How to Do a Liver Transplant (25 page)

I knew straight away that this might be the most dreaded of liver transplant complications: ‘primary nonfunction'. This means that there is something intrinsically and unpredictably wrong with the donor liver and that it has no hope of ever working in its new owner. Fortunately it is a very rare event and this was the first time I had ever actually had a patient experience it.

When I arrived at the hospital the little boy was already back on the operating table waiting for me to open him up again. I had to do this because sometimes there is a relatively simple problem with the blood vessels that might be an alternative explanation for what was happening. When I got my first glimpse of that liver, though, I knew that it couldn't be saved and that the situation for this little boy was dire. The liver was mottled and instead of the normal red colour, it had turned to black. My blood vessel hookups were all working well and blood was flowing normally into the liver and out the other side. The only explanation was that the liver cells themselves had inexplicably failed. Leaving this dying liver in the little boy's abdomen was not an option. To do this would mean his system would be irreversibly poisoned. Professor Fawcett and I made the agonising decision to take out the new liver and send out an
urgent SOS around Australia for another one to be found as quickly as possible. This meant that the next donor liver with the right blood group to become available belonged to this little boy and we would have to rely on sheer chance alone to see if one came along in time.

The operating theatre fell silent as I removed that dead liver and slipped it quietly into a waiting bowl. I closed my eyes and wished it wasn't true. I don't ever remember feeling so helpless. I closed his abdomen over the space where his liver should be. It was a very unnatural thing to do to a living person and the reality was if a liver did not become available soon, he wouldn't be living for long. A human can be without their liver for a day or so before all the intensive care in the world can no longer keep them going. All we could do was hope.

I walked slowly and with dread back to Intensive Care knowing that I would have to tell this little boy's family that everything was not all right. That room was cold and unwelcoming as I told them that their son's new liver had been removed. Their eyes widened with disbelief when I explained that we did not have another one to put in him, and this had left their son fighting for his life with only a matter of hours left.

‘My baby,' his mother cried out. My heart skipped a beat. She appeared deep in thought for a moment obviously trying to search for a solution to this diabolical problem.

‘What about his old liver?' she said. ‘Can you put it back in to keep him going for a while?'

It was a good thought, actually. His old liver had absolutely nothing wrong with it to look at and it would have been perfect if it hadn't already been preserved in formaldehyde for examination in the pathology laboratory. I was so desperate that for a second I actually considered getting it back and washing it off. Instead, I gently explained that it wouldn't work and we'd have to wait. If a liver became available he was still in with a chance.

Unbelievably, within a few minutes of my conversation with his family, a transplant unit in another state called to say they were working up a donor who might be suitable for our boy. We eagerly accepted their offer. Of course, there is always a catch. The donor was not brain dead but had no hope of recovery.

We call these Donors after Cardiac Death or DCDs. This means that instead of taking the organs while the patient is still on the ventilator with oxygen circulating in their blood, the patient's heart must stop beating and they must die in the more traditional way before the organs can be removed. Australia had only just begun taking livers from these types of donors and they are used sparingly. Sometimes the livers from DCDs do not work very well because the tissues are deprived of oxygen for a longer period of time while waiting for the heart to stop beating. We had not tried a DCD liver in a situation like this, but
in absence of a better offer, we had no choice. There was not a moment to lose.

The second difficulty was that the donor was an adult and the liver would need to be cut down to fit. This takes a lot of time, so instead of making us fly down to do the donor surgery, a kindly local transplant surgeon sprang into action. In record time, a new piece of liver was on its way to us on a specially chartered jet. As soon as we got the word that the plane was about to land, we took our dying patient around to theatre and re-opened his abdomen. Everything had to be ready to sew that new liver in the moment it arrived. The police picked it up for us at the airport and sped that precious cooler through Brisbane's peak hour traffic with their sirens blaring. We were all scrubbed and ready and within 20 minutes of that liver arriving, having only been out of its old owner for about four hours, we released the clamps on the blood vessels and it pulsed back to life. That was as close to death as any person can get.

