What happens when a surgeon turns his eye from the operating room to crime fiction? In "Stone Hearts", Craig R. Smith, MD, cardiac surgeon and former Chair of the Department of Surgery, builds a medical caper rooted in transplant, intrigue, and the peculiar moral weather that hovers above and beyond the hospital.
Follow along each Friday as we release the novel one chapter at a time. You can also see more on Dr. Smith's Substack, Long Incision.
In Chapter One, featuring two characters, Eva was interrogated by an NYPD detective. Two main characters (Elias and Jean) were introduced through dialog. Plot points were foreshadowed.
The muffled crackle of an overhead page stirred the doctor from deep sleep. The smell of the stiff sheets, the institutional blanket, and the blank side of the gray metal desk close to his head oriented him. Elias Bessette was in the cardiac surgery call room, a bedroom almost as familiar as the one back in his upper West Side apartment. He knew he would have left his beeper, wallet, ID badge, and wristwatch on the desktop within reach of his right hand, and with a reassuring pat he confirmed that assumption. Elias could sleep with all those accessories when necessary but sleeping free of his time cuff was especially liberating. He picked it up by the band and turned the face into view—8:37. Hours later than usual, causing momentary reflexive guilt, but it was Sunday, and he’d only gone to bed a little before 03:00.
Late Saturday, a 25-year-old man in septic shock and heart failure had shown up in Denomination’s emergency room. Elias had been out to dinner with friends when he got the call. Another intravenous drug user, with infected and badly leaking aortic and mitral valves. A sadly predictable story, but also a varsity skill test for a young heart surgeon not quite one year out of residency, who knew that the young man had a one-in-three chance of dying in his hands. Elias had transported his new patient from the OR into the cardiac surgery intensive care unit at 01:30 Sunday, still critically ill but with two new valves that closed normally and with the bacteria eliminated from his circulation. Elias hovered at the young man’s bedside for an hour to be sure the bleeding stopped, then decided to sleep in the call room instead of riding the subway back to his apartment.
Elias noted that his sleep had not been interrupted by calls from the ICU—a good prognostic sign. He swung his legs over the side of the bed and sat up, still wearing rumpled, light blue scrubs, so no time was wasted on dressing. During the short walk to the unit Elias allowed himself to savor another few millimeters of ascension up the greasy pole of his chosen specialty. Inside the ICU he bantered briefly with his coronary bypass patient from Friday morning, who was sitting in a chair beside the bed. A normal recovery seemed assured. The young man with infected valves was monopolizing two nurses, but was requiring less aggressive support of his blood pressure, he was making urine, starting to move his extremities, and seemed likely to survive. His HIV assay had come back negative. Life was good.
After finishing leisurely rounds on his inpatients Elias made a quick detour outside. He squinted in bright spring sun that warmed his shoulders. Compared to the building he’d just left, looming above him, the quiet of a Sunday morning made the streets feel safe, calm and orderly, until an approaching siren broke the spell. He grabbed a brown-bag breakfast with coffee from his preferred sidewalk food cart and was settled back in his office when his beeper went off. It was the transplant coordinator. “We have a possible heart donor. Sounds excellent. 18-year-old male, 6’1”, 78 kilos, O-poz. No downtime.”
“Cause of death?” Elias asked.
The coordinator paused and sighed audibly. “Another young-donor story that breaks your heart—his 14-year-old brother shot him in the head with their father’s gun. Accidental.”
Elias knew those sighs. So typical. So awful.
“They’re still working on placing the liver, kidneys are staying local, lungs are going to Cooper in Toronto. One unusual twist—the donor’s outside the US, in Montreal. They reached out to UNOS because they can’t place the heart anywhere in Canada. Or the liver. They’re calling Pittsburgh about that.”
“Dave is on recipient call,” Elias pointed out. “Or does he want me to do this one too?” Elias knew what to expect, after ten months of sharing transplant call with Dave, who was the Director of the heart transplant program.
“No, he wants to do this one. It’s a perfect case for the boss.” That meant it was likely to be an easy case. “The recipient is Ronald Ellsworth. 34-year-old idiopathic. Not a reop. Remember Jerry’s away, so there’s only you or Dave for the donor.”
That explained it—an easy recipient operation would tie Dave up for three or four hours, versus half a day to retrieve a donor from Montreal. Dave was several years his senior. Elias would never say so, but he considered Dave’s rate of acceleration up the greasy pole unimpressive, and decreasing. Elias was within reach of his ankles, and gaining.
