How to Do a Liver Transplant (8 page)

Every doctor has their own collection of fantastic poo stories. They usually get told when we get together over dinner at a fancy restaurant. It's juvenile and we can get loud. We often don't realise how crass we are being until our spouses elbow us in the ribs and we notice that all the other diners are staring at us with their mouths open. Humour is simply our way of dealing with this part of the job.

There is not an object invented that has
not
been inserted into an anus. If something will go close to fitting and occasionally even if it won't, people will attempt to put it in there. This feat is usually achieved at unspeakable hours of the night and the insertee will usually attempt any and all measures to extricate the item prior to attending the hospital so as to avoid the red-faced embarrassment that will surely follow. On the other hand, there is a group of patients who get their kicks not from the act of insertion, but from the hospital staff's reaction to what they have done. They are the ones who manage to get some seriously large objects up there. The reasons given for putting things up their bums vary widely and can be pretty funny. The most common one is blatant denial: ‘I woke up and found someone had put it up there,' is the usual story. ‘I tripped over the cat on the way out of the shower and I happened to fall on a pool cue,' is another.

Vibrators are pretty standard fare when it comes to insertions and to tell you the truth, it takes something a lot more creative than that to pique my interest. It's pretty amusing, though, if it is still operating and the victim is emitting a constant low humming noise. Vibrators are usually pretty easy to retrieve. Just lube up a gloved hand and in I go. Then there was the young man who put a tube of builder's foam up his bottom and pulled the trigger.

This is the type of gap filler that expands to mend cracks in walls. Once it fills the space, it sets hard. This crazy guy filled his entire large bowel with this expanding foam and I had to cut him open to remove it. He did manage to get a perfect cast of his colon as a souvenir of the experience. A year later he did the same thing, except this time he went up his penis and got a similar model of his bladder. A collector, I guess.

Then there was the ‘peanut guy' who every few months would put four to five peanuts up his penis. Goodness knows what device he used to poke them up there. His particular thrill was derived from having a telescope put up his penis to remove them. After several calls, all after midnight, to tell me that he was back with his bladder full of peanuts, I would flatly refuse to leave my warm bed to go and help him.

‘Just put him in the ward and I'll deal with it tomorrow,' I would bark. By the time the morning came, he had usually peed them out and I wouldn't have to lift a finger, depriving him of his pleasure. He would just deposit the nuts in a little bottle on the nurse's desk, shrug his shoulders and tell them he was off home. ‘See you next week,' the nurses would call out as he left.

But by far the most famous of all ‘inserters' was the ‘butternut pumpkin man'. Yes, you read right. He was a regular attendee to the Emergency Department with a full-size butternut pumpkin up his bum. Needless to say,
this took years of practice and many attempts to achieve this incredible feat and it also goes without saying that you could easily park a bus in his rectum and that he had to wear an adult diaper full-time.

One of the terrible side effects of taking narcotic drugs like heroin and morphine is severe constipation. After a while the bowels stop pushing the poo forward and the addict might only have a bowel movement every two weeks or so. A lady who was a long-term abuser of prescription pills was admitted with this very problem. She had not opened her bowels for many days and was in a desperate situation. She was so backed up, she was actually vomiting. We put her under anaesthesia so I could put my gloved fingers into her bottom and scoop out the hard rocks of poo. Those few lumps, however, were the tip of the iceberg. The only way to really get things moving in this situation is to give the patient two to three litres of salty water to drink. This results in a massive evacuation that goes on and on until the bowel is empty. It is a very unpleasant process.

Because of her drug addiction, this particular lady was very difficult to work with. She was demanding and abusive toward the nursing staff, yelling and screaming at them to get her more drugs to relieve her pain. This continual barrage of insults, not surprisingly, caused the
nurses to dislike her immensely. After she finally drank the litres of salty water I had prescribed, the woman then demanded that the nurses give her a very heavy sedative to knock her out. She was sick and tired of us all and just wanted to ‘zone out'. The nurses told her that they did not think it was a good idea, but she abused them some more and insisted. ‘Fine,' they said, ‘do what you want,' and gave her the pills. After taking them, she stripped off her clothes and got into bed, quickly falling into a deep, drug induced sleep. An hour or so later, the bowel treatment began to take effect but this sad lady remained in her deep slumber. You can imagine what happened next.

The nurses were alerted a few hours later by loud screams and when they ran to see what was wrong, they were greeted by a wild-eyed woman wandering naked down the hall, covered from head to toe in her own faeces. Her bowels had completely emptied themselves into her bed and she had slept through the whole thing. She had turned brown. She continued to hurl abuse at the nursing staff about her dignity being compromised. They put her in the shower and hosed her down, all the while trying to stifle their laughter and remain professional. She recounted her horrible ordeal to me later on rounds. I, too, struggled to keep a straight face. Bless the nurses, they have to deal with some horrible stuff.

