Slice Girls

by Joan Arakkal

  Meeting friends for a meal or a movie was a treat we all looked forward to after a hard day’s work as an intern. Draping lengths of beautiful thin silk with its woven thread borders over my slim body, I felt like Cinderella. The sari always made me feel beautiful. But I never felt fully dressed until I had carefully pinned jasmine garlands into the braided silky hair that snaked down my back to reach my waist. Placing on my forehead a red bindi – with no thought given to the third eye it represented – I stepped out to have a good time.

  Over a meal of hot, crispy dosas stuffed with spicy potato and a steel cup filled with brewed coffee that smelled of chicory, we chattered away. Our patients were far from our young minds. In the land of ‘arranged marriages’, the unarranged ones held much fascination. Who was dating whom? Who had parental permission to do so? Who had flouted and crossed the barriers of religion to follow their heart? All these questions occupied a large part of our conversations.

  For those of us who had not fallen in love or had not been given permission to fall in love, our parents were busy arranging matters so we would one day be married. Marriage was seen as a necessary complement to our careers. We did not object to being introduced to the men our parents sought out as potential future partners. Today, this would be likened to speed dating.

  Now, in the third decade of my arranged marriage with all its glories, challenges, tears and laughter, I am convinced my family did well when they introduced me to my husband. I was thrilled when I received a bottle of Chanel No. 5 a few months into our marriage. But what moves me most deeply today is the jasmine he leaves by my bedside. It comes from my garden in Perth, but it takes me back to my carefree days at Coimbatore.

  When I walk the sterile corridors of the Perth hospitals, the diagnostic clues of smells neatly masked by odour neutralisers and room fresheners, I know medicine has travelled a long way – and in the right direction, too.

  Wearing my black skirt – the white coat has been long abandoned – and with the gentle smell of Chanel No. 5 clinging to my crisp shirt, I realise how far I have travelled too. My journey across countries, and the times and stories woven into the plot of my life, keep me interested and curious to see what the future holds. Somewhere deep inside, though, I hanker for the lusty scents of the past that remind me of the common humanity to which every one of us belongs. Smells and all.

  WEALTH AND PRIVILEGE

  When my eight-year-old son wanted to retrieve the toy that I had put away on a top shelf in my study, he did not look for a stepladder. A stack of Campbell’s Operative Orthopaedics on top of a telephone book gave him just the height he needed to reach his precious virtual pet, which he had lovingly fed and trained for weeks. When I caught him in the act, he looked a bit sheepish, knowing that he had another twenty minutes to go before he was allowed to claim his toy. The inexplicable lure of the creature housed in the small, red screen had brought him indoors and I caught the mischief in his big brown eyes as he stepped off his perch.

  ‘That was a bit naughty, John. It isn’t time for your digimon. And you should not stand on books.’

  ‘Why, Mama?’

  ‘Because books can make you smart and you have to respect them.’

  I left the conversation at that, but the image of Sarasvati, the Hindu goddess of learning, flashed through my mind. Standing on a book was considered a slight to the goddess.

  In the Hindu pantheon, there is a god or goddess for every element of life – music, dance, learning, wealth, sex, death, obstacles, prosperity. A transcendent divinity perceived in every aspect of life, and in every stone and blade of grass, is the metaphysical concept of Brahman, the cosmic principle. Not wanting to burden John with the concepts of the Ultimate Reality, I left him in his virtual world.

  It was five years since I had applied for a training position. It was also five years since my cancer diagnosis. The treatment was behind me, and I was now working as an assisting surgeon. In a private theatre in Perth, an operation was coming to a close. Chiselling, sawing and precision cutting had removed the patient’s old, arthritic hip. After some more hammering, the glistening, round head of a shiny steel implant was manoeuvred into place with a symphony of movements. The satisfying clunk of the head falling into the socket heralded the home stretch of the operation. The bionic hip would do most of what the patient’s natural hip used to and, with the nerve endings gone, he would have no more pain. After a few months of recovery, the seventy-year-old farmer would be able to return to his golf, drive his tractor, play with his grandchildren and celebrate his fortieth wedding anniversary on a cruise ship.