“I get it. Of course I’ll do the donor.”
“As soon as we know about the liver I’ll schedule the plane. Call me if you need help setting up your team.”
This Sunday-morning jiggle on the transplant bobbin prompted Elias to reflect on his progress as a cardiac surgeon qualified to operate independently, an “attending” in the parlance of academic medical centers. His first anniversary was just over a month away. An old saying came to mind, “It’s a long way to the other side of the table.” Long indeed, he thought. An eleven-year journey from medical student to attending—from the assistant’s side to the opposite side of the table, where the attending surgeon stands, and bears the ultimate responsibility. Shouldn’t the final step, from chief resident to attending surgeon, rapture him up from the salt mines into the C-suite? Where stress is reduced, leisure time is restored, and sleep is unlimited, after so many years of the opposite states?
Elias allowed himself a faint and weary smile. The end of one journey is the beginning of another. He remembered rocking back in his new swivel chair on his first day, in July, 1988, admiring his slit-like view of the Hudson River peeking between buildings to the west, his desk clean, his office uncluttered. How quickly such self-satisfied reverie had been replaced with deep unease. At the beginning of his new journey Elias was less busy in the operating room, and around the hospital in general, than he had been in many years. He had to suppress stabs of panic when he allowed himself to dwell on how he would justify his lofty new role. After clawing his way up the ladder since high school the top rungs were almost in sight, yet he could still fall and break his professional neck.
On this Sunday morning in May that felt like decades ago. Elias had made progress. By “sharing” responsibility for the heart transplant program with Dave, Elias was doing most of the work in one of the busiest heart transplant programs in the world. As the youngest of five cardiac surgeons at University Denomination Medical Center in Manhattan, Elias was also first-up for cardiac emergencies. Tied all together, Elias was becoming known for technical skill, reliability, and good results. What more could he ask?
Elias decided he didn’t have time to go home. He shaved and took a shower back in the call room. Stepping out of the shower he glanced surreptitiously at his own reflection in the partially fogged mirror over the sink, for a progress check. He wasn’t twenty-two anymore, he could see that, but probably still close enough to peak fitness to draw admiring glances. From Eva, even? No way; the girl never missed a trick. He dressed, then busied himself at his desk with paperwork and reading. Later, as he sat watching a large red ore freighter glide north in thirds through his tall rectangular slice of the Hudson River, his daydreaming was interrupted by another beep to the transplant coordinator’s number. Elias picked up the receiver cradled on his desk and dialed.
“Pittsburgh accepted the liver. Transport will be out front for a 16:15 departure. Wheels-up in the Lear 16:45. Jeff’s the pilot. He says we shouldn’t need passports for US or Canadian citizens. Flight time is 90 minutes, ground travel at that end 30 minutes or less. First guess on incision time here is 22:30. We’ve called in Mr. Ellsworth, he’s ninety minutes out.”
Elias had a few hours to pull together the donor team. He stayed in his office and started to make phone calls. Ralph, a fourth-year surgery resident doing a year of research in the cardiac physiology lab, came in from home to pack the go-bag and prepare the cooler. He would be scrubbed in the donor operation, assisting Elias. Tom, one of the cardiac surgery Physician Assistants, started in from home. He would function as the circulating nurse for the heart-donor team, not scrubbed, handling bedside issues. The essential elements of the donor team were set, so Elias had time to be generous. He turned his attention to the standing list of eager spectators, who were mostly aspiring cardiac surgeons from the medical school. The first two on the list didn’t answer.
Montreal…a city that had been home to more than a few Bessette ancestors over the past few hundred years. It was possible his older brother, Jean, was still living there. Elias worked backwards mentally over a path in time he had carefully swept clean, concluding that it was about three years ago that Eva had come between them. The brothers hadn’t spoken since. It was still painful to contrast those three years with the Eva years preceding them. Elias remembered that night in May of 1981 when he was sharing a large table at the Lion’s Head with other fourth-year med students, and two attractive young women had invited themselves to fill two empty seats, as if dropped out of the heavens. Suddenly he was seated across from a stunning young woman, an aspiring actress who said her name was Eva.
Elias had never met anyone quite like her. On the surface was the come-hither model-actress party-girl, but underneath was a steely self-possessed intelligence that broadcast “cross my line and I will rip your eyes out.” He couldn’t believe that this beguiling creature seemed to find him equally fascinating. They sat engrossed in conversation long after everyone else had left the table, almost to closing time. When relating their origin story Elias remembered the sweet pain of Cupid’s arrow, while Eva called it “so rom-com.”
When he met Eva, Elias was just about to begin the legendarily grueling life of a surgery resident. Eva also worked hard, chasing her own dreams, in the relentlessly discouraging grind to make a living in the dramatic arts. Going to bed early whenever possible soon became very competitive with more socially exciting alternatives. The professional challenges facing both contestants reduced their relationship to a slow boil, and he and Eva didn’t start sharing an apartment until 1983. Elias had found their years of monogamy and domesticity more satisfying than he thought possible and had wanted to get married. He sometimes wondered if he and Eva had swapped gender-role stereotypes.
But it was never enough for Eva—or was he never enough? Without explaining her motives or offering a path to rehabilitation she flipped the old rom-com script by leaving him for someone else. Considering all the options available to an attractive and charismatic model/actress in Gotham, why did she have to choose his older brother Jean? Her choice assured that Elias would be reminded of his inadequacy at every family gathering for the rest of his life. At least she didn’t claim to have fallen in love with Jean, a concession Elias could never quite wring out of her, try as he might. Whenever Eva couldn’t avoid having the subject come up, she would always say she was “missing something inside,” and didn’t know what love was. Small consolation, Elias thought. Soon after Eva and Jean got together in New York, and finished dismantling Elias’s personal life, they abruptly departed—to Montreal.
A donor in Montreal…A gift of life from Montreal…how droll—and on a Sunday when Elias was once again consumed by work, that undiscovered country in whose bourn he had been burying himself, like so many similar souls. Was it providential? Elias hadn’t spoken to Jean or Eva since the day he walked out of the apartment he and Eva had shared. Was this donor a sign that Elias should consider reconciling? Montreal…Elias pulled his address book out of his desk drawer, flipped it open to the B’s, found the Bessette section, and located Jean. He’d made the most recent entry when his parents passed along Jean’s new phone number, a year or two ago. Knowing Jean, it could have changed three times in the interim.
Elias decided reconciliation required more thought. He turned back to the spectator list. After a few more calls he found Gus, a second-year medical student, who could be in the lobby on time. It would be his first donor run and Gus was very excited. When Elias pushed the spectator list aside on his desktop it exposed his address book, still spread open to his brother’s listing. He studied Jean’s number, as if looking for guidance from numerology. He dialed. No answer, and no answering machine, although it sounded like a working number. Elias distracted himself by going over his calendar for Monday, in case a late return from Montreal required that he move things around. It was 16:00, and time to walk down to the lobby. He tried Jean’s number again. It was answered on the fourth ring: “JB Import Export.” Elias instantly recognized Jean’s voice but thought it was missing a few grams of the usual bombast, even a bit tentative.
Should I hang up? He’d never know who called….Be decisive!
“Jean? Elias. It’s been a long time.”
The silence that followed was approaching uncomfortable limits when Jean said: “Elias! It has been so long! Too long. So much has happened! How’re you doing? What’s on your mind?” Elias was not surprised that Jean sounded a bit wary.
“You won’t believe the coincidence—I’ll be landing in Montreal around six-fifteen tonight. Our team is picking up a heart donor at the General. I might have some downtime to say hello, if you can drop by the hospital.” Elias waited a few long beats. “Assuming the coordination of all the donor teams isn’t perfect. It usually isn’t.” He allowed another long silence: “I know there’s so much we could say and a lot we can’t say but maybe we should start somewhere.” Still no response. It sounded like a live connection. Elias was wondering what to say next when Jean broke in, with a surprising new level of excitement.
“Wow! Man, we definitely have to make this happen!” He sounded almost giddy. “Can’t possibly pass it up! Where should I go?”
“At most places we come in through the ER. Hang out at the entrance.”
“Can’t wait!”
Related:
- A Conversation with Dr. Craig Smith on His Novel “Stone Hearts,” the Art of Writing, and the Surgeon’s Imagination
- Lessons Learned: Surgeon Craig Smith Reflects on Career in the OR
- Nobility in Small Things: A Look Back at The Leadership of Craig Smith, MD