Slice Girls

by Joan Arakkal

  Lying on the operating table, patients are unaware of the machinations that result in inflated out-of-pocket expenses demanded for their surgery by surgeons who face very little competition. One wonders when the federal government will intervene to disband orthopaedic cartels whose self-serving interests are paid for by the general public.

  Bias and prejudice are inevitable in human interactions, but when it seeps into the systems that are meant to uphold truth and justice, the Tony Galatis of the world have a formidable battle before them.

  Without a specialist registration, I am unable to do clinical orthopaedics. I now work as an approved medical specialist providing independent assessment for patients referred to me by insurance companies and lawyers.

  The smell of freshly brewed coffee wafted down the corridor as I opened the door for the patient with whom I had just spent the last hour. She was a cleaner who worked in the hospitality industry. Years of vacuuming and floor mopping had left her with pain in her shoulder. Her general practitioner’s attempt at alleviating her pain proved futile and she was referred to an orthopaedic surgeon. Her insurance company approved her workers’ compensation claim and she went under the surgeon’s knife. Through tiny keyholes, fluid-filled sacs around her shoulder were cleaned out and the end of her collarbone was nibbled away.

  But as the weeks rolled into months, it was clear she was not regaining her shoulder movements. Her shoulder was stiff and painful and the label of ‘frozen shoulder’ was added to her diagnosis. Almost eight months later, she still hadn’t returned to work. Her frustration and dejection were easy to understand. Providing an independent assessment of her shoulder for the insurance company was easy enough. However, answering some of their more direct questions about when she was likely to return to work was more difficult. It is hard to predict when a frozen shoulder will thaw out. Some can take years. When the patient asked me if she might have been better off without the surgery, my answer was ambiguous.

  What would I have done?

  I might have chosen to rest it initially and taken a more conservative approach. I may not have paid much heed to the slightly inflamed bursa – I see them in the scans of the shoulders of most patients over the age of forty. I would have had a very high threshold before I chose to have it operated on. I saw no value in sharing these thoughts with the patient, so I pointed out her improving range of movement and assured her she was on the right trajectory. She thanked me and left.

  Surgeons perform numerous unwarranted arthroscopies and justify them as patient-driven procedures. Today’s surgical procedures are undoubtedly safer than they were decades ago. But is the decision to operate misguided when other measures, like exercise and nutrition, may well achieve a better result? Is the sanctity of the human body being traded for personal wealth?

  I recalled a day in the theatre many months earlier, when I expressed some dismay at the large woman being transferred on to the operating table.

  ‘Joan, you’re a fattist,’ a colleague remarked, with a laugh.

  The patient only just fit onto the regular operating table of the theatre. The larger tables were usually set aside for bariatric surgery but, lately, more and more patients were requiring them.

  ‘I’m not a fattist or a pessimist,’ I replied. ‘Just a realist, concerned about the patient’s care, and the difficulties we could encounter going ahead with her hip surgery.’

  There was no avoiding the fact that people were getting bigger. The hospital had policies and plans in place to manage the obesity epidemic. It poses a risk not only for surgery but also during the recovery phase.

  On this day, the experienced anaesthetist struggled to secure an airway that would keep the patient breathing safely throughout the surgery. When the cannulas finally found their way into veins that were barely discernible through the layers of fat, he sighed with relief. A urinary catheter was needed to monitor the patient’s fluid output throughout the surgery and later on the wards, but the perineal area was hidden behind an apron of abdominal fat that overflowed onto the pubic triangle. With two staff members parting the thighs and another lifting the ‘apron’, the catheter was introduced. As the amber fluid trickled out, we all felt a sense of victory. But we hadn’t even started the surgery.

  With the patient now positioned on her side, and held between struts and props, the surgery could begin. As the sharp surgical blade dug into the tissues, a thick layer of yellow fat glistened under the operating light. We went deeper into the layers, using large retractors to separate the tissues until the ball and socket joint of the hip was exposed. The head of the femur was sawn off with an electric saw and replaced with a shiny steel prosthetic head attached to a stem. With a new socket lining in place, the joint was manoeuvred into position. The wound was sutured and dressings were put in place.