After more than a month spent in the hospital recovering from this closest of calls, that little boy is back at home, finally getting to do all the things that healthy kids take for granted like running on the beach and playing football with his friends. I hope I never again have to close a patient without their liver where it should be.

You have three months to live

I
sat on the edge of the bed, trying to hold back my tears as I held his hand. This man had been in and out of my life for four years now. I knew him well. I called his wife and kids by name and I knew how hard he had fought his cancer. We had gone through a lot together. I had stood over him for hours, working to remove half his pancreas, his bile ducts and part of his stomach that were all riddled with cancer. I had done this on Christmas Eve, no less. I had sent him to the chemotherapy doctors so they could fill his body with their poisonous cocktails to help him have a better chance at beating his terrible cancer.
Then, a couple of years later, I had sat in front of him as he presented me with his latest scans. I tried to keep my face emotionless as I immediately saw his cancer was back and it was everywhere. I sent him once again to have more chemo. He lived another year, bravely fighting while his appetite slipped away until he was skin and bones. There were days that he was in terrible pain but still he fought.

Now I sat with him on what would be his last day on earth. I knew it and so did he. We were alone; his family had gone to have a break from their 24-hour vigil. It is hard to know what to say to someone on their last day. You can't exactly talk about the future. There is nothing to look forward to. We talked about his kids and mine for a while and I told him a few funny stories from my day, just like I always had. It came time for me to leave. I said goodbye, knowing it would be for the last time, there would be no more ‘see you tomorrows' and I felt my hot tears well up. I embraced him so he wouldn't see them and he whispered ‘Thank you for everything' in my ear. He was so weak that even the effort of the hug seemed to drain a little more life out of him. I left the room and just made it to the doctor's desk before I broke into a sob. Another person that I couldn't save and I took it very personally. It ripped my heart out.

Almost every day, I get to see people on the worst day of their lives. It is my job to tell them that everything is
not
going to be all right and let them know how their life will
end. I think I would rather do a thousand rectal examinations than have to do this and I feel sick to my stomach every time it comes around. It is something they never really prepared me for in medical school. I take my role of giving bad news very seriously and I consider myself privileged to be a witness to the dignity that people manage to muster after they hear the worst news imaginable. I have dreams sometimes about the day it will be my turn to sit in that chair and have some doctor that I have just met tell me it's time for my life to come to an end.

‘I'm sorry,' they'll say, ‘there's nothing we can do.'

What will I do on that day? Will I cry? Will I punch a wall? I don't know and no one does until it happens to them. Most people just sit there and take it with quiet grace and I am not sure how they manage to stay in control.

Telling someone they are going to die is as uncomfortable, poignant and gut-wrenching as you would imagine. Seeing the pain on people's faces can be unbearable. You might think I would become hardened to it over time, but I don't believe that will ever be the case. I certainly hope it won't, anyway. After a while, some doctors find breaking bad news to be an almost impossible task and will do anything to avoid it. It seems to break them and I wonder if one day it will break me too. It takes a toll. At the end of the day I meet with my colleagues and we have a debrief about how many people we've given ‘the death talk' to that day. Amongst ourselves, when no one is listening, we call it
‘putting on the black hat' or ‘telling people not to start any long books or make any new friends'. Humour, especially black humour, is usually our way of softening it. Laughter and tears seem to be two emotions that are not very far apart. It is our way of coping with the darkness and to some it may seem callous. Even our husbands and wives don't really understand.