The smell of faeces frequently pervades the room in the course of a general surgical operation. Patients can quite naturally have a bowel movement at the start or end of a case owing to the relaxing effect that anaesthesia can have on the anal sphincter. In general surgery it is usually just a minor irritation. We can't see it under the sterile drapes and all we have to do is put up with the smell until the end of the case and then find some excuse to be out of the room when it comes time to clean up the patient. In orthopaedic operations, however, this sort of soiling can be a really serious problem.

A patient recently told me her story of the time when she was about to undergo a hip replacement. This operation requires everything to be perfectly clean. An infected joint has disastrous consequences and must be removed immediately. As the lady was put off to sleep for her operation, her bowels discharged themselves on the operating table. Faecal matter became smeared all over the skin, exactly where the incision was to be made. The orthopaedic surgeon became hysterical at the sight of the smelly brown mess running all over his operative site.

‘Cancel the surgery,' he shrieked.

All they could do was wake her up – sans operation – clean her up and try again another day. She told me that instead of hearing ‘Congratulations, you have a brand new hip,' she got, ‘Well done, you did a great big poo.' She was so embarrassed.

The call of the bile

M
y second year of surgical training saw me move to Brisbane, the subtropical capital of Queensland. Andrew and I moved yet again and he found yet another job as a flight instructor at a local airport. I was slated to work at one of the most famous surgical hospitals in Australia, the Princess Alexandra or ‘PA'. The whole point of working at the PA as a surgical trainee was to be exposed to the different specialties within general surgery or ‘super specialties'.

The Princess Alexandra was home to world leaders in all the specialties of general surgery but none more so than the members of the Queensland Liver Transplant Service.
I had already worked at the PA for six months doing relieving jobs just before I started training as a registrar and was truly intimidated at the prospect of returning there as a registrar with considerably more responsibility. I would actually have to work closely with surgeons who were considered geniuses and I was worried that they would discover how truly stupid I often felt. I found out that my first job back at the PA would be as the registrar in the transplant unit. This would be followed by six months in Hepatobiliary where, instead of transplanting the organs, the same surgeons would cut pieces from them, ridding patients of terrible cancers.

To say that I began to hyperventilate on hearing this news would be an understatement. Of all the jobs available to a surgical trainee, these two were considered the most difficult and demanding of all general surgery rotations. The transplant rotation was often referred to as the ‘new car job' because you worked so much overtime that after six months you could pay cash for a brand new car. I was terrified and at the same time pleased. Getting assigned to these jobs was a real honour because they were not given out to just anyone and especially not to a trainee who was thought to be struggling. Somebody, somewhere, must have thought I was doing a half decent job.

The surgeons in the transplant unit at the PA were almost like mythical creatures. Everyone I talked to spoke of them in hushed tones and there were many legendary
stories about their intellect and stamina. Any problem that could not be solved by other surgeons ended up in their hands. They were constantly followed around by a troop of surgical groupies, usually transplant surgeons from overseas, who had come to train and observe their skill.

The head of the unit was Professor Russell Strong, the surgeon who I had dismally failed to meet with a couple of years before. He was Australia's most celebrated surgeon, a Companion of St Michael and St George, a Commander of the Order of Australia and a Queenslander of the Year to name just a few of his accolades. Alongside the great American surgeon Thomas Starzl, Professor Strong was a pioneer of liver transplants and was the first person to perform a successful one in Australia. In a procedure eventually named the ‘Brisbane Technique', he was also the first person in the world to cut an adult donor liver in half to get a piece small enough to transplant into a child. He was a bona-fide living legend, a man who never needed to say a word to command the respect of those around him. This was lucky because he rarely uttered one. However, whenever he did speak, incredible pearls of wisdom would spill out of his mouth and any person fortunate enough to be in earshot would be taught a lesson in surgery they would not easily forget.

He once shared with me how he was feeling before he did his first liver transplant for a child dying of liver failure. Thankfully, children rarely die, so child-size donor livers
are uncommon. For a child to die of liver failure, however, is more common and something had to be done to bridge the shortfall and stop babies dying while they were waiting for a new liver to come along. By borrowing the techniques used to remove cancers from the liver, Professor Strong felt it would be possible to take an adult liver, split it in half and give the smaller piece to a child. There were a great many people who thought it would never work. It was seen as expensive, risky and the ethics were hotly debated. One newspaper article even compared it to the monstrous work of Dr Josef Mengele, saying that such a transplant would produce ‘stunted children'. Professor Strong was under enormous pressure to succeed.