to you any more.’ We quietly retreated from the room. Note to self – get to the point quickly.

I have taken all these experiences on board, good and bad, and every time I have to tell somebody they are going to die, I try and approach it in a way that I hope will meet the needs of each person as an individual. It is so important not to beat around the bush and to say the words as plainly as possible, pulling no punches. The word ‘cancer’ has to be used in the first sentence and once that cat is out of the bag, I am careful to pause to let it all soak in. As soon as the word ‘cancer’ leaves my lips, that person won’t hear another thing I say for a little while.

Sometimes I pick up the chart as I get ready to see my next patient and read their referral letter, and as I read it becomes obvious that their cancer is really bad and there will be absolutely nothing I will be able to do for them. I take a moment before calling them in, wishing with all my heart I could be anywhere else. I stand there, taking a few deep breaths, knowing that in a few minutes I’ll be delivering a death sentence.

When I’ve collected myself, I ask them to come in and I say hello. I feel convinced that what I’ve got to say is already written all over my face. We sit together for a few minutes, dancing around the topic while I ask some general questions about pain and appetite as I try desperately to establish even a little bit of rapport with this complete stranger. I do a good job of putting things off for another few minutes by carefully considering their x-rays and looking at their blood tests. As I put their scans on the viewing box, all I can see is big black blobs of cancer everywhere. It is confirmed, they will be dead very soon. No hope of cure, no treatment to make it go away, there is nothing I can do to make this better. I feel helpless and hopeless. Finally, when I have run out of questions to ask, I just have to do it. I try to hold my emotions in check but my mouth dries out and a lump develops in my throat, making it difficult for me to begin to speak. This pause always gives it away, before I can even say it. My heart thumps hard in my chest as I start to say the words:

‘You have cancer and it is bad. It is not removable with an operation and it will end your life in the next few months.’

I just want to take them into my arms and tell them that everything will be OK, but it won’t be. I truly have nothing good to say. That person will walk out of my office that day with no solution or hope.

There is no doubt in my mind that the most heart-wrenching patients are the ones I have previously operated on, intending to cure them. The optimist in me wants more than anything to have managed to cut every last cancer cell from their body. I want to believe that every single one of them will be the fortunate one for whom the cancer will be gone forever. The scientific doctor within me, though, knows that because of the types of cancers I look after – those of the pancreas and those that have spread from other places – that a high proportion of my patients will see their cancer return one day. I put my blood, sweat and tears into caring for these patients and I get to know them and their families as dear friends. I am happy to see them each visit because it means they are still alive. With each clear scan they are closer to a cure. Then one time, months and even years later, just when I dare to think they may be in the clear, a scan will reveal that their cancer is back. They feel no pain and are not unwell. This is how cancer is for a while. The only sign of its existence is a mark on an x-ray. It is just sitting there, silently killing them. Suddenly, the happy consultation must turn serious as I say the words that no cancer patient wants to hear:

‘Your cancer is back and this time I can’t remove it.’

I feel like I have failed and it is deeply personal to me because I have got to know the patient so well. I feel they have become part of my family. I tell them how sorry I am.

No matter where people come from in the world, there is a very particular order of emotions everyone goes through when they are told they are going to die. First, there is stunned silence followed quickly by some sort of visceral reaction – tears, anger, violence, screaming, vomiting or shaking. Then there is silence again, moments spent collecting their thoughts, drying their eyes, composing their questions. Then come the questions. Why me? What caused it? How aggressive is it? What treatment can I have? The next reaction is variable. Most people gather all their strength and get ready for the fight of their life. They are enthusiastic, ready to take it head on and prove me wrong. There are a few who fall apart and become clinically depressed, giving up completely. Some get so angry – sometimes with me, for not being able to help them, or at themselves for perhaps not leading a healthy lifestyle. Some feel that they have done something wrong.

Then there are the surprising reactions. One lady’s first response to being told her husband was dying was to fly into a rage at him for not having life insurance. She was staring her future in the face. All of this pain makes it difficult to move forward with any plans straight away. The utter disbelief and distress makes it impossible for people to make rational decisions. I send them away for a while so they can come back and we can talk after it has all sunk in a little and they are ready to hear more.

As the patients move through these phases of grief they will finally get to the question that everyone wants answered: ‘How long do I have?’ Of course this is an impossible question for me to answer. For most of the conditions I treat, the answer is usually a few months, or at best a couple of years. I tell people to put their affairs in order and to take care of any unfulfilled wishes.