  The operation had commenced an hour ago, when the sleeping patient was positioned on his side between two well-padded struts. I had painted his naked hip and leg using antiseptic from a newly opened Betadine bottle. I barely used half of the brown liquid to sterilise the skin and the remaining liquid was thrown with casual aplomb into the plastic-lined bin. I couldn’t help thinking how far we have travelled from the days of Dr Semmelweis’s insistence on handwashing with chlorine to avoid maternal deaths – and how his idea was ridiculed by the medical fraternity who refused to acknowledge the role of antisepsis in saving lives. The physician–scientist died in a mental asylum aged forty-seven. The modern practice of using disposable items wherever possible has cut down the rate of infection, despite enormous costs, not only to the nation’s economy, but the planet at large. As I banished the partly used bottles to the bin, I thought of the naval officer I had treated many years ago during my internship. If I had been able to use more antiseptic to wipe away his tetanus, would he still be sailing the high seas?

  The procedure was coming to an end and everyone relaxed. The anaesthetist began to taper the gases so the patient would wake up on time. As the gaping, bloody wound was sewn back together, layer by layer, the surgeons, nurses and the technicians slowly unwound. Social chitchat was made, gossip exchanged and there was a gentle increase in the flurry of activities that signalled the end of the procedure. Another name was crossed off the displayed theatre list.

  As the anaesthetist and his trusted assistant roused the patient from his anaesthetic slumber, the patient’s wound was dressed and his modesty restored as the white gown was drawn into place. The final act of the symphony was the arrival of the ‘boys’, the lighthearted theatre orderlies who always bring with them a sense of comic relief. The patient was neatly and effortlessly transferred from the operating table to a regular bed with wheels. Rambling incoherently, he was wheeled to the recovery area. The theatre floor was mopped, drops of blood that had landed on the operating lights were wiped away, anaesthetic drawers were refilled with vials of sedatives and relaxants, and preparations were made for the arrival of the next patient on the list. These are bread-and-butter procedures for most of the staff in the theatre. For the surgeons, though, it would be caviar and blini tonight.

  Behind the drama of the theatre, diligent secretaries do the paperwork and central sterile services department technicians clean, wrap and sterilise innumerable instruments which the nurses then stack on shelves with the surgeon’s names neatly on display. Scrub nurses count and recount the supplies and tools to ensure no swabs or instruments are accidently left behind in the patient’s wound when they leave the theatre. It is a tribute to the diligence of the nursing protocols that such incidents are substantially low. A tiny needle, shaped like a newborn’s fingernail clipping, once went missing after it was used to sew an artery. The fastidious nurse would not allow the wound to be closed until the needle was accounted for. A few minutes later, she found it on the floor with the help of a magnetic swab. Even though we deliberately leave behind surgical staples that are much larger than the missing needle, with no consequence to the patient, the checklist was followed to a tee. The nurse’s insistence ensured a high standard of baseline performance.

  Once upon a time, hip and knee replacements were difficult, dangerous and rare. Now, however, they are everyday procedures – one of a category of staple orthop
aedic operations that ensure the ever-escalating lifestyles of orthopaedic surgeons. General practitioners refer patients to an orthopaedic surgeon. Subtle methods of canvassing with bottles of expensive wine and dinners – and not so subtle advertisements in the media (where the truth can be elusive) – ensure a generous flow of patients onto the surgeon’s private lists. Surgeons have to keep the referring doctors happy, otherwise the numbers could plummet in an unsettling way.

  For a fully qualified orthopaedic surgeon, every patient entering the door of the practice wears a large dollar sign. There is money to be made in consulting, operating and follow-up of these patients until they are discharged from care. Fear of litigation and loss of referrals ensures that basic standards are maintained. Many procedures could well be avoided but are justified as ‘patient-driven’. It is always possible to argue that patients demand quick solutions, so costly and potentially unnecessary services can always be legitimised. The principle ‘Primum non nocere’ – ‘First do no harm’ – is often overlooked. After all, Hippocrates didn’t have a new Porsche to pay off.

