How to Do a Liver Transplant (26 page)

‘You have cancer and it is bad. It is not removable with an operation and it will end your life in the next few months.'

I just want to take them into my arms and tell them that everything will be OK, but it won't be. I truly have nothing good to say. That person will walk out of my office that day with no solution or hope.

There is no doubt in my mind that the most heart-wrenching patients are the ones I have previously operated on, intending to cure them. The optimist in me wants more than anything to have managed to cut every last cancer cell from their body. I want to believe that every single one of them will be the fortunate one for whom the cancer will be gone forever. The scientific doctor within me, though, knows that because of the types of cancers I look after – those of the pancreas and those that have spread from other places – that a high proportion of my patients will see their cancer return one day. I put my blood, sweat and tears into caring for these patients and I get to know them and their families as dear friends. I am happy to see them each visit because it means they are still alive. With each clear scan they are closer to a cure. Then one time, months and even years later, just when I dare to think they may be in the clear, a scan will reveal that their cancer is back. They feel no pain and are not unwell. This is how cancer
is for a while. The only sign of its existence is a mark on an x-ray. It is just sitting there, silently killing them. Suddenly, the happy consultation must turn serious as I say the words that no cancer patient wants to hear:

‘Your cancer is back and this time I can't remove it.'

I feel like I have failed and it is deeply personal to me because I have got to know the patient so well. I feel they have become part of my family. I tell them how sorry I am.

No matter where people come from in the world, there is a very particular order of emotions everyone goes through when they are told they are going to die. First, there is stunned silence followed quickly by some sort of visceral reaction – tears, anger, violence, screaming, vomiting or shaking. Then there is silence again, moments spent collecting their thoughts, drying their eyes, composing their questions. Then come the questions. Why me? What caused it? How aggressive is it? What treatment can I have? The next reaction is variable. Most people gather all their strength and get ready for the fight of their life. They are enthusiastic, ready to take it head on and prove me wrong. There are a few who fall apart and become clinically depressed, giving up completely. Some get so angry – sometimes with me, for not being able to help them, or at themselves for perhaps not leading a healthy lifestyle. Some feel that they have done something wrong.

Then there are the surprising reactions. One lady's first response to being told her husband was dying was to fly
into a rage at him for not having life insurance. She was staring her future in the face. All of this pain makes it difficult to move forward with any plans straight away. The utter disbelief and distress makes it impossible for people to make rational decisions. I send them away for a while so they can come back and we can talk after it has all sunk in a little and they are ready to hear more.

As the patients move through these phases of grief they will finally get to the question that everyone wants answered: ‘How long do I have?' Of course this is an impossible question for me to answer. For most of the conditions I treat, the answer is usually a few months, or at best a couple of years. I tell people to put their affairs in order and to take care of any unfulfilled wishes.

For a few unfortunate souls, their time left on earth can be measured in days or even hours. This is the case for a hideous tumour that grows in the liver. Hepatocellular cancer can be so bad that it will behave worse than the most vicious alien Sigourney Weaver could ever encounter. Just like a parasite, this cancer loves to punch holes in big veins to get access to the blood it needs to satisfy its voracious appetite. Once the tumour has made it into the blood vessel, its growth goes unchecked until it completely fills the vein with soft, murderous tentacles. The veins give the cancer a clear pathway to propagate out of the liver and it will eventually fill the heart with tumours. Without warning, a big hunk of gelatinous cancer will break off
and lodge in the lungs, suspending the flow of blood and causing almost instantaneous death. Because the veins fill with the tumour very slowly, patients with this horrible cancer have very few symptoms. Unbeknownst to them, they are ticking time bombs and there is not a thing I can do about it.

This was the case with a patient I saw. I told him that not only did he have this terminal cancer but that he could die at any moment. One minute earlier, all he thought he had was a bad case of indigestion. It was a lot like telling someone they are going to be executed but we don't know when or where, just any day now. Go home and wait. What could I possibly say to make him feel better? Absolutely nothing. About an hour after that patient left my office I got a call from an ambulance officer to say they had him in their car. His heart had stopped and they were doing CPR. They asked me what they should do next.

‘Just stop,' I said forlornly, ‘there is no hope.'

Most people have a little longer than that, thank goodness. When the dust has settled on the diagnosis and the initial shock has passed, the questions will inevitably come about alternative or complementary therapies. People are very suspicious about western medicine for some reason. As part of their grief, people can't comprehend why I can't always fix things for them. I think some people believe that I might even be withholding some sort of special treatment that I have hidden up my sleeve. I let them know that if
there truly was any type of treatment or cure available that was safe and that worked, I would be the first to use it. I am looking forward to the day when we can unlock the secrets to treating these cancers because that is the day when I can buy that Winnebago and retire. I also let people know that they should be very careful about spending their money on crazy treatments where people promise them miracle cures. Some patients will leave my office, sell everything they own and blow the lot on dubious and sometimes painful treatments that make them miserable and don't change a thing.

The most traumatic experience I have ever had when delivering bad news occurred when I was a surgical registrar. I was working at a district hospital when I admitted a 19-year-old who was mum to a small child. She had terrible pain in her stomach and was vomiting everything she ate. A dark lump had appeared on her abdomen a week before. From her story and x-rays it became clear that she had a blockage somewhere in her bowels. I was not sure why this was happening to her and because of her youth, cancer was the furthest thing from my mind. Clearly the problem was pretty serious, though, and she was unwell enough to go straight to the operating theatre for surgery. I opened her belly and found hundreds of blobs of fleshy black melanoma studded along her bowel causing blockages at multiple levels. There was nothing I could safely cut out, nothing I could do to help her. Taking out these cancers would have meant she would lose her entire bowel and that would be
no life at all. Melanoma does this from time to time. As I closed her up, I did it slowly, knowing that I would have to walk out soon and tell her father that his daughter would be dead within days.