For a few unfortunate souls, their time left on earth can be measured in days or even hours. This is the case for a hideous tumour that grows in the liver. Hepatocellular cancer can be so bad that it will behave worse than the most vicious alien Sigourney Weaver could ever encounter. Just like a parasite, this cancer loves to punch holes in big veins to get access to the blood it needs to satisfy its voracious appetite. Once the tumour has made it into the blood vessel, its growth goes unchecked until it completely fills the vein with soft, murderous tentacles. The veins give the cancer a clear pathway to propagate out of the liver and it will eventually fill the heart with tumours. Without warning, a big hunk of gelatinous cancer will break off and lodge in the lungs, suspending the flow of blood and causing almost instantaneous death. Because the veins fill with the tumour very slowly, patients with this horrible cancer have very few symptoms. Unbeknownst to them, they are ticking time bombs and there is not a thing I can do about it.

This was the case with a patient I saw. I told him that not only did he have this terminal cancer but that he could die at any moment. One minute earlier, all he thought he had was a bad case of indigestion. It was a lot like telling someone they are going to be executed but we don’t know when or where, just any day now. Go home and wait. What could I possibly say to make him feel better? Absolutely nothing. About an hour after that patient left my office I got a call from an ambulance officer to say they had him in their car. His heart had stopped and they were doing CPR. They asked me what they should do next.

‘Just stop,’ I said forlornly, ‘there is no hope.’

Most people have a little longer than that, thank goodness. When the dust has settled on the diagnosis and the initial shock has passed, the questions will inevitably come about alternative or complementary therapies. People are very suspicious about western medicine for some reason. As part of their grief, people can’t comprehend why I can’t always fix things for them. I think some people believe that I might even be withholding some sort of special treatment that I have hidden up my sleeve. I let them know that if there truly was any type of treatment or cure available that was safe and that worked, I would be the first to use it. I am looking forward to the day when we can unlock the secrets to treating these cancers because that is the day when I can buy that Winnebago and retire. I also let people know that they should be very careful about spending their money on crazy treatments where people promise them miracle cures. Some patients will leave my office, sell everything they own and blow the lot on dubious and sometimes painful treatments that make them miserable and don’t change a thing.

The most traumatic experience I have ever had when delivering bad news occurred when I was a surgical registrar. I was working at a district hospital when I admitted a 19-year-old who was mum to a small child. She had terrible pain in her stomach and was vomiting everything she ate. A dark lump had appeared on her abdomen a week before. From her story and x-rays it became clear that she had a blockage somewhere in her bowels. I was not sure why this was happening to her and because of her youth, cancer was the furthest thing from my mind. Clearly the problem was pretty serious, though, and she was unwell enough to go straight to the operating theatre for surgery. I opened her belly and found hundreds of blobs of fleshy black melanoma studded along her bowel causing blockages at multiple levels. There was nothing I could safely cut out, nothing I could do to help her. Taking out these cancers would have meant she would lose her entire bowel and that would be no life at all. Melanoma does this from time to time. As I closed her up, I did it slowly, knowing that I would have to walk out soon and tell her father that his daughter would be dead within days.

A few hours before this, I had seen a girl of a similar age also with belly pain, but of a far less serious nature. I hadn’t yet worked out what was wrong with her, but it certainly wasn’t cancer. I walked out to the waiting room to find the father of the girl with the melanoma. I had not met him before his daughter’s operation and I was feeling more than a little emotional about what I was about to do. A nurse was waiting there with a man who she pushed forward, telling me that this was the father of ‘the young girl’. I began to tell him the terrible news and an unusual look came over his face. He was shocked but there was something else in his expression that I couldn’t put my finger on. He was stunned and couldn’t speak. As I began to talk more and more about his daughter, he looked more and more confused. He let me go on for about five minutes, looking weird, but seemed to be accepting what I was saying. I gave him a hug and turned to leave. There was something about the whole exchange that bothered me. When I reached the door, something made me turn around and go back.

‘You are the dad of Miss X with the melanoma, aren’t you?’ I asked him.

‘What?’ he said. ‘No, my daughter is Miss Y with the tummy pain.’

I suddenly realised my terrible error. I had just told the wrong person that their daughter was dying. It had happened so easily – I was very affected by having to do it so I didn’t remember to double-check who he was. I really lost it then, I started blubbing and threw myself into the arms of this poor man and this time I couldn’t let go. I sobbed that his daughter was fine and apologised that I’d made a horrible mistake. Of course, I then had to face telling the actual father the news all over again. I was so upset with myself but the dad of Miss Y was so relieved that his daughter would be OK that he went and bought me a cup of coffee and a lotto ticket. He tried to calm me down. I couldn’t believe he was so understanding. He looked at it like it was his lucky day – what an amazing person. I’m not sure I would have been so conciliatory.

I am a person who is always looking for the silver lining. It gets me through the awful parts of my job. Giving people such terrible news has taught me many things about my own life and it has been an amazing gift to be allowed such intimate access into people’s lives. I now understand that I can never take anything for granted. Human life goes by in the blink of an eye and this is why I live the life that I do. I try and pack as much into every day as possible. There is always something to see or do and there is always a little joy to find in any situation. I live my life like every day is my last, because you really never know when it will be. I tell my kids how much I love them every time I see them and try to instil in them a passion for life and respect for others. These are the lessons I take away from my amazing patients.

