How to Do a Liver Transplant (22 page)

‘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

W
hile 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.