  Extra orderlies were needed to transfer the patient to her air bed. As the theatre doors were opened and the patient wheeled out, I hoped her recovery would be smooth. The challenges ahead would be many, ranging from avoiding infections to getting her up and moving. While these issues confront all post-operative patients, they are more difficult in extremely overweight people.

  You don’t have to be a mechanical engineer to understand that if a joint carries more weight than it is designed to, the wear and tear process is hastened. Joint replacements are often a consequence of obesity. Bariatric surgeons are not the only ones that benefit from the obesity boom. The greatest threat to the earning power of orthopaedic surgeons might well be improved wellness in their patients.

  In this land of the plenty, malnutrition results in oversized people, as opposed to nations struck with famine where people are reduced to living skeletons. When I saw programs like The Biggest Loser, I wondered if we should have an equivalent ‘biggest gainer’ in those nations. Some years earlier, when I enrolled in a course at the Australasian College of Nutritional and Environmental Medicine, the organisers told me there weren’t many surgeons interested in this branch of medicine, least of all orthopaedic surgeons. Healthy bones reside in a healthy body, so I believed it was necessary to advise patients on their overall wellbeing. Using the knowledge gathered from the course, I would spend five to ten minutes of each consultation discussing the patient’s general health, and I was usually rewarded with grateful acknowledgement. Unbelievable as it may sound, an orthopaedic surgeon in Tasmania was disciplined by the medical board for providing nutritional advice as a weight-loss measure for his obese and diabetic patients.

  The smell of coffee was too strong to resist so I followed my nose to the doctors’ lounge. Dr Pratt was already getting his espresso. When I greeted him, I realised he was seething about something. I wondered if it was a disgruntled patient, but it turned out that his frustration was not with a patient.

  ‘You must be seeing a few of these unnecessary procedures being done,’ he said as he picked up his mug. ‘And they are being done by senior surgeons in the field, just because these are workers’ compensation cases and the remuneration is high. This is unconscionable.’

  I nodded. ‘But who is going to tell them that the emperor has no clothes?’

  ‘The AOA is so powerful. It could destroy you if you spoke up against them,’ he replied.

  Dr Pratt was a member of the AOA. To survive as an orthopaedic surgeon, membership was essential. I read him the section of the Italian penal code that defined a mafia-type association:

  … those belonging to the association exploit the potential for intimidation which their membership gives them, and the compliance and omerta which membership entail and which leads to the committing of crimes, the direct or indirect assumption of management of control of financial activities, concession, permission, enterprises and public services for the purpose of deriving profit or wrongful advantage for themselves or others.

  The emperor wore no clothes but the little boy who shouted out, ‘But he hasn’t got anything on!’ was conspicuously missing from the crowd.

  Like an aorta, the Kwina
na Freeway connects Perth’s people and places. Peak-hour traffic creeps through the city, transporting people from the south to the north and north to south. Looking over Mount Henry Bridge, I saw a million diamonds sparkling on the Swan River. Yachts rested peacefully as their pointy sails reached for the sun, asking for more. A train rushed past through the middle of the freeway. ‘Catch me if you can,’ it teased. The cars inched along.

  It is never what it seems. The Narrows Bridge appeared, but only after I had glimpsed the red bricks of the old Swan Brewery. Sitting below Mount Eliza, hugging the water line, the heritage-listed building posed stylishly as if for a photograph – much as James Stokes might have done in 1837 when he laid claim to the land on the banks of the Swan River. The Noongar people were removed from their fishing ground and dreaming tracks. Their razed huts left no footprint. Fresh water was converted to beer and the Stokes family prospered. The brewery gleamed white and red in the bright Perth sun. The settlers’ prosperity continued. The Stokes and Sherwoods were the first to settle the sandpits of the river – the first to bully, threaten and kill so they could build their castles.