It has taken me a long time to figure out how to break bad news in a way that might come even remotely close to being acceptable – if it is possible to use the words ‘acceptable' and ‘you're going to die' in the same sentence. It has to be done with compassion and kindness but most of all with honesty. This is the greatest skill that a doctor has to learn and I still think I have room to improve. Nothing can be held back and things should never be made out to be better than they are. Because terminal cancer is the most significant news that someone will ever be told, the way it is done will never be forgotten by the patient or their family. I believe I have done my job as well as I can when I am so sad that I am crying right along with everyone else. As well as being compassionate, it is also my duty to be a rock for the patient. People feel utterly helpless and vulnerable at that moment and have no idea what to do next. It is my job to take everything in hand and make sure I navigate them through the confusing maze of medical procedures in a difficult health system that has no real empathy for anyone.

There are a few courses around that teach doctors how to give bad news, but for the most part it is learnt on the job by watching other people do it. Just as I have seen my mentors do it with great empathy, I have also watched others stumble through it appallingly. I have seen surgeons take phone calls part way through the death talk and I've heard them tell people that they have years to live when they simply do not. But nothing I have seen compares to the night we had worked on a young car accident victim in the operating theatre for an hour or so.

It became apparent that his injuries were so bad that we were losing the battle for his life and we reluctantly stopped our attempts to revive him. After a short time, we watched forlornly as the heartbeat monitor turned into a flat line with our hands still in his abdomen. I followed my boss (whose speciality meant that he did not have to deal with this type of death very often) solemnly toward the visitor room where there were 20 or so family members anxiously waiting to hear news of their relative's condition.

The surgeon began to tell them about how their boy was terribly injured and that we had attempted multiple procedures and manoeuvres to stabilise him. He went on in an emotionless monotone for about five minutes, regaling them with technical medical jargon: ‘We packed his liver, resected his spleen, evoked the massive transfusion protocol …' The family leaned closer and closer in hopeful
anticipation, obviously concluding from this long dissertation that there was a reasonable chance that everything was all right. Then, out of nowhere, the surgeon ended with ‘… and then he died.'

The words just hung there in the air and a look of astonishment crossed the face of everyone in that room. There was exactly five seconds of stunned silence before pandemonium erupted. The women began to make a primordial sound, a type of guttural keening, as they collapsed to the floor. The men swore – the noise was extraordinary. I looked on at the scene, feeling terrible for this family and bemused when my boss just kept prattling on, not knowing how else to comfort them.

‘We did everything we could,' he said to no one in particular as they huddled together on the floor, rocking and moaning.

I touched him on the arm and said, ‘I don't think they are listening to you any more.' We quietly retreated from the room. Note to self – get to the point quickly.

I have taken all these experiences on board, good and bad, and every time I have to tell somebody they are going to die, I try and approach it in a way that I hope will meet the needs of each person as an individual. It is so important not to beat around the bush and to say the words as plainly as possible, pulling no punches. The word ‘cancer' has to be used in the first sentence and once that cat is out of the bag, I am careful to pause to let it all soak in. As soon as
the word ‘cancer' leaves my lips, that person won't hear another thing I say for a little while.

Sometimes I pick up the chart as I get ready to see my next patient and read their referral letter, and as I read it becomes obvious that their cancer is really bad and there will be absolutely nothing I will be able to do for them. I take a moment before calling them in, wishing with all my heart I could be anywhere else. I stand there, taking a few deep breaths, knowing that in a few minutes I'll be delivering a death sentence.

When I've collected myself, I ask them to come in and I say hello. I feel convinced that what I've got to say is already written all over my face. We sit together for a few minutes, dancing around the topic while I ask some general questions about pain and appetite as I try desperately to establish even a little bit of rapport with this complete stranger. I do a good job of putting things off for another few minutes by carefully considering their x-rays and looking at their blood tests. As I put their scans on the viewing box, all I can see is big black blobs of cancer everywhere. It is confirmed, they will be dead very soon. No hope of cure, no treatment to make it go away, there is
nothing
I can do to make this better. I feel helpless and hopeless. Finally, when I have run out of questions to ask, I just have to do it. I try to hold my emotions in check but my mouth dries out and a lump develops in my throat, making it difficult for me to begin to speak. This pause always gives it away,
before I can even say it. My heart thumps hard in my chest as I start to say the words: