Slice Girls

by Joan Arakkal

  As I tried to recall the peace mantra from the Upanishads, I remembered my school principal’s words of wisdom: ‘Kick the ball, not the player.’

  A flamboyant surgeon was spending an evening instructing a handful of registrars who were about to sit the FRACS examination. The young men came to his private rooms and gathered around the patients who had agreed to be clinical subjects. They examined hands and wrists for signs that would lead them to one plausible diagnosis among a myriad of clinical possibilities. The wide-eyed future surgeons were quizzed on all the likely conditions. As they rattled off their knowledge, fresh from their recent reading, the surgeon goaded the more timid ones. ‘Be more confident. You were chosen for training because you are the best in the medical field.’

  This reference to the orthopaedic registrars as the crème de la crème took me by surprise. Did he really believe that? It dawned on me that he did. It explained the arrogance displayed by many orthopaedic surgeons as they strutted through hospital corridors and the aura that surrounded them in operating theatres. Yale’s secret ‘Skull and Bones’ society (which, despite its name, has nothing to do with orthopaedics) came to mind. Informally known as ‘Bones’, its members are called ‘bonesmen’. Founded in 1832, it was strictly for men until – against much opposition – women were admitted in 1992. As an organization which has traditionally had over 95% men, it would appear that the AOA carefully selects and fosters men who would honour the codes of the organisation. Operating under the cover of old men and even older mores, the AOA also found it hard to march into modernity and include women.

  This feeling of superiority fostered in their formative years convinces many orthopaedic surgeons that they are the ‘chosen ones’ of the medical fraternity, yet they are often slow to make changes that are needed to keep them current and progressive. Their concessions to modernity often remain confined to the choice of newer implants sold to them by suave representatives of multinational companies. Many surgeons flying in business class seats paid for by these companies to Davos and New York with promises of golf courses and ski slopes feel they have truly arrived. Anyway, how is ‘superiority’ associated with putting together broken pieces of bones using implants carefully designed by biomaterial scientists? The technical work of replacing a joint or putting broken fragments together is the culmination of the teamwork of men and women, past and present. Wouldn’t it have been better for the surgeon to tell the registrars about the privilege that lay in front of them and the honour of being a cog in the medical wheel of healing?

  The full meaning of Professor Ganesan’s words from my medical school days in India began to made sense to me as my career progressed. It does not matter whether you pursue the god of knowledge, the god of service or the god of wealth, as long as you do not move away from the ethical path in reaching your goal.

  How ethically were my colleagues pursuing the god of wealth? Was it ethical to make money by restricting competition? Was it ethical that patients waited for surgery on long, artificially created lists due to protectionist practices? Was it ethical to charge patients enormous gaps simply because the surgeons believed they were ‘worth it’? Professor Ganesan’s ethical god of wealth appeared unrelated to the prevailing orthopaedic deities.

  And what of the god of service? I’m not sure when I first noticed doctors being referred to as ‘service providers’ or patients increasingly being referred to as ‘clients’. The spirit of service is giving way to efficiency, precision and safety. These imperatives are commendable, but they needed to be enveloped in an ethic of care and humanity. Einstein once said, ‘It has become appallingly obvious that our technology has exceeded our humanity.’ When I saw a renowned surgeon express his disgust by pretending to vomit after his twelfth patient left a ten-minute appointment with him, I realised how bored he was. He had been performing the same routine shoulder procedures over and over again for decades to ensure a private school education for his children, as well as a lavish lifestyle in a home with the right address.

  What about the god of knowledge? Within four hefty volumes of Campbell’s Operative Orthopaedics, which John had stood on to reach his confiscated toy, lay most of the knowledge of bones garnered over the centuries. Inside Mercer’s Textbook of Orthopaedics and Trauma and Watson-Jones’s Fractures and Joint Injuries lay more of the wisdom that was available to the orthopaedic fraternity. During my training years, I had devoured and digested the contents and the knowledge packed within those pages.

  While we learn standing on the shoulders of the giants who have gone before us, the duty to expand that knowledge rests on our shoulders. The lure of lucre can be toxic. It can relegate research and innovation to the background. The ‘scholar– surgeon’ is increasingly seen as an oxymoron, as rare as the yeti or the Tasmanian tiger. Many papers, published so their authors would not perish, are of little value to science or humanity.

  While registry-based research and the collation of data undoubtedly contribute to the advancement of orthopaedic practices, genuinely new ideas that could herald revolutionary change in clinical management are relatively rare. The opportunity costs of pursuing science are high and make it almost impossible to step off the monetary treadmill. Science often takes second place to financial gain.

  FIGS

  One crisp morning in early autumn, I was out in my garden. I reached for a purple fig covered with dew and it dropped into my palm. I marvelled at the beauty of this fruit, which wasn’t actually a fruit at all. Growing out of a hollow stem, the flower and seeds lay compressed within in a purple brown casing. As I bit into the succulent flesh, I did not dwell on the fig wasp that died to help the tree pollinate. The interconnectedness of nature was reflected in the plump fruit that tasted like holy nectar.

  At the hospital, we gorged on figs. After we finished the operating list, the whole team would set out on a fig-gathering expedition. Weaving between large bins at the back of the hospital, we reached the edge of Kings Park. The fig-laden tree beckoned to us with its sprawling branches and large leaves. The lure of the luscious fruit saw us forsake any concerns for our safety as we scrambled up the steep gradient. We reached for the purple fruit and gathered them into a bag, eating a few along the way. The tall anaesthetist with the long arms was the most valuable member of the team. His hands reached for the fruits where ours could only get tantalisingly close. With our stomachs and bags full, a long day ended on a sweet and sated note.

  We returned to the theatre change room and got out of our fig-stained scrubs. The excited chatter of the nurses leaving their shifts mingled with those who were just arriving. A young nurse called Belinda greeted me.

  ‘I’ve not seen you for ages,’ I said. ‘Where have you been?’

  Pointing to her splinted wrist, she explained that a netball game six weeks ago had resulted in a fractured scaphoid. Despite having been in a cast ever since, there was no healing and her orthopaedic surgeon was considering operating on it. The prolonged period away from work was affecting her wallet and her mood.

  Driving home, I thought about Belinda and the many other young men and women who had come my way with a broken scaphoid, particularly one patient earlier in my career.

  The emergency doctor had rung me. ‘Dr Arakkal, there is a young man in the emergency department with a fractured scaphoid. Would you like to see him before I send him home?’

  Mr Evans was a footballer. On the field that day, he’d misjudged a drop punt and slipped. His sharp reflexes saw him stretching out his hand to catch himself. Ignoring the pain at the base of his thumb, he got up and continued playing. When the game was over and the rush of adrenaline had subsided, he noticed his swollen, painful wrist. His impressively stocky build did not sway the nurse when he presented in the late hours of the evening. His injury was designated low-priority and it was almost midnight when I examined him. He flinched with pain when I pressed on the area known as the ‘snuffbox’. The name harked back to the days of snuff users who, by making an exaggerated thumbs-u
p sign, created a little dent at the base of their thumb from which snuff could be neatly inhaled with one long drag.

  At the bottom of this dent is a peanut-shaped bone called the scaphoid. The X-rays showed a neat line passing through the middle of his scaphoid. A fracture. I applied a plaster of Paris cast to immobilise his wrist and thumb and asked him to come back in a week for another X-ray. The chances were that eight weeks of immobilisation would allow nature to knit the bone fully and Evans could get back to his job as an apprentice carpenter, while also following his footy passion. But I knew this simple approach was not always rewarded. In about five per cent of these cases, the fracture did not heal. There was no way to predict which unlucky patients would join that club.

  As I watched him leave the emergency department with his plastered hand in a sling I thought how, despite all the advances in imaging techniques, we were still unable to predict reliably which of these innocuous-looking fractures were headed for non-union. This tiny bone in the wrist has the potential to create far-reaching havoc in people’s lives.

  Over a cup of tea the next day, I discussed the problem with my brother. As a physician himself, it did not take long for Abe to see the problems associated with the fracture – the uncertainty, the loss of productivity and the economic cost.

  After graduating from medicine in India, Abe had decided to follow his passion for mathematics. He joined the Indian Institute of Technology in Mumbai and plunged headlong into the world of numbers. As his masters program was nearing completion, he won a scholarship to pursue a doctorate in mathematics at Oxford. The way his mind worked had always intrigued me. Elegant mathematical solutions seemed to come naturally to him. He had worked in the field of simulation modelling at Oxford, looking at gradients across the migratory path of cancer cells that resulted in its spread. The interaction between directed convection and diffusion currents, rarely observed in nature, was well-observed in the human body. Motivated by his background in medicine, the mathematical problem crystallised in his mind. Weaving through the multidimensional space of mathematics he chanced upon a singularity, which led to his doctoral thesis. He continued his work at Harvard Medical School and his published papers are quoted in the fields of cancer research and mathematics.

  When I told him about my frustration with the scaphoid, he raised the possibility of a telltale gradient across the two broken ends that might serve as an early warning of a lack of healing. His ability to understand gradients and the forces that form them, using hard-nosed mathematics, was beyond my facility with math.

  His excitement grew. Leaning forward, he asked, ‘What if we can find a gradient across the fracture line that could act as a predictor for non-union of the scaphoid?’ As we talked, long into the evening, the seeds of an innovative research program were sown. And so we embarked on finding a predictor for bone healing.

  After looking through hundreds of digital X-rays of wrist bones, a marvellous pattern emerged. Soon after an injury, X-rays showed a steep gradient emerging across fractures, which could be measured. As healing progressed over the ensuing weeks, these gradients gradually faded, returning the bone to the normal pre-injury pattern. But for the five per cent of fractures that did not unite, the gradient remained steep. Building on these observations, we worked at finding a biomarker for fracture healing.

  Every aspiring orthopaedic trainee is asked to present a piece of research. The merit of the work contributes to selection into the training program. Our pilot study of the scaphoid fractures was showing promise, so I presented our research to Perth’s AOA members. At the end of my presentation, very few questions came my way from the audience. This could either indicate that I had delivered a very comprehensive presentation that left little doubt in the audience’s minds, or that the science behind the study had not been fully understood. My attempts to get into the training program failed again, and the research paper went unmentioned.

