A puddle of water on a highway changed Dr Dinesh Palipana’s life forever. Halfway through medical school, Dinesh was involved in a catastrophic car accident that caused a cervical spinal cord injury. After his accident, his strength and determination saw him return to complete medical school – now with quadriplegia. Dinesh was the first quadriplegic medical intern in Queensland, and the second person with quadriplegia to graduate medical school in Australia.
Despite all of the pain and hardship he’s faced, Dr Palipana now sees his accident as a turning point for the better in his life. He believes it has made him a better doctor, with a better grasp of the concerns and fears of his patients, and a more sensitive, open human. He fights for equal and equitable access for disabled people, and is a compassionate and skilled doctor working in one of Australia’s busiest hospitals.
After everything he’s been through, Dr Palipana believes he is now happier, stronger and more capable than he was before the accident. It helped him to clarify what is important in his life, and taught him that happiness and strength can always be found within.
Below is an edited extract of Stronger, out now.
I had no cash reserves when I started as a doctor. I used my credit card to buy some business clothes and shoes, and spent that Saturday and Sunday feverishly preparing to start work on Monday. My mind was so prepared to be unemployed that the idea of starting work took a bit of getting used to.
I was due in the hospital early on Monday. I woke up at the usual ungodly hour to get ready. This day, I wasn’t catching a tram as a student, but as a doctor.
I arrived at the hospital for orientation. It was scary. Starting work as a doctor is scary for anyone; the idea of having someone’s life in your hands, even under strict supervision as a baby doctor, is nothing to be sneezed at. Doing that with quadriplegia just amplifies the nerves.
The media came to cover my first day. They asked me how I felt. ‘Excited, but terrified!’ was my answer. Some of the journalists had taken the whole journey with me, so we were all happy to see that day come to fruition.
We spent two weeks in orientation, which covered things like prescribing, referrals, ward rounds and other basic topics that the medical intern should be able to do. There were also the tick-box exercises mandated by human resources. Some of these were pointless online activities, often to mitigate a risk that has appeared on a bureaucrat’s radar at some point. No one learned anything, but the organisation can say that their staff was trained in whatever topic it was – usually at a significant cost.
I also had to complete training that other doctors didn’t need to do. I sat in a room for the better part of a day learning about occupational violence and its management. The hospital thought that I was at higher risk of experiencing violence.
The hospital and I then planned how I was going to tackle the year and complete the necessary rotations to gain full registration. A key question for me was which medical specialties to do. That involved a conversation with a doctor who looked after the interns.
He was a good man, but an occasionally intimidating one. It wasn’t unusual to see him storming around the hospital yelling profanities about subpar management by other doctors. Still, he had a heart of gold. We set up a meeting. He said to me, ‘We need to do this year in a way that is not tokenistic, not too easy, and has credibility.’ There are some specialties well known for having less than vigorous workloads. I was not to spend too much time in those specialties.
We decided on psychiatry; obstetrics and gynaecology; vascular surgery; general medicine; and extended time in emergency medicine. Vascular surgery in particular was known to be a spirited specialty. But I was going to be starting in psychiatry. Just as in student life, it had a better pace for me to get used to being a doctor. In contrast to being a student, though, I had actual responsibility now.
During my time in psychiatry, I was still figuring out how to do some things. As an intern, many tasks were new to me. But sometimes the problems came from unexpected quarters. I had a colleague who was just barely my senior on our team. From very early on, they stopped talking to me. If I said good morning, there was no reply. They often didn’t share the patient list with me. They didn’t discuss what was happening with our patients. Most of our interactions were filled with awkward silences, with them not responding to anything I said. I still have no idea what that was about. I must have got them offside at some point. I loved the work, but dealing with this colleague every day wasn’t fun. I tried to ignore it and keep going. I just needed to get through the internship. To my relief, the psychiatry term quickly came to an end.
Everything is a big step in early intern life – even prescribing paracetamol. What if I cause liver failure? What if the patient has a reaction? When I had days off, I was terrified that I would come back to find that some monumental error had killed someone.
This is not far-fetched. In a moment of vulnerability, one doctor told us about losing a young patient to a pulmonary embolism. Ever since he lost the patient, that doctor has been extra vigilant about pulmonary emboli. Medicine does that. When we make an error, we swing far the other way to being overcautious, sometimes to the point of detriment. My colleagues have experienced the sudden loss of paediatric patients, adult patients, and even people they have known personally. The marks left by these losses are deep. Imagine carrying the death of someone with you.
As an intern, you learn more about the medical hierarchy. The medical student is more insulated because they have little responsibility. The intern is responsible for things, and they answer to those above them. Those above aren’t always forgiving. Ryan Holiday said in his book Ego is the Enemy that, ‘It is a timeless fact of life that the up-and-coming must endure the abuses of the entrenched.’ In medicine, the entrenched wield power not just by virtue of seniority, but by the influence they have on a junior’s career. They can make or break it.