How do you do it all?

For some inane reason, I thought becoming a fully fledged surgeon might mean that I could relax a little and let my underlings take up a bit of the slack. The biggest secret they keep from the registrars is that this is not the case at all. I imagine it is like that because no one would actually become a surgeon if they knew that the pace never relented. The hook is that once you have committed eight or so years towards training for it, you can hardly walk away. As well as working at the PA and Royal Children’s Hospital looking after the transplant and cancer patients, private practice also beckoned.

Interestingly, almost as soon as I started work as a surgeon in a public hospital, I found myself not operating as much any more. Of course, I still did the transplants, but because the PA was a training hospital, I spent much of the time during the other surgeries teaching my junior staff how to operate, paying back all the hours of training that were afforded me. Private practice offered the opportunity to continue to do what I loved by doing as many operations as I liked, whenever I liked.

As if I didn’t have enough on my plate, along with the actual operating involved in private practice comes the need to have somewhere to see the patients afterwards. I found myself buying offices of my own at Greenslopes Private Hospital and becoming the employer of two wonderful secretaries in the process, without whom I would find it pretty difficult to function. Andrew and I had our hands full running the business and running the house. I was rarely home. So, just when we thought we couldn’t fit another thing in, what did we decide to do? Have another baby, of course. Four years after I started back at the PA I gave birth to my fourth child, a handsome boy this time. We named him George, after George Washington and George Hopkins, my faithful friend who, as registrar at Nambour hospital, played a big part in helping me through my first operation and getting me where I am today.

Life is now busier than I could have ever imagined. Every day I wonder how I will keep going, but I always do. I have to go into work almost every day, weekends included. There is always one of my complicated patients who needs my attention. I sleep with my phone within arm’s reach and it even accompanies me to the toilet in case it rings while I am in there. One minute I can be in a deep sleep and the next I find myself boarding a small plane at a deserted airport, jetting off to take the organs out of dead people. Unlike the US, at my hospital, senior surgeons still do the donors. I sleep with a set of scrubs next to the bed, so I can put them on and go, shaving valuable seconds off my time if I’m called in urgently. I worry about my patients constantly. I dream about them. A long time ago I decided to keep a notebook by the bed so I could write my worries down so they didn’t keep me awake all night. I get so tired sometimes that I fall asleep in the shower, my face pressed against the tiles, drool running out of the corner of my mouth.

People seem to be endlessly fascinated by how I could possibly manage to do all this and have the family that I do. It’s just something I do and it does not seem unusual to me, though it may seem so to others. The most common thing I’m asked is the same question they asked in my job interview: ‘How do you do it all?’ My answer is, ‘I don’t do it all.’ But I do have it all. I have a small but brilliant group of people around me to help keep all my balls up in the air, and in more ways than one we are all married to my job.

My team is led of course by the unflappable Andrew. On our return from America, he got a job as an internal auditor for a while. But even when we had just two small children at home, cracks started to appear in the way our household worked. I couldn’t be alone with the kids, because the nature of my work meant that I would often have to drop everything and rush in to the hospital, leaving no one to look after them. It was costing us more than he made in babysitters and nannies, so we made the decision that Andrew would give up his job and stay home. This brought a great deal of stability into our lives. Our ‘reverse 1950s household’, as Andrew calls it, has worked well for us and, like all stay-at-home parents, he has the important job of driving the family bus to ballet, guitar lessons and school.

I feel endless guilt that I am not there for every moment of my children’s lives and I make it my business to be involved in the things that really count. This might require flying overnight to get home, icing a birthday cake at 10 pm or sewing sequins on a leotard in between operations – Andrew and I do what it takes. Like all working parents, I miss a lot of things and Andrew has been known to keep my children seated just in case they walk for the first time while I am away from home.

I am very proud of what I have achieved being both a surgeon and a mum, but it is not so extraordinary just because I happen to be a woman. I simply worked as hard as all the other doctors in my company and I am fortunate to have a loving family and people who believed in me to help me along the way. This is what all successful surgeons need. It is true that women are pretty rare in surgery but it is not really hard to understand why. Quite simply, women give birth, and without some pretty specific arrangements, surgery is not a lifestyle conducive to being at home and looking after children. It takes sacrifice and that is not for everyone. The long hours involved in surgical training and the almost all-consuming and selfish commitment required means that it is a mountain that most women doctors are unwilling to climb.