  Between operations, the surgeons do all they can to protect and oil the cogs of the lucrative machine that pumps out flashy homes and expensive holidays. So how does the machine work? The profession functions like an old-style guild. Quiet conventions and invisible barriers ensure the prosperity of the guild’s members. As long as they do not steer far from the path, they are protected. Their leaders ensure that competition is restricted, loyalty rewarded and any dissidence thwarted. Young orthopaedic trainees learn early to become attentive, compliant apprentices.

  Orthopaedic surgeons spend a great deal of time in the operating theatres and the wards. Not surprisingly, many of them marry nurses, bestowing on them a higher status and more wealth than their nursing careers could ever provide. While the surgeons chisel and hammer away diligently, their spouses keep a close eye on their bank accounts. A few flit between coffee shops, simultaneously discussing charity work in exotic third-world locations while dropping into conversation the fact that their riverfront home is featured in a glossy magazine. Some wives accompany their husbands when they travel overseas to render their surgical services.

  Tales of lives reformed by selfless modern-day missionaries warm our hearts. Well-meaning nurses and doctors rustle up discarded theatre items and drugs and load them onto planes operated by commercial airlines that waive the excess baggage fee for the charity work ahead. Maimed and deformed people welcome the medical teams that arrive on their soil. Stepping off the treadmill of everyday orthopaedics, the surgeons collect ‘continuing professional development’ points to satisfy the Colleges, while they tut-tut about the abysmal plight of the country and the corruption that keeps its people shackled to a poor healthcare system.

  The surgical opportunities for visiting orthopaedic surgeons to rush in and operate on conditions that are relatively rare in Australia is hard to pass up. However, without the advanced theatre facilities in which they are trained, many Western doctors struggle to deliver a meaningful service. That does not always stop them from wielding the knife and shoring up experience by performing surgeries for which they are ill-prepared on unsuspecting patients, sometimes doing more harm than good.

  I heard about one child treated for club foot by a team that travelled overseas. It sounded a far cry from the happy endings I had seen back in my days at Calicut Hospital, where Dr Vishwanathan had zealously monitored the treatment of this congenital deformity. It appeared the procedure did not have the desired outcome, perhaps because it was complicated by an infection. There was little the visiting surgeon could do to save the life of the child. The parents were placated and nominally compensated, and the visitors departed. Without significant accountability, the consequences do not follow the surgeons back to the medically defended shores.

  Honing one’s surgical skills in developing countries, where there is little fear of litigation, is not unheard of. Imagine if a similar incident occurred in Perth. The lawyers would have found it hard to ascertain a value for the child’s life. If the media were to discover the story, there would be public outcry and outrage. The parents would be interviewed and the lawyers would speak up. However, secrecy and silence shroud mishaps and misdemeanours in far-off nations.

  So, we march on, scalpels sharp and gowns sterile, untroubled by the absent patter of happy feet on the mud floors of a distant hut.

  Orthopaedic surgeons tend to have more children than the average man. This is due not only to their higher earnings, but also to their assertive masculinity. Their wives are often their practice managers. The women run the homes, look after children and supervise the cashflow of their practices.

  Also supporting the bonemen in their professional lives are other women who play useful roles. Female GPs are courted for patient referrals. Within the hospital, female physicians are valued for their general medical knowledge, something the orthopods seem to lose when they pick up their tools.

  But the sexist attitudes that lurk just below the polished exteriors of some of these surgeons surface when lightly scratched. A senior orthopaedic surgeon once referred to a younger female colleague as a ‘bitch’ and to a woman anaesthetist as ‘eye candy’. Comments made to me about the personal appearance of a nurse manager that another surgeon disliked were cringeworthy. Surprisingly, many of these surgeons’ careers continued to flourish despite their swearing, inappropriate comments and blatantly sexist attitudes. The protection afforded by the collective power they wield, seems to leave them with little to fear.

