A Surgeon's Heart: The Crisis

By R.W. Sewell, M.D.

A Surgeon's Heart: The Crisis is the third novel in this series which tells the story of the systematic destruction of the American health care system. For those who have been called to the medical profession and have dedicated their lives to the Oath of Hippocrates, what has been happening and continues to happen is a tragedy of epic proportions. Theirs is a story that is not being told by the talking heads and political pundits who attempt to "enlighten" everyone regarding what health care is, and why they need someone else to be responsible for ensuring it.
For such a story to have a lasting impact the characters must feel real, and the reader must relate to them on an emotional level. Jack Roberts is just such a character. Jack is a fictional pediatric heart surgeon who is just like many physicians we have all known. He is grounded in his core principles and traditional ethics. He is surrounded by forces which strive to change him into something much different. His heart is dedicated to those whom he serves, not to the growing forces of corporate greed and government controls, but his resolve is tested by personal crisis.
While the story is about health care, it is more about the people who provide life-changing services to those in desperate need. It's about individuals who are engaged in intimate relationships surrounding all different matters of the heart. In this case, it's the tale of A Surgeon's Heart, and The Crisis.

• Language: English
• Publisher: R.W. Sewell, M.D.
• Release date: Aug 8, 2014
• ISBN: 9780990405122

R.W. Sewell, M.D.

Robert Walter Sewell was born on November 20, 1950, in Independence, Missouri, and moved to Texas with his parents at the age of twelve. He has lived in Texas since, attending Thomas Jefferson High School in Port Arthur and Lamar University in Beaumont, where he received a bachelor’s degree in biology. He went on to the University of Texas Medical Branch at Galveston, where he achieved his medical degree in 1974. He was accepted into the general surgery residency program at the University of Texas Health Science Center in San Antonio and completed his surgical training in 1979.After finishing his residency, Dr. Sewell immediately began his surgical practice in the Mid-Cities between Dallas and Fort Worth in North Texas. He moved his practice to its current location in Southlake, Texas, in 2003, and remains an active surgeon today, with an emphasis on minimally invasive general surgery at the Texas Health Harris Methodist Hospital Southlake.As a recognized specialist in the field of laparoscopic surgery, Dr. Sewell has lectured on various minimally invasive procedures throughout the United States and around the world. He is a member of the American Society of General Surgeons (ASGS) and was elected president of that organization in February 2008. He is also a fellow of the American College of Surgeons (FACS) and has served as a governor since 2013. Dr. Sewell maintains memberships in the Association of American Physicians and Surgeons, the Texas Medical Association, the Tarrant County Medical Society, as well as the prestigious Texas Surgical Society.Along with his wife, Donna, Dr. Sewell resides in Colleyville, Texas, where he enjoys golf, photography, computer graphics, video production, gardening and, of course, writing.

Book preview

A Surgeon’s Heart:

The Crisis

by

R.W. Sewell, M.D.

Smashwords Ebook Edition

Copyright 2014 R.W. Sewell, M.D.

All rights reserved.

(Robert Sewell, M.D.)

DEDICATION

To my fellow physicians and the nurses who tirelessly support us. To those who understand and embrace the meaning of self-sacrifice in the service of our patients. To those who refuse the designation of provider and instead hold sacred the Oath of Hippocrates and the Pledge of Nightingale. This current crisis will eventually pass provided we hold firm to our traditional time-honored ethics and pass on that heritage to the next generation.

INTRODUCTION

A Surgeon’s Heart: The Crisis is the third volume in this series. In the first two books the fictional characters encountered a host of life’s common trials and tribulations. Jack Roberts, a talented pediatric heart surgeon, is challenged by the growing influence of big business and intrusive government on his profession. Jack, along with his wife Elaina, elected to retreat to their vacation home in Nicaragua rather than compromise his professional ethics. His early retirement leaves the surgeon conflicted, and he longs to find an alternative to the rapidly deteriorating American health care system.

Elaina’s son David was only two years old when his rapidly worsening heart condition brought her and Jack together. From the moment he gazed into her emerald green eyes, Jack knew he had found the love of his life. He was equally committed to being the father his son would need as he grew into a man.

A Surgeon’s Heart: The Crisis is a continuation of the epic story as David strives to follow in his father’s pioneering footsteps. He encounters an academic environment that offers limited clinical experience, and stresses conformity and countless protocols, which stifle independent thinking and intellectual growth.

The story provides insight into the impending collapse of American health care, as the nation marches rapidly toward a single payer system, one that is ruled by government mandates and oppressive regulations. While rising storm clouds suggests a systemic collapse, the characters face yet another type of crisis.

Throughout this story of health care, there is a sharp contrast between the forces of evil that are working to undermine the ethical standards that have differentiated the medical profession from all other human endeavors for more than two millennia. The struggle against those forces is being waged every day by men and women around the world who have been called to this great effort. For those who are dedicated to the traditions of medicine, surrender is not an option. In the coming years, every person, every organization, and every government will be compelled to make a choice between freedom and servitude, between responsibility and dependence. