Slice Girls

by Joan Arakkal

  Dismissal and delusions of reprieve are common responses when someone is diagnosed with a life-threatening illness. It’s woven into our human psyche. The responsibility for finding out what is wrong with the patient does not just lie with the radiologist who interprets her mammogram or the pathologist who grades her tumour. Taking her hat off and examining her body closely and thoroughly is all part of the training that elevates doctors from technicians to healers.

  When time is seen through the lens of money, any delay in the money-making machine is exasperating. And sometimes there is also a sense of entitlement to the generous fees we can receive for our services. I recall one young orthopaedic surgeon who came into the operating theatre of the private hospital livid with anger. He announced that a patient had the temerity to question the huge gap he had charged them on top of the generous Medicare and private insurance company reimbursement. His face grew redder as he indignantly announced, ‘I do not get any time to spend with my three-year-old daughter because of how hard I work.’

  Listening to this diatribe as one who was recently denied one of the limited number of training positions, I realised that the pursuit of money had overtaken this man’s life. When he squeezed his portly figure into a compact sports car, he fit perfectly into the caricature of the average orthopaedic surgeon. Protectionist attitudes entrenched in the system ensure that only a limited number of surgeons entered the orthopaedic arena every year. This limits any competition for the millions of dollars that could be made each year by individual surgeons.

  Yet it was never enough. Working into the late hours of the evening means fewer hours at home. When time is money, reading a bedtime story to your children is an expensive proposition. In this world, a growing bank balance compensates for the shrinking hours you can spend with your family. When the partners of these surgeons can no longer cope, some of them leave. New relationships begin, and the surgeons have to work even longer hours to sustain the lifestyles of their current and past partners. Under these financial pressures, the golden goose that allowed their earnings and culture to thrive has to be closely guarded and protected.

  There is little that can be done to stop orthopaedic surgeons from ensuring that their private practices flourish at the expense of a floundering public health system. The public hospital appointments and their restrictive sessional fees are an unattractive proposition for many established surgeons. Yet these hospitals are a great place for young orthopaedic surgeons with their shining new FRACS shingle to gain experience, often with minimal consequences to their reputation if they make a mistake.

  Appointments to the public hospital are scrutinised and influenced by the AOA, which puts the public health system in the hands of surgeons with private-practice incentives. Meanwhile, uninsured patients attending public hospitals sit on long waiting lists, have surgeries cancelled at the last minute and are often treated by under-supervised trainee surgeons.

  Australia’s Indigenous people often present to public hospitals. Institutionalised racism towards Australia’s First Peoples is not a secret, but what was striking was the impunity with which racist remarks were made. When an anaesthetist scoffed at the announcement that Indigenous sportsman Adam Goodes was to be named Australian of the Year, the orthopaedic surgeon in the theatre smirked in agreement. The anaesthetic technician added her agreement and the conversation continued with great gusto. They were unaware of my presence near the theatre door until I asked if they were talking about the elite AFL player, winner of two Brownlow medals and two premierships, and Indigenous leader. There was an uncomfortable silence. The other theatre staff were keen to distance themselves from the event and later expressed their disapproval. I remembered a surgeon overseas who once told me that training positions were reserved for the ‘boys from South Africa’. This entrenched racism is reminiscent of the apartheid era. It is even more disturbing that it is perpetuated by people who occupy the highest rungs of a so-called ‘noble’ profession.

  The consultants and registrars met at the hospital every week for an early morning clinical meeting. Patients with difficult problems were discussed and their X-rays were displayed. Images of shattered bones and dislocated joints were followed by images of aligned bony ends held together by wires, screws and plates carefully placed to avoid vital structures and joint cavities. Follow-up X-rays were examined for white fluffy material around the fracture site that indicated that healing was underway.

  Having aligned the bones and held them in place with metalwork, the surgeons awaited nature’s healing forces. Sometimes nature disappoints – the healing does not happen and, as the weeks go on, the fractured ends lose their sharpness and take on a rounded appearance. This indicates the fracture is headed for non-union and more desperate measures are required to promote healing. It is at this stage that questions are asked about why the natural process failed. The answers can often be found in a misplaced screw or over-diligent surgery stripping the bone of its blood vessels or the intrusion of unwelcome bacteria into the area. Bearing weight on a fractured leg can also prevent healing. That is why patients are initially given crutches to take the weight off their leg. Most people comply with the instructions, but there are always some who don’t.

  One week, a registrar displayed the X-rays of a broken leg he had operated on some weeks earlier. The edges of the broken tibia under the metal plate and screws were starting to look smooth and rounded. The fracture was not healing as expected. The X-rays belonged to a twenty-seven-year-old Pitjantjatjara man who had fallen from a rock he was climbing. The Royal Flying Doctors Service had flown him to Perth where he was left in the care of the young registrar. As the registrar honed his skills operating on this difficult fracture, the consultant on call was busy in a nearby private hospital.