  I was going to the Swan Brewery as a guest of the neurosurgeon, Dr Emil Popovic. The renovated building had restaurants with views of the Swan River. Dinghies sailed along and cruise boats carried people on a day out. Ferries sped past laden with tourists headed for Rottnest Island. The fermenters and mash tuns had long gone, and now wine flowed into the cellars from the vineyards of the Margaret River, France and Italy. Dr Popovic wanted to host the team that had supported him and his work through the year and about twenty of us sat down to dine on seafood at the long table.

  That lunch was many years ago now. Emil is no longer a neurosurgeon. He was forced to leave the field in which he wanted to work the most. He had entered the neurosurgical profession with a bucketload of talent and a shy, friendly smile. Like me, he did not notice the ‘keep out’ sign. He had trained in Melbourne and the Mayo Clinic and his expertise allowed him to venture into areas where those less skilled hesitated to go.

  Some of his fellow surgeons moved in on the soft-spoken man with their sharpened knives. The phasing out was slow and the cries for help went unheeded. The tall surgeon with his team of nurses and his anaesthetist brother continued to remove tumours from the brain, fused vertebrae that had slipped, put in artificial discs when the old ones had worn thin, and drained excess fluid from the brain into the large abdominal cavity.

  Many years ago, a patient was languishing in a Melbourne hospital with symptoms that did not make sense to the neurologists. Dr Popovic took a biopsy, from the brain of the patient, hoping to get a diagnosis on his mysterious illness. A diagnosis of Creutzfeldt-Jakob disease (CJD), or ‘mad cow disease’, was mistakenly offered by the pathologist who looked at the biopsy specimen. Outcries of improper theatre protocols in dealing with this very rare infectious condition poured out. A zealous nurse, a phone call, a government minister looking to step into the limelight – the nightmare had only just begun. The politician threatened the hospital and wanted Dr Popovic dismissed. Emil found himself in the middle of a storm over which he had little control. A review of the pathology slide proved the mad cow diagnosis had been wrong. But the damage was already done. No apology was offered by the politician, nor was the public told about the finding.

  Emil moved to Perth to do what he did best – neurosurgery. Slowly but surely he was cut down. They took away his public hospital appointment, reported him to AHPRA, restricted his practice and took him to places no surgeon wanted to go. Unlike Yagan’s, it was not a clean cut; that followed later. Emil kept going. The bullies gained strength.

  Emil continued to operate. He wrote letters to those who had shamed him and asked for justice. The world marched on. He smiled less and less. His depression deepened. He chose his fifty-fourth birthday to leave the world forever.

  A statue of Yagan, the Noongar warrior, now stands on the riverside. There is talk of a trophy to honour Emil. As I drove on the freeway I wondered how many future Yagans and Emils were speeding past me.

  PICKLES

  In Australia, June marks the beginning of winter. Summer cottons return reluctantly to their boxes. Jumpers leap out and colourful scarves lighten the winter greys. The birds twitter a little later every morning. I hesitate to leave the comfort of my duvet and Francis’s warm body nestled against me. The smell of filter coffee reaches me well before the brew hits the warm milk. As the chicory-laden beverage warms my mouth, a glow of satisfaction seeps through my body. Invigorated, I start the day.

  When we left the UK for Australia, I was scared of the upside-down winter months. Canberra, where we spent the first year, was very cold, but when the sun shone bright, my spirit lifted and my heart sang.

  Later, when we moved to Perth, we embraced its Mediterranean feel. As the years rolled on, I came to enjoy the four seasons and the changes they bring. Autumn is my favourite time. As the crispy cool days arrive, so do the fruits on our suburban trees. The bright yellow polished citrus shine against dark green leaves. Sweet tangerines, tangy lemons, pink grapefruits compete in their profusion. The limes make up for their small size with tart juice that bursts out of their thin skin. The guava trees, the fruit packed with vitamin C, are just as plentiful as the citrus. Fruit flies hover. People and flies share in the fleshy softness of the guava fruit, although its strong scent wards off many. The pomegranates crack open and their ruby seeds peek at the world from beneath their leathery casing. They sit daintily on top of desserts and cakes and lend allure to the pages of cookbooks. Bloody beetroots and crunchy carrots are dug up and add their colours to our rainbow diet. As if to beat the oncoming winter blues, nature’s cheerful bounty surrounded us.