  Despite this, Abe and I continued our work. Our excitement grew as we realised these innocuous-looking gradients had implications that went well beyond the scaphoid. The gradients offered an opportunity to customise periods of immobilisation after a fracture. The economic implications of reducing unnecessary immobilisation appeared to be significant. More important was the likely impact on patient care and wellbeing. Furthermore, these simple gradients were also seen in osteoporotic bones. The ability to use gradients as a screening tool would be invaluable in addressing the growing numbers of thinning bones in an ageing population. The science was turning out to be more interesting than we had ever imagined.

  When we filed for a patent a few years later, IP Australia studied all our claims and found them to be unique and novel. The work received an Australian patent and also went on to receive two medical research grants. Before going to San Francisco to present the paper to the American Society for Surgery of the Hand, I offered to present to the Western Australian branch of the Australian Hand Surgery Society. The lukewarm response to our work was not unexpected, but I knew that we had laid the foundation for a groundbreaking future approach to fracture healing.

  The acronym FIG has now come to describe these fracture-induced gradients, and my fondness for the delectable fruit remains unsated.

  MINING FOR GOLD

  My high school geography teacher did little to kindle my interest in the mountain peaks and valleys of the world. His lanky frame looked ready for flight even as he entered the classroom. Students shuffled around noisily, the chatter increased and the boys and girls prepared themselves to offer a challenge to the irate figure that stood before them. His empty threat of sending us to the principal was greeted with giggles and mocking pleas of, ‘Please sir, no sir. Please sir, no sir.’

  He raised his voice over the cacophony and pointed to the world map. ‘Today we will look at Australia and its deserts.’

  ‘Oh sir, that’s too dry,’ came a cheeky retort. ‘And it’s so far away – why do we need to learn about it?’

  He turned to the blackboard and drew the smallest continent on the earth. Drawing a straight line through almost a third of the land, he labelled it ‘Western Australia’. I had set aside the class to delve into a Billy Bunter story that I was halfway through. The previous night I had left Billy under a table, hiding from an outraged fellow student whose cake he had just gobbled. Australia and its deserts could wait. Greyfriars School was a lot more interesting. Placing the book on my lap under the desk, I was soon lost in a faraway land. The teacher’s voice washed over me – aborigines, terra nullius, gold rush, early settlers …

  I heard him mention mining towns. I heard him say ‘Kalgoorlie’ and ‘Coolgardie’. That caught my attention. I loved the names and the cadence that accompanied them. I listened to the story of the discovery of gold nuggets in these areas that attracted prospectors who rushed in and then stayed on. When the lesson finished, I was no more educated about the deserts of the island nation but the names Kalgoorlie and Coolgardie were imprinted in my mind.

  As my son, John, grew up, he showed no desire to follow in his parents’ footsteps. Instead, he had a boyish fascination with stones and pebbles. My career had centred around people and their lives, and it was hard for me to understand his passion for immutable, lifeless rocks. One Mother’s Day, with supressed excitement, he gave me a limestone fossil with tiny shells embedded in it and explained that it was from the Cambrian period. I shared in the thrill of holding a piece of rock from the time of Gondwana, when my adopted country had not yet cleaved from my birth country. John eventually pursued a degree in geology in Canberra, the city where he was born. Later, when he described his experience in the underground mines as ‘mystical’, I knew his passion was real.

  That was not the first time that I wished I had paid more attention to those high school geography classes. Kalgoorlie, or more appropriately a boy from that mining town, came to prominence when Barry Marshall won the Nobel Prize for Medicine in 2005 for his discovery of the role Helicobacter pylori plays in peptic ulcer di
sease. I was thrilled to think that a man who walked the corridors of the hospital in which I worked was being recognised for his momentous work. I loved the story of the boy from Kalgoorlie, whose persistence and tenacity against all odds had won him such a coveted prize.

  I first met Professor Marshall at an innovators’ meeting and he agreed to meet with me to discuss my work on fracture healing. The Nobel laureate walked in apologising for being late, instantly putting me at ease with his unassuming and disarming personality. At the end of my presentation he likened my digital biomarker to the Mayo Clinic’s endoscopy ‘camera pill’, which used an algorithm to predict when a person might need a liver transplant on the basis of a range of blood tests. Later, in an interview with Business News, he would describe my work as being among the four most important clinical research projects in Western Australia.

  Barry Marshall travels around the globe lecturing and educating. He changed the way we treat gastric and peptic ulcers. What did not change though, was the man himself. He remains accessible and encourages the pursuit of science. He is indeed the best-mined nugget from Kalgoorlie.

  There were other Australian men who stood by me and my work and would also later support me in my legal battles. They sat in the witness box and attested to my skills. They made the point that there were other doctors in my situation who were working as specialists with British fellowships but were not subject to the same treatment from the medical board as I was. This contrasted sharply with my orthopaedic colleagues, whose only show of support came in hushed tones when they caught me alone.