A few hours before this, I had seen a girl of a similar age also with belly pain, but of a far less serious nature. I hadn't yet worked out what was wrong with her, but it certainly wasn't cancer. I walked out to the waiting room to find the father of the girl with the melanoma. I had not met him before his daughter's operation and I was feeling more than a little emotional about what I was about to do. A nurse was waiting there with a man who she pushed forward, telling me that this was the father of ‘the young girl'. I began to tell him the terrible news and an unusual look came over his face. He was shocked but there was something else in his expression that I couldn't put my finger on. He was stunned and couldn't speak. As I began to talk more and more about his daughter, he looked more and more confused. He let me go on for about five minutes, looking weird, but seemed to be accepting what I was saying. I gave him a hug and turned to leave. There was something about the whole exchange that bothered me. When I reached the door, something made me turn around and go back.

‘You are the dad of Miss X with the melanoma, aren't you?' I asked him.

‘What?' he said. ‘No, my daughter is Miss Y with the tummy pain.'

I suddenly realised my terrible error. I had just told the wrong person that their daughter was dying. It had happened so easily – I was very affected by having to do it so I didn't remember to double-check who he was. I really lost it then, I started blubbing and threw myself into the arms of this poor man and this time I couldn't let go. I sobbed that his daughter was fine and apologised that I'd made a horrible mistake. Of course, I then had to face telling the
actual
father the news all over again. I was so upset with myself but the dad of Miss Y was so relieved that his daughter would be OK that he went and bought me a cup of coffee and a lotto ticket. He tried to calm
me
down. I couldn't believe he was so understanding. He looked at it like it was his lucky day – what an amazing person. I'm not sure I would have been so conciliatory.

I am a person who is always looking for the silver lining. It gets me through the awful parts of my job. Giving people such terrible news has taught me many things about my own life and it has been an amazing gift to be allowed such intimate access into people's lives. I now understand that I can never take anything for granted. Human life goes by in the blink of an eye and this is why I live the life that I do. I try and pack as much into every day as possible. There is always something to see or do and there is always a little joy to find in any situation. I live my life like every day is my last, because you really never know when it will be. I tell my kids how much I love them every time
I see them and try to instil in them a passion for life and respect for others. These are the lessons I take away from my amazing patients.

How do you do it all?

F
or some inane reason, I thought becoming a fully fledged surgeon might mean that I could relax a little and let my underlings take up a bit of the slack. The biggest secret they keep from the registrars is that this is not the case at all. I imagine it is like that because no one would actually become a surgeon if they knew that the pace never relented. The hook is that once you have committed eight or so years towards training for it, you can hardly walk away. As well as working at the PA and Royal Children's Hospital looking after the transplant and cancer patients, private practice also beckoned.

Interestingly, almost as soon as I started work as a surgeon in a public hospital, I found myself not operating as much any more. Of course, I still did the transplants, but because the PA was a training hospital, I spent much of the time during the other surgeries teaching my junior staff how to operate, paying back all the hours of training that were afforded me. Private practice offered the opportunity to continue to do what I loved by doing as many operations as I liked, whenever I liked.

As if I didn't have enough on my plate, along with the actual operating involved in private practice comes the need to have somewhere to see the patients afterwards. I found myself buying offices of my own at Greenslopes Private Hospital and becoming the employer of two wonderful secretaries in the process, without whom I would find it pretty difficult to function. Andrew and I had our hands full running the business and running the house. I was rarely home. So, just when we thought we couldn't fit another thing in, what did we decide to do? Have another baby, of course. Four years after I started back at the PA I gave birth to my fourth child, a handsome boy this time. We named him George, after George Washington and George Hopkins, my faithful friend who, as registrar at Nambour hospital, played a big part in helping me through my first operation and getting me where I am today.

Life is now busier than I could have ever imagined. Every day I wonder how I will keep going, but I always
do. I have to go into work almost every day, weekends included. There is always one of my complicated patients who needs my attention. I sleep with my phone within arm's reach and it even accompanies me to the toilet in case it rings while I am in there. One minute I can be in a deep sleep and the next I find myself boarding a small plane at a deserted airport, jetting off to take the organs out of dead people. Unlike the US, at my hospital, senior surgeons still do the donors. I sleep with a set of scrubs next to the bed, so I can put them on and go, shaving valuable seconds off my time if I'm called in urgently. I worry about my patients constantly. I dream about them. A long time ago I decided to keep a notebook by the bed so I could write my worries down so they didn't keep me awake all night. I get so tired sometimes that I fall asleep in the shower, my face pressed against the tiles, drool running out of the corner of my mouth.

People seem to be endlessly fascinated by how I could possibly manage to do all this and have the family that I do. It's just something I do and it does not seem unusual to me, though it may seem so to others. The most common thing I'm asked is the same question they asked in my job interview: ‘How do you do it all?' My answer is, ‘I don't do it all.' But I do
have
it all. I have a small but brilliant group of people around me to help keep all my balls up in the air, and in more ways than one we are all married to my job.

My team is led of course by the unflappable Andrew. On our return from America, he got a job as an internal auditor for a while. But even when we had just two small children at home, cracks started to appear in the way our household worked. I couldn't be alone with the kids, because the nature of my work meant that I would often have to drop everything and rush in to the hospital, leaving no one to look after them. It was costing us more than he made in babysitters and nannies, so we made the decision that Andrew would give up his job and stay home. This brought a great deal of stability into our lives. Our ‘reverse 1950s household', as Andrew calls it, has worked well for us and, like all stay-at-home parents, he has the important job of driving the family bus to ballet, guitar lessons and school.