  I wanted to hold on to this colourful plenteousness, and so the idea of pickling was conceived.

  The gynaecologist was partial to guavas and the general surgeon’s garden had a profusion of citrus. The anaesthetist loved her olives, the accountant chose the colourful tubers and I went for the purple aubergines.

  And then there was tomchat, Isobel’s tomato chutney. It was easy to see how a sprightly young Isobel found her place in Perth’s public sector in the 1950s. Working diligently for years, while her male counterparts married, had children and flourished in their jobs, Isobel remained single. The few women who worked in the public offices mostly chose to stay in their careers and did not marry. Career and family were considered incompatible for women. Now retired, the quietly spoken eighty-year-old joined us to squeeze the flavours of seasonal tomatoes into a chutney.

  Once a year, these women gathered in my kitchen. They chopped, they mixed, they ground. The cutting boards were splashed with the colours of julienned, diced and cubed products from our gardens. Garlic and ginger blended in a mortar as the pestle worked away adding to the aromas of roasted spices. Patients and theatre lists were forgotten as we faithfully followed the recipes handed down from our mothers. My mother’s lime pickle was made in a black cast-iron pan, blending the spluttered mustard seeds and fried curry leaves. As the last touches of asafoetida and fenugreek were added, the men were invited to taste and comment. A little more vinegar, maybe some salt, a hint of sugar, and gradually the pickles came together. The piquant flavours – hot, spicy, tangy – waited to be bottled.

  The pretend Nigellas, Jaffreys and Tarla Dalals laughed, talked, stirred and tasted. It got hot in the kitchen but no-one wanted to leave until the assorted bottles that had once held jams, salsas and coffee were filled with pickles and labelled with names and dates. The colourful bottles cooled on the kitchen counter while we sat down to lunch with the families. Husbands and children gathered around to join in the gaiety and festivity of the annual pickling.

  This year, the tomchat was missing, as was Isobel’s smiling face. She had visited her general practitioner complaining of diarrhoea and a distended abdomen – ovarian cancer comes stealthily and unbidden. Surrounded by her nieces, nephews and their children, this genteel lady glided out of
her body on Boxing Day. She took with her the stories of other women who had chosen to pursue a career. Stories of stifled ambition, love and marriage foregone, dead-end positions, lower wages, subservience and sexism. Stories of male domination.

  With cooking shows filling much of the air time on televisions, the male surgeon’s comment to a female registrar was understandable. ‘If it gets too hot in the kitchen, it is time to leave.’ His disapproval of her was clearly on display when she fumbled. She had been allowed into the kitchen, but the heat was being cranked up, a few degrees at a time. ‘Leave the cutting to the men,’ he said.

  ‘What if you are not allowed to enter the kitchen in the first place?’ I asked.

  His wan smile was telling. I read it as a personal message to me. ‘Stick to your pickles.’

  Equal opportunity for women, it appears, is often more spoken about than practised. A cloak of civility carefully hides the sexism lurking not far below the surface. These chauvinistic attitudes were pervasive and I wondered what feminism really meant in the nations that first conceived the movement. Is Western feminism a myth? I thought back to my years in India and what feminism meant then.

  I am my parents’ first-born child. The story of my father’s unbound joy at the birth of his daughter is still told with relish. As for my grandfather, the birth of his first granddaughter was equally momentous. I grew up believing I was special. My gender added even more value to my status. I didn’t see any gender bias in the other middle-class families we interacted with. There was probably some emphasis placed on girls learning sewing, housekeeping and cooking – skills necessary for the efficient running of a home. These skills continue to serve me in my role as a homemaker and mother. Though I’m not the world’s greatest cook, I can organise my home and give it a cosy and personal touch.