There are also power differentials between specialties. Radiology, for example, is at the end of the line. Everyone needs something from them, but radiologists rarely need anything from anyone else. Therefore, requests to radiologists can be met by snappy rebukes. Emergency medicine refers patients to every specialty. Other specialties, apart from general practice, rarely refer to emergency medicine. This creates a power imbalance that sometimes results in difficult conversations. The way people behave in situations of perceived power differentials sometimes shows the dark side of the human nature.
To me, since I was a student, the emergency department was always a good society fostered by great leadership. They employed a flat hierarchy. Consultants were happy to be called by their first names. This created an environment in which an intern could approach the consultant without fear. In some other specialties, the unspoken rule for an intern is never to contact the consultant directly. I’ve seen a breach of that rule result in retribution affecting a person’s entire intern year.
Even though the emergency physicians were great to their interns, the interns couldn’t be shielded from the harshness of other specialties. One night, for example, I was sitting next to another intern in the emergency department. It was late; approaching midnight. An ambulance accidentally delivered a terminally ill young cancer patient who was actually intended for a private hospital to our emergency department, and the intern assumed care of them. The patient was normally looked after in that private hospital, who had all their records. The staff there were familiar with them and knew what this patient needed to be comfort- able. The family hoped to arrange the prompt transfer of this young patient to the private hospital so they could be somewhere peaceful and familiar, away from the chaos of an emergency department.
The intern called the private hospital. The nursing staff there were happy to accept the patient. However, the on-call oncologist needed to accept the transfer. Those were the rules. So, the intern called the on-call oncologist. Nearly immediately, I heard their screaming response over the phone.
‘I don’t give a f*** about this patient. They belong to another oncologist. Don’t ever f***ing do this again,’ they shrieked, and continued with a long tirade full of expletives. They refused the transfer.
The intern cried. They finished the shift, then cried some more in the car park. The patient stayed in our emergency department till the morning, until another on-call oncologist started at the private hospital. This type of thing is sadly too common in medicine.
Medicine isn’t easy. Aside from the weird social structure within, the technical demands of the job are high. Mistakes can kill people. Chaos can ensue within seconds. We are thrown into complex situations regularly, without warning. Training is long and arduous.
While medicine is criticised for these things, I think there is some basis for the way it is structured. The hierarchy is necessary, because at the end of the day someone needs to be responsible for the patient. If there is an adverse event, the responsibility often falls on the person at the top of the food chain. Why wasn’t the surgeon adequately supervising their junior? Why didn’t they double-check the order? Most problems become the responsibility of the senior-most doctor.
Training needs to be long and arduous, because at the end of the journey you are going to be that senior-most person. People will look to you for a decision. You will be responsible for everything, including the lives of multiple patients simultaneously.
For all its complexities, though, I love being a doctor. The opportunity to be challenged, to learn every day, to grow, and to do all that while helping someone is a unique privilege. Medicine humbles me daily. It teaches me to be a better person, much through my interactions with the humanity within it.
Later on, when I was doing the intern term in general medicine, administrative tasks were common. Many of the general medicine patients had complex social issues. They didn’t fit neatly into another specialty like cardiology. Therefore, there was a lot more going on than medicine alone. It was easy to get caught up in the mundane tasks of the day, forgetting why we were there – the patient.
One day, I was leaving work after a long day in general medicine. It was early evening. I was tired. Just as I exited the ward, a nurse ran after me.
‘Are you finishing up?’ the nurse asked. ‘Yeah, I’m just leaving.’
‘That’s okay then. The family of that terminally ill patient just wanted to talk to a doctor. I can get the ward call doctor.’
I knew that the ward call doctor wouldn’t know this patient. At night, the ward call person looks after a large number of patients. They often tend to minor tasks like recharting medications. They don’t assume the ideal continuity of care for a patient like this.
I stopped at the door for a minute. I had a choice. I was off the clock; I could leave and forget about the whole incident. Or, I could go back and talk to the family about where we were at. I had the ability to explain everything clearly as a doctor from the treating team. I knew that the family would benefit from a chat with a doctor familiar with the patient. I went back. The family were grateful.
That moment at the door allowed me to reflect on something that I haven’t forgotten to this day. For me, that was just another day at work with many patients. For that family, it was one of the biggest events that they’ll go through in their entire lives. We’re faced with these choices all the time. Do we decide to be a human or a drone?
When I rotated into the vascular surgery department, the days became much longer. Ward rounds started anywhere from 6.30 am to 7.30 am. For me, that meant waking up between 3 and 4 am.
