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 Four, Ron Ellsworth, a cardiac transplant recipient, began a wide-ranging interview for a hospital publicity piece. Dr. Bessette had done his transplant operation almost one year previously.
Sunday, May 7, 1989
Elias joined the three other members of his team in the lobby. An eager young man with an unruly blondish forelock strode forward to vigorously shake his hand—”Dr. Bessette, I’m Gus Henderson. Thank you for including me!” The two who stood their ground had already met Gus, and greeted Elias with the practiced grunts and nods of comfortable familiarity. All three pivoted to follow their leader out the door. Ralph and Tom slung the go-bag and the well-scuffed Coleman picnic cooler from Kmart into the back of the Denomination’s Organ Transport Chevy Suburban, then all four climbed into the seats. Elias always took shotgun, justified by seniority, and based on his preference to avoid small talk. That proved an elusive goal on this trip, and Elias was pulled into conversation with the rear seats before they were on the westbound George Washington Bridge.
Ralph opened the conversation. “Elias, didn’t you say you have family history in Montreal? Very cool! I’ve never been there.” Ralph Livingston, born and raised in a one-stoplight town in west Texas, had been a University of Texas Longhorn through college and medical school, but caught the New York City bug during an elective month at NYU in his fourth year, and had ranked Denomination first on his match list. He’d visited far more new cities and towns while picking up donor organs than he’d seen in the rest of his life. “Have you lived there yourself?”
Elias twisted enough in his seat to be heard in the back. “No, but I visited growing up. Both sides of my family go back two or three hundred years in that part of the country. Continent, I guess I should say. And my brother lives there now.”
Slowing to be waved through the toll booths on the New Jersey side of the bridge interrupted conversation. Even though he’d seen it hundreds of times, the swirl of roads leading west from the busiest bridge in the world still impressed Elias. Aided by its flashing lights the Suburban barged across several lanes to the left and merged onto I-95. Elias watched the familiar sights scroll past along I-95 and onto I-80. As he often did while gliding through Teaneck, Elias strained to catch a glimpse of the corner where a meeting was supposed to have taken place, in a bar long since swallowed by growth…what was it, 1974? What if Jean hadn’t agreed to the switch…. The Teterboro exit sign had just come into view in the distance when Gus broke the silence. “Dr. Bessette, I really appreciate this! Perfect timing! Gets me out of dinner at my mother’s apartment, and I can miss path and pharm tomorrow morning if I have to.”
“You’re welcome, I hope you find it valuable. You should be back in plenty of time for classes. You might be a little sleepy, is all.”
After a few quick turns off the I-80 exit they crossed Route 46 onto Industrial Avenue, and a half mile farther turned left into Atlantic Aviation, where the electric gate to the runway was already clanking open on its saggy steel cables. Moments later the Suburban was parked on the tarmac next to the Learjet. Elias and Ralph bantered with the pilots while Tom and Gus carried the go-bag and cooler into the cabin. Elias scaled the steep steps into the cabin and walked in a slight crouch to his accustomed position in the middle of the bench seat at the back of the cabin, where he could stretch out his legs in the aisle. The other three were seated ahead of him on port and starboard. Wheels were up ten minutes later, ahead of schedule.
It was Gus’s first time in a private jet. He delighted in the cushy seats, toyed with the standard collection of breath mints and chewing gum tucked in a recess under the windowsill, and enjoyed watching the New York skyline recede rapidly from view as the Lear stood on its tail like a rocket. Collectively the other three had logged many hours in this jet, other jets, turboprops, and helicopters. The overall enterprise was inherently momentous and exotic, even to the veterans, but they varied in their ability to enjoy hours of inescapable sociability in close quarters, and so often in the middle of the night. Gus and Ralph were luxuriating in their comfortable leather seats, facing Elias, a few feet away.
Ralph was not good at silence. When the plane leveled off, he said to Elias “I didn’t know you had a brother!”
Yeah, because I never talk about him, Elias thought. Talking about Jean meant thinking about Eva. But maybe it was time to work back to family. Isn’t that why you called him? Elias asked himself. He and Jean had been close for so many years, as brothers, friends, and business partners. “I do have a brother—Jean. Four years older than me.” To avoid the appearance of harboring a brother-specific void, he expanded. “I also have a sister, Alice, two years older. She lives in Seattle, and I don’t see her much. She’s the smart one, a real quant.”
That contented Ralph for a few minutes. They were above thick clouds and there wasn’t much to see out the window. “What does Jean do in Montreal?”
“He runs his own Import/Export company.” Does that sound shady to everyone, or only to me? Elias wondered. I’ll try telling a better story. “Basically, he solves logistic problems and does it very well. Jean was always a good problem-solver, kind of ingenious with a lot of the stuff other people don’t think about.”
“You must speak French!” Ralph continued.
Gus chimed in, eager to be part of the team, and show off his erudition: “So when we get to the OR up there you can say ‘Nous sommes ici pour avoir un nouveau Coeur!’ Or even ‘changement d’avis!’”
“Peut etre,” Elias replied, “nice word play, but the truth is my French isn’t very good. Jean is fluent.”
Ralph asked Gus how he learned French. “I went to the Lycee in Manhattan, K through 12. My mother’s side is from Paris, she wanted all of us to be fluent. Helps explain why they named me Augustin.”
“Augustin?” said Ralph.
“Augustin Beauchamps Henderson!” Gus replied.
“You just earned the role of translator,” Elias said. “Truth is, they’re all very bilingual, but sometimes they like to bust balls by starting with French. You show them a little fluency they’ll be impressed, and happily switch to English.”
The co-pilot appeared at the cabin entrance, facing aft to address his passengers. “We should be landing at 18:05. Low clouds but not much wind, nothing to worry about.”
Elias said “Speaking of roles, Ralph, why don’t you explain things to Gus. This is his first donor.”
Ralph opened a bright green roll of wintergreen Life Savers from the cache under his windowsill and popped one in his mouth. He leaned over towards Gus, who was across the narrow aisle, facing aft on the port side. “I’ll assume you’ve been in the OR before and know how to stay away from the sterile field, not brush against people in gowns, and all that.” Yes, Gus assured him he was familiar.
“Here’s what you’ll see—me and Elias will open the sternum, expose everything. Sorry, I meant Dr. Bessette and I!” Ralph digressed. “You see, Dr. Bessette was ‘Elias’ to me when he was my senior resident and I was an intern. He’s a really slick surgeon but as a senior resident he was one hard-ass motherfucker to us little grunts! But fair, impressive to watch, and willing to teach. Anyway, Dr. Bessette and I will hook up the cardioplegia needle in the aorta, Tom will be standing by with the preservation solution. When all the teams are ready, Dr. Bessette will clamp the aorta, cut a vent in the left atrium, and Tom will pump in a liter of UW. Then chop-chop aorta and pulmonary artery, finish the left atrium, chop-chop both cavae, and lift the heart out.” With each chop-chop Ralph made dramatic scissoring motions with his first two fingers. “We drop the heart inside a sterile plastic bag and seal it. That bag goes into a second sterile bag that Tom is holding open for us. You probably get the idea—even though the outside of the final bag is out in the world, the inside of that bag stays sterile, and that’s the surface that’s in contact with the inner sterile bag holding the heart. A kind of fastidiousness you might keep in mind for your girlfriends. Into the cooler, cover it with ice, and off we go.”
“You should also know that it can get very crowded if there are different teams for heart, lungs, liver, kidneys. The donor hospital sometimes sends spectators out of the room, but we’ll have you come in with us carrying one end of the cooler, so you look less disposable. When I was in your shoes, if we got there early enough, I would go right up to anesthesia side of the ether screen and stake out a little place to stand. That’s the best view of the heart anyway. Up there you do need to be aware of the anesthesia team and stay out of their way. But no matter how it works out, don’t take it personally if you can’t get a ringside seat”
Ralph popped another Life Saver and allowed his lecture to sink in for a minute, then expanded: “The politics can be very interesting. You’ve got two or three, sometimes more, well-trained surgeons with big egos advocating for their own organs. Like they’re the Senator from Liver and the Representative from Lung. Senator Liver wants all the IVC including a piece of right atrium, but President Heart can’t allow that to happen. Senator Liver pulls down on the cava. We pull back, discuss, negotiate, but we hold the scissors, so the heart should never lose essential territory. The same thing goes on sometimes between us and the lung team over where to cut the pulmonary veins. We have a little more room to cut deals there.” Ralph chuckled with amusement at his own wordplay, but couldn’t leave it alone: “So to speak.”