  In Perth’s operating theatres, over the sound of hissing cauteries, noisy suckers and clanking instruments, routine procedures offer an opportunity to discuss non-medical topics. With the male surgeons, this was mostly sport. I usually stayed out of these discussions but whenever the Indian cricket team lost to the Australian team there would be some lighthearted ribbing. I tried to join in the banter, suppressing George Bernard Shaw’s cricket aphorism: ‘Eleven fools playing, 11,000 fools watching’.

  When news about the massacre of twelve people in the Paris offices of the satirical magazine Charlie Hebdo was splashed across the world, everyone was discussing it. My daughter had travelled to Paris the previous day, arriving in the eye of the storm. I expressed my maternal concern and also my frustration at people provoking each other in the name of freedom of speech. The surgeon I was assisting remarked that Islam was a religion to be ridiculed and the freedom to say so was anybody’s right. The nurses and orderlies in the theatre represented a variety of cultural and religious backgrounds. After making the sweeping statement about a religion – one that is sacred to almost a quarter of the world’s population – the surgeon continued operating.

  I threw in my two cents’ worth. Anyone, I pointed out, could take the worst of any religion and ridicule it. And that was precisely the danger of fixating on a single isolated story. There was nothing to be proud of in the atrocities mentioned in the Bible – the proclamation of death for unchastity, the murder of babies or the sanctioned rape of little girls. The cruelty towards women and children and the condoning of slavery are parts of the Bible that get swept under the carpet, as is St Paul’s attitude towards women and his orders to cover their heads lest they offend God. The burqa, now famously associated with Muslim women, has its origin in early Christian and Judaic practices. Yet if we dwell on the unsavoury aspects of the faith and forget the important message of Christ, we do ourselves a great disservice.

  As I spoke, I could not help but think about the country of my birth, which had allowed me to choose the god I wished to pray to. I also silently gave thanks to my parents, who were unfazed when, as a child, I made equal offerings to ‘Krishna God and Jesus God’. This open-mindedness remains one of the fascinations that India holds for me. When I hear of religious intolerance in India today, I think about a land where millions of gods thrived and peacefully coexisted for centuries until two late arrivals upset their timeless balance of power.

  My re
ligious beginnings have now moved to a different place. I find myself drawn to Hindu philosophy where the ethical and moral struggles of human life have been allegorically set in a battlefield. Having been born in the land of the river Indus, I will always be a Hindu first and foremost. A mere 2000-year-old conversion of my ancestors by St Thomas cannot divorce me from my ancestral faith that is many millennia older.

  Back in the operating theatre, there was an uncomfortable silence. As the surgery drew to a close, the surgeon appeared to be lost in deep thought. Then he piped up: we lived in the West, he said, but I was ‘anti-West’.

  ‘West is a direction,’ I replied, ‘based on your point of reference.’ Did he mean Western Australia, or Western Europe, or the developed world, or the cluster of liberal and progressive values to which that world was supposedly committed? If the latter, then how, I asked, could respect for another religion be construed as ‘anti-West’? Were religious intolerance and cultural prejudice acceptable Western qualities? He chose to answer me with silence. Yet, when he met with his colleagues outside the theatre later, he had much to say and did not appear to mind that I could overhear him.

  As for the virtue of freedom of speech, I wondered if this freedom was only for a chosen few. When the Medical Forum magazine published an article I wrote questioning the collusion that took place in orthopaedics and the negative effects of that on society and scientific progress, one orthopaedic surgeon told me that what I had written had hit home the point but I would not escape the consequences. A urologist was more forthcoming. He agreed with me but expressed his disquiet about my finding employment. ‘Who will employ you?’ he asked. ‘You have to toe the line and keep your head low to survive.’ Another surgeon told me that I had ‘burnt my bridges’.