Some women surgeons make a conscious choice not to have children because they just never stumble across the right domestic situation to make it work. Because I have managed to do it, I often get labelled a ‘superwoman’. I am far from it, believe me, and my male colleagues are no less super. They too make the same sacrifices to have a family and a life in surgery. The only difference is they don’t have to give birth and, in the end, the six weeks after having a baby when you physically can’t work is all we are talking about here. I figure that women have been producing babies for millions of years and whilst it is very special to the individual, it is hardly unusual. I chose to have kids because my husband and I can work as a team to make it possible. It has taken a lot of compromises on his behalf, as the spouse of every surgeon around the world has to make.

The most important thing I have learned from the last 18 years in medicine, watching life begin and end, is that it is a really short journey and you are a long time dead. Andrew and I want to pack in as much as possible.

Organ and tissue donation saves lives and enhances the quality of life for many people. Every Australian has the potential to save lives by discovering the facts about donation, making an informed decision and, most importantly, discussing their wishes with their family and friends.

You can register your decision to donate on the Australian Organ Donor Register by accessing the DonateLife website at www.donatelife.gov.au or calling 1800 777 203.

Acknowledgments

My life is about halfway through right now and it has settled into a routine like life does. I’ve packed a lot of stuff into the last 40 years. But as Hillary Clinton says, ‘It takes a village’, and these are the people who belong to mine:

To Andrew, love of my life, partner in everything, thank you for helping me get this far and I love you very much.

To my babies Abigail, Madeleine, Priscilla and George, thank you for your smiling faces when I get home, I am so proud to be your mum.

To my parents Bob and Elwyn and my sister Lauren, thank you for your hard work for all these years that has allowed me to do what I want to do in life. (You can stop now!)

To Rebekah Ferris, thanks for being my friend, girl. May we spend every Friday for the next 20 years discussing pubic hair and world domination.

To Jonathan Fawcett, thank you for being my mentor, friend and sounding board over all these years. Who would have thought that after you first watched me take seven painful hours to take out a pancreas, you would one day find it in your heart to give me a job and call me a colleague. I value your wisdom, humour and friendship every day.

To Stephen Lynch, thank you for everything you have done for me over the years. You have helped me fulfil some pretty big dreams and I admire you for always being a man of your word.

To Greg Hall, the long-suffering husband of a medical wife who has heard all these stories before but still took the time to read them and tell me honestly what he thought.

To Ann Kirby, thank you for being our family when we felt all alone in a new country and for holding my leg when our little American came into the world.

To Allan Smith, who taught me much of what I know about being a good surgeon.

To Carmel Hawley, thank you for showing me that women can do anything.

To George Hopkins, thank you for being my friend through thick and thin.

To Joy Foo, Jennifer Coulthard, Jane Elms, Jody Mandic, Sandy Schultz, Rhonda Adams, Jane Biglin, Vonnie Bagwell, Tammy Lye-James, Desley and Brandi Thompson, Cindy Simpson, Penny Trevethick, Sanya Bosnar and Aileen Sly: thanks for keeping our whole crazy show on the road and being the most organised girls in the world.

To Tina Coco, thanks for your guidance.

To Jamie Von Nida and Michael Von Papen: thanks for being my best buds for the last 25 years.

To Igal Kam, Michael Wachs and Tom Bak: thanks for teaching an Aussie girl how to transplant, even if I scared you sometimes. You are like family to me and any time you have a vacant position in Colorado, all you have to do is call ...

To Russell Strong, Daryl Wall, Brian Miller, Jon Cohen, John Hansen, Michael Borton, David Gotley, Mark Smithers, David Theile Snr, Terry Mulhearn, David Schache, Michael Muscio, Ian College, Adam Louie and Vijay Kanagarajah: thank you for instilling in me a love for surgery.

To Tom O’Rourke, Peter Hodgkinson and Tony Griffin: thanks for being great work partners and for being there any time I call for help.

To Krystal and Lynn: thank you for being a part of my life and allowing me to tell your stories so others can be inspired by your courage. I think of both of you every day.

To Larissa, Steven and Charlotte: you are a gorgeous family and that was one of the scariest days of my life. I am so glad that you have your beautiful girl back in your arms.

To Graham Bennett, Barry Hough, Ron and Judy Derrick, Peter Jesburg, Kyran Woods, Len Peel and Ross Dahlenburg – all amazing teachers who guided me through school and let me dream big.

To the nurses I work with every day, thank you for your incredible dedication in looking after our patients and for your amazing stamina to stand at the operating table with me for eight hours at a time.

To the thousands of patients I have seen over the years, thank you for allowing me to be a part of your lives and I hope that I have helped.

References

I heart gallbladders

De U, ‘Evolution of cholecystectomy: A tribute to Carl August Langenbuch’, Indian Journal of Surgery, 66(2), 2004, pp. 97–100.

The call of the bile

Strong R, Ong TH, Pillay P, Wall D, Balderson G & Lynch S, ‘A new method of segmental orthotopic liver transplantation in children’, Surgery, 104(1), 1988, pp. 104–7.