How to Do a Liver Transplant (10 page)

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

A
fter 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.