How to Do a Liver Transplant (7 page)

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

N
o 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.