How to Do a Liver Transplant (21 page)

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.