The vascular surgery team liked to have an evening ward round too. There were three junior doctors on our team, so we took turns staying back on alternate days. Some days, I didn’t get home till 9 or 10 pm.
As long as the days were, we had a blast. Regular but short post-ward round coffee sessions gave us time to get to know each other. Every now and again, we had dinner together. We had tough days, but we got through them together.
At the end of my time in vascular surgery, I sat down with a senior surgeon for my review. He said that I had excelled. He concluded by saying, ‘When I first heard that you were coming to work with us, I was unsure. I didn’t know what to think. Today, I’m disappointed in myself for thinking that way. My perception of what medicine can be has changed.’
We are quick to make judgements. It takes humility to allow the evolution of those judgements. Sometimes, this never happens. Sometimes, it happens, making room for respect.
After graduating as an intern, I obtained full registration and became a resident. I was even a nominee for an intern of the year award. I started plotting out my career plan in earnest.
Early on as a junior doctor, I met two specialists to talk about a prospective career in a certain specialty. The first was supportive, and congratulated me on getting so far in my career. They spoke to me alone first, then called a second specialist. I’ll call the second one Palpatine. This doctor was a key decision-maker in who would be accepted into specialty training at the hospital. They wielded this power over potential trainees, sometimes making them jump through many hoops just to be told that they’re not good enough.
Without even saying hello, they immediately became aggressive. ‘I have so many concerns about you coming to this specialty. Can you even type?’ they said. I could. I learned how to type at about sixty words per minute with my knuckles. After a period of telling me about why I couldn’t do one of the less physical specialties in medicine, Palpatine ended the conversation.
Some specialties in medicine require you to be liked by the entrenched people within the system. In this one, too, it’s an unspoken rule that potential trainees meet all the key specialists at various hospitals. Those doctors size up the trainee, then give feedback about their prospects of entering the training program. Many specialists, both inside and outside my hospital, were supportive of me, but by no means all.
Over the subsequent period, I felt that Palpatine was taking it upon themselves to derail any career aspirations I had in their specialty. One attempt was to tell me that they wouldn’t pay me to work in their department. They asked me to find my own salary to work, whether it be as a resident or registrar. Then, I understand they asked the hospital for extra money to have me as a junior doctor for a term.
When I worked for them as a resident, I felt that life was complicated. I felt I was at Palpatine’s mercy. As the junior-most doctor, I was at the bottom of the pecking order for certain tools required to work in that specialty. Often, the tools that were accessible to me were taken. When I asked about finding these tools, Palpatine’s answer was that I should ‘take them from a consultant’. By this point, you will know that I could never ask a consultant that.
Research was another important aspect of building a career in that specialty. I was involved in two research projects during my term. I stayed late nearly every day and collected data from hundreds of patients for a couple of weeks. I wrote a notable amount of the draft paper for that study. Palpatine apparently asked other team members to exclude my name from the studies, then to present them without giving me any credit.
One day, I emailed Palpatine to ask for their reasoning for their approach to me. Instead of replying to my email, they sent me a text message asking me to call. When I did so, they said, ‘You just can’t work in this department. We can’t have someone with a spinal cord injury here. I don’t want you to tell anyone that I said that. If anyone asks, you need to tell them that it’s the position of our entire department that you are not wanted here.’
This dislike of me was probably amplified by some of the politics within that specialty. I wondered if I had friendships with specialists who were disliked by the leadership. Some of them hated each other. It wasn’t unusual for a consultant to feverishly criticise another in a public space, in their absence. The specialty had enemies outside itself too. It has in the past come under public scrutiny for their practices.
For example, you know those pesky mandatory modules? Well, Palpatine once asked the residents to go around and do them all for the consultants and registrars.
Palpatine then sent another specialist to have a conversation with me. ‘The politics mean that you can never work here in the future,’ they said after pulling me aside one day when I happened to bump into them. At another event, the director of junior doctors called me over. They said that a discussion with the department had taken place. ‘You should consider a career outside clinical medicine. Leave those things to people who have the physical capacity to do it,’ they said. I had a contemporaneous record of all these events. I even had some emails. When I summarised it all to a human resources director, their response was essentially, ‘Move to a specialty that’s supportive.’ The union for doctors was powerless. No one could do anything.
Having someone attack you based on physical differences is heartbreaking. That’s why racism is so destructive. Discrimination based on physical ability is just as destructive. It strikes at the core of your being, because the attacks are focused on attributes over which you have no control.
Having said that, there’s no point allowing someone’s bigotry to dictate your life. Anger can destroy us. I once read a story about a python that found a knife. It initially wrapped itself around the knife. As the knife caused it more pain, the python became angrier. It wrapped itself tighter around the knife. As the pain increased, the python tightened their grip even more. Eventually, the knife killed the python. Anger is like that. If we hold on too tight, it destroys us from within. It’s one of the ways in which the Palpatine of Star Wars created Darth Vader in the series. And hey, I don’t want to become Darth Vader.