“Good description,” interjected Tom, who rarely took part in the social chit-chat on donor flights. Tom may have sensed a class boundary that others ignored, or didn’t feel. He had been born to a single mother in Newark. Nine-year-old Tom found her dead of an overdose on the couch in their rat-infested apartment. He shut five-year-old Annie in the bathroom until the police were gone so his sister wouldn’t have to see it. Tom and Annie were taken in by their uncle Richard, who raised them all by himself with a devotion that surpassed anything the children had received from his late sister. He had been a Navy medic in Viet Nam, humping through the bush with the Marines, seeing and doing indescribable things. In the 1970s Richard was part of the small cadre of other former medics who were first to be accredited in the new profession of Physician Assistant (PA). After finishing junior college Tom felt privileged to follow in Richard’s footsteps. Back in the Lear on the way to Montreal, Tom had a point to make: “But there’s also a person in there. The donor. Who used to be just like us.”
Although he and Tom were about the same age, as the hierarchical adult in the room Elias felt subtly chastised. He shouldn’t allow Ralph’s Tammany Hall, smoke-filled-room metaphor to dominate the stage set in the mind of an eager student who’d never done this before. “There are some politics,” Elias said, “but you should also be prepared for the feelings. Everyone’s excited about giving their recipient a shot at life, but that never completely drowns out the sense that we’re drafting on some kind of personal tragedy.”
Elias paused to think about how far to go. “This one’s no exception. Perfectly healthy 18-year-old accidentally shot in the head by his 14-year-old brother. I don’t know where, or exactly how, put picture that!” Too melodramatic? Add more context? “Like, I remember a teenager who died falling out of the church balcony at his brother’s wedding. And a 4-year-old whose Dad didn’t know he was outside and backed over him pulling out of the garage. Or the young suicides. It can make you cry, seriously.”
The cabin went silent. Maybe I overshot. Find something more positive? “You won’t see the aftermath tonight because we’re always first to leave the OR, but we’ve all seen it when the donor operation’s a home game. It gets very quiet. The organs have all scampered out the door, but the nurses are still there. You can see it, in the way they handle this empty body, how they try to show their respect for what the donor and the donor’s family have done.”
Elias felt like he’d failed again to find just the right setting on the mood dial, but it gave all the passengers something to think about while mid-flight monotony settled in. Twenty minutes after Elias’s sermon, Ralph probed Gus for biography after finishing at the Lycee. Gus obliged—Princeton, intramural squash, Ivy Club, History major. After graduation, having discovered his passion for medicine, Gus endured the legendarily cut-throat post-baccalaureate pre-med year at Columbia. “Some of those guys would stab their mothers in the back to get ahead of you,” he said.
“I guess you made out ok,” Ralph offered. “How’s your mother’s pneumothorax?”
“Yeah, right! I had decided I really wanted to do this, and just studied really, really hard. Stayed away from the vipers in study groups. You could wake up missing a kidney.”
Ralph shook his head. “I know you New Yorkers like to think the rest of the country is all Mayberry, or Leave it to Beaver, but it wasn’t all that different in Austin. Ambitious people are ambitious people, and not all of them play nice.”
Elias joined the game. “Ralph, tell Monsieur Gus about west Texas. Lots of prep schools and squash courts, right? Your town had a Lycee?”
“Oh, for sure!” Ralph turned to Gus. “It was pretty much how I bet you picture it. Ranches, 4H, boy scouts, Friday night football. No trees, lots of wind, dusty and dry. Bad winters. But my parents worked hard and wanted me to get educated. I went off to Austin wearing Levis, cowboy boots, and snap shirts. I came back looking just like you…” He looked Gus up and down with an exaggerated air of appraisal. “…well, not quite. Of course, I don’t speak French. I have quite a bit of working Spanish, though.”
Elias was dozing when wakened by the change in cabin angle indicating descent. The Lear touched down exactly on time. The team loaded the go-bag and cooler into the back of the Urgences-santé ambulance waiting for them on the tarmac. The pilot gave Tom the phone number in the FBO pilot’s lounge so that he could call ahead when the ambulance was coming back. Elias tried to avoid riding in the back of ambulances. Rocking around in a closed space with no windows made him queasy, and he needed to be on his game when they arrived. Since there was only one driver and no crew, he was granted permission to ride shotgun. Twenty minutes later they were unloading at the Emergency Room entrance of Montreal General Hospital.
Previous chapters:
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