  Consultants are very busy men, often moving between two theatres with as many as ten knee arthroscopies on their private operating list. Two anaesthetists and two assisting surgeons keep the theatres running seamlessly as the surgeon flits between the two. Scrubbed and ready, he strides into the theatre in his blue gown. He drives the long narrow fibre-optic tube of the arthroscope into the knee. The tiny camera projects magnified images on the monitor. The small tears in the cartilage are devoured by an oscillating shaver, much like the blades in a rotating grooming shaver. Larger tears are grabbed in the jaws of the forceps. When the meniscal fragment leaves the joint, and is away from the magnification, it looks far less impressive. More unimpressive fragments are grabbed and the camera is swished around to take colourful pictures, copies of which will be given to the patient. The knee joint, which was filled with saline to allow the arthroscope to enter through the keyhole incisions, is now emptied. Fifteen minutes after entering the theatre, the surgeon strips off his gloves. His assistant closes the tiny wounds, applies the circular bandage and releases the tourniquet. The surgeon now enters the adjacent theatre, where another patient lies in deep anaesthetic slumber with his leg, neatly painted with a pink antiseptic, dangling down the operating table. The tourniquet is inflated and it is not long until the inside of another knee is displayed on the monitor and the process plays out yet again. The surgeries roll on. Four hours and ten surgeries later, the surgeon’s cash register is brimming over. Many of these patients obtain no significant benefit from this expensive procedure. The placebo effect of the surgery and the colourful glossy pictures (which make little sense to the patients) are their consolations.

  A registrar’s request for help to piece together a mosaic of broken pieces of leg bone can be seen as a nuisance and an intrusion on this production line. It doesn’t take long for young registrars in public hospitals to realise that calling their supervising consultants away from their private operating theatres is not a good career move. Instead, they soldier on as best as they can, consoling themselves that one day they too will go from being understudies in a public hospital operating theatre to highly paid stars in a private one.

  The losers in this scenario are the uninsured patients who
present to a public hospital. This was the case with the young Pitjantjatjara man whose fractured tibia was not knitting as it should have. At the early morning meeting, the registrar who had operated on this young man skimmed over the badly placed metalwork on the X-rays and emphasised the cultural background of his patient. He made a condescending remark about the patient being better than the stereotype that normally came his way. He then said that it was possible that the young man had not complied with his instructions of using a crutch, because of his ethnicity. The senior consultants condoned his assumptions with their silence.

  Every 26 January, India celebrates Republic Day. The constitution that gave citizens the power to govern themselves by choosing their own government is celebrated with pride across the nation every year. One year, like every other, in the remote village of Bhuj in the district of Kutch, schoolchildren sang patriotic songs and flags ascended flagpoles to flutter freely. Every Indian knows this story.

  Kutch lies on the rift of the fault lines between the Indian and Eurasian plates. The earthquake did not last long. Two minutes after the fault line adjusted itself, everything had changed. Homes and lives lay scattered in the rubble. Historical sites were razed, hospitals turned to tombstones and those patriotic songs froze on the lips of dying children. In the quiet ruins that followed, 20,000 people eventually died. Rich and poor were united in their loss. Countries across the globe offered aid as the people of Kutch came to terms with the natural disaster that had shaken their world.

  When I woke up the next morning in Perth, the deaths of 10,000 people in the Indian earthquake was reported in the inside pages of the daily newspaper. A football match covered the front page.

  Still trying to comprehend the magnitude of the death toll and the destruction that had just taken place in my country of birth, I arrived at the hospital for another working day. An eighty-year-old man had hurt his knee while swinging his golf stick. He would need an arthroscopy to unlock his knee and remove the torn bit of cartilage caught between his bones. A basketball player had jumped too high and landed on his ankle, and it needed to be untwisted. A cyclist who had come off his bike while riding to work had got off lightly with a broken collarbone that would heal well in a sling. As I attended to these patients, my mind returned to the victims in Kutch. I wished I could help with the rescue effort. But, with a husband working long hours and two small children to take care of, I knew my orthopaedic services would not find their way there. I moved between the cubicles of the emergency department where my patients rested comfortably, their pain relieved with adequate medication.

  One senior medico that day was a man who did not hide his disdain for career women. When one day I had asked him, half in jest, if he believed a woman’s place was in the kitchen, his dismissal was not entirely convincing. Discussing the earthquake and the horrendous death toll, I was unprepared for his flippant remark reminiscent of a modern-day Churchill.

  ‘Oh, that’s all right. They’re only Indians. There are lots more of them.’

  WALYALUP

  Not far from the hospital is the Fremantle Markets. They come alive over the weekends. Stepping into the carnival-like atmosphere, I leave the hospital environment behind and grab a quick respite from work. ‘Freo’ is a melting pot of people who arrived on its shores from faraway lands, giving it a unique flavour.

  Until 1829, this area was called Walyalup. The Noongar people lived here for 45,000 years in close harmony with its lakes and waterholes, sand plains and limestone hills, swamps and marshes. When the subjects of King George IV arrived, in the suitably named HMS Challenger, the Noongar people welcomed the newcomers. They believed them to be their ancestors emerging from the sea. Their kindness was reciprocated with dispossession, incarceration and murder.

