How To Do A Liver Transplant

Stories from my Surgical Life

By Kellee Slater

University of New South Wales Press Ltd

Copyright © 2013 Kellee Slater
All rights reserved.
ISBN: 978-1-74223-342-0

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,

CHAPTER 1

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 thegeneral 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.

CHAPTER 2

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.

(Continues…)Excerpted from How To Do A Liver Transplant by Kellee Slater. Copyright © 2013 Kellee Slater. Excerpted by permission of University of New South Wales Press Ltd.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.