According to Buddhism, pain arises from our attachment to things, and attachment to hurt causes more pain. The only way to relieve the pain is to remove attachment from past hurts.
I once had a girlfriend who was bullied in high school, where she had been an outcast, the uncool kid. She carried this hurt into her adult life. She often made comments like, ‘I bet you prefer that preppy rich girl who plays tennis.’ She hated her mum because of things that happened while she was growing up. She didn’t trust men, because her dad had left. She had insight into all these things. She explained it all to me. But she was never freed from the hurt. I felt for her. I often wondered, though, how long can you go on letting those feelings dictate and destroy your life?
I tried to take responsibility for my feelings so that I could move on from events that caused hurt, like Palpatine’s behaviour. I don’t hate them. I forgive them. And that is liberating.
Apart from my rotations in psychiatry and that specialty, the rest of my terms as a junior doctor were filled with good times. In my intern year and second year, I spent time in obstetrics and gynaecology. I must like unpredictability, because obstetrics and gynaecology is loaded with it. There are some incredibly special moments, like when a baby is born. I’ve been in the room when new life comes into the world. I’ve even been sprayed with amniotic fluid. Apart from the magic of the moment itself, it always made me think back on the journey that my mum must have taken. The special moments can quickly turn, though, when things go terribly wrong. Mums can start bleeding critically. Babies can get sick inside the womb. Time is of the essence.
There’s no room for mistakes.
The obstetrics and gynaecology juniors had some busy days on occasion. One Christmas, I was the only resident floating around for some reason. I had three phones. That day, I counted at least fifty phone calls. One of them was from the ward about a complication from a Bakri balloon. This is a device that can be inflated inside the uterus if a mother is experiencing ongoing bleeding after delivering a baby. It stops the bleeding by applying pressure. I arrived at the patient’s bedside. I had no idea what to do. I called the registrar, but she was in the operating theatre. There was no one else around to help. A theatre nurse put the phone to the registrar’s ear so she could talk to me while operating.
‘Get down there and tell me what you see,’ the registrar said.
I got down in between this patient’s legs and described what I saw.
‘Okay, you need to pull it out,’ she said.
She gave me some brief instructions and hung up the phone. I called her back. I had never even heard of a Bakri balloon before, let alone seen one. Neither had the nurse looking after the patient. It was an intimidating prospect to pull something I’d never seen before out of someone’s vagina. The registrar reiterated that it was a simple task, and directed me again to pull it out. To be absolutely sure, I looked up the details again online, and they matched up with the registrar’s instructions. The nurse and I pulled it out. For the record, the patient was okay.
The obstetricians and gynaecologists were supportive of me. The midwives were excellent. I once delivered a baby with a midwife, Lauren Skinner. The baby’s mum took a photo with us. A couple of years later, the mum returned to have her second baby. She was with Lauren again and fondly remembered our time together at her first birth. These are the moments that make medicine special. Lauren and I have been friends ever since I was a student.
I learned about medical storytelling too. Medicine, like advertising, likes a good story – but that story has to be delivered quickly. These are stories delivered from doctor to doctor when they are discussing the clinical care of a patient. Medical students generally go into too much detail. Without clearly delivering important points, they’ll go through the history, examination, investigations, and on occasion the diagnosis with the plan. The intern will quickly refine this technique, because they soon realise that they won’t last long if they’re not able to tell a compelling story quickly. The senior doctors are veterans at getting the story across fast. In general, the story should take 10 to 20 seconds for an uncomplicated patient. If it takes longer, you can sometimes see the senior doctor’s attention wander. Their eyes will literally dart away. Some will ask you to move on. Some will interrupt.
I remember calling an anaesthetist once to tell them about a stroke patient who was going to the operating theatre for a procedure called a clot retrieval. In this procedure, the blood clot in the patient’s brain is retrieved using a minimally invasive method to restore blood flow.
‘I just wanted to let you know about a stroke patient coming up to you for a clot retrieval. They have a history of –’ I started.
‘Stop there,’ the anaesthetist interrupted. ‘So, a stable patient is coming up for a clot retrieval?’
‘Yes.’
And they hung up.
It’s not that doctors’ attention spans are short – they just want to know the important information in a timely manner.
Communication was important in every single specialty I tried. As I moved along with my medical career, I learned the nuances of what different specialists want to know about their patients. Over the first couple of junior years, though, I kept coming back to the emergency department. It felt like home. Eventually, I started working there constantly without rotating to other specialties.
This is an edited extract of STRONGER by Dr Dinesh Palipana, Pan Macmillan Australia, RRP $36.99. Available now.