  The displaced people dragged their kangaroo skins and fishing spears further and further away, but one young warrior, Yagan, chose to stay and lead the fight for his people and their country. Yagan was both feared and admired by the settlers, and stories about his exploits appeared regularly in the local newspaper. He escaped capture until 1833. He was shot, his head was cut from his body and his back was skinned to preserve his tribal markings. Some months later, Yagan’s smoked decapitated head travelled across the seas where it was displayed in a museum in Liverpool. Yagan’s head was a trophy, like the bison heads and branching antlers that hung in the homes of the British aristocracy. It was finally returned to his descendants in 1997, after decades of lobbying.

  The Anglo-Celtic population of Walyalup, now called Fremantle, after the captain of the HMS Challenger, was joined by Italians, Greeks, Dutch, Germans and Croats. More recently, South Africans have been drawn to its Mediterranean climate and Indians and Chinese have been added to the ever-expanding cultural mix. Nowhere is the multicultural aspect of Fremantle more obvious than in its eateries. Eating out in Freo can be challenging because of the multiplicity of choice. The restaurants scattered along its waterfront offer fresh seafood. Battered and fried calamari rings compete with chilli mussels floating in red sauce. Thin-crusted pizzas straight out of a woodfire oven smell delicious. When I walk into the food court, my senses are assaulted by the fresh smells of Eastern cuisine – pad thai, tom yam, ginger honey chicken, samosas, tempuras – the list is long. I wander from one stall to another, trying to make up my mind. I settle for a Chinese mee hoon. The thin rice noodles lie in a clear, flavour-filled soup along with a medley of seafood. I settle at a table under a tree and bend over the steaming bowl. Alternatively using the chopsticks and the short wide spoon I have been given, I quickly make light of the meal.

  I still have time before I return to the hospital, so I walk down the cappuccino strip of South Terrace and sit on the footpath sipping a freshly brewed cup of coffee. The busker’s plaintive song attracts little attention. I am tempted to tell him to sing an uplifting one if he wants to earn a few more coins. A dark-skinned man approaches me. He looks bedraggled. His gait is unsteady.

  ‘Hey Sis, have you got a cigarette?’

  I look away, not wanting to engage with the inebriated man. He curses under his breath and moves on. The coffee loses its flavour as I see the retreating back of the descendant of proud Yagan. My phone rings and I retrace my steps to the hospital. I walk past the market square. I see children clapping their hands at the showman who has just finished his acrobatic tricks. The birdman, with his whistles whittled from bamboo, tweets away. The didgeridoo man bellows his cheeks and vibrates his lips into the mouthpiece of a hollowed eucalyptus tree trunk. An ancient, deep meditative drone resonates with a primal boom.

  I walk on and the music fades as I enter the old hospital building. A broken bone awaits my attention.

  PADDLING UPSTREAM

  While I was applying for training positions in orthopaedics with a view to being admitted as a fellow of the Royal Australasian College of Surgeons, I was encouraged to apply for a position in orthopaedics at a peripheral non-teaching hospital. At the time, following an arrangement with the Minister for Health and the Australian Medical Association, specialists were being recruited to areas where there was a shortage. Based on my overseas qualifications and experience, I was offered the position and the Western Australian arm of the Medical Board of Australia accordingly registered me as a specialist.

  I was aware that this position would not further my career goal of pursuing hand surgery and conducting research. Working from an outer-suburban hospital with few chances to see complex injuries or pursue any significant research, made the offer less attractive.

  Without a FRACS, I would be forced to remain in peripheral positions and there would be little opportunity to move ahead. I had a conversation with a senior hand surgeon, who told me that it would be almost impossible to pursue that subspecialty without being a fellow of the College. That conversation goaded me to pursue opportunities to gain a fellowship while remaining registered as a specialist with the Medical Board of Western Australia.

  I applied, yet again, for a training posit
ion and made an appointment with the head of the department for feedback on my progress. He told me that I had exceeded all expectations and that they were impressed that I had not allowed my maternal role to get in the way of my work. I also had a discussion with the chairman of the training committee, who said that my prospects for entering training were looking good. I had done numerous surgeries with no significant complications, dispensed my duties in the outpatient clinics and the wards with ease, and maintained good relationships with staff, colleagues and patients, so I had no reason to worry.

  When the results were announced, I was shocked and heart-broken that I had not been successful. Despite seven years of working in Australia, doors remained closed to me and it was beginning to appear that my persistent knocking was futile.

  The regret expressed in the letter from the AOA rang hollow, but I decided to follow up their offer of feedback about why I had not been admitted to training. I made an appointment with the senior orthopaedic surgeon, and a consultant who was involved with the registrars’ training.

  On the day, I entered the room and took a seat across from the senior surgeon. The consultant sauntered in with a loosened tie, brimming with confidence. After the initial pleasantries, the surgeon explained that, while I had placed well above the other applicants on the objective aspects of my assessment, on the subjective scale I had not done so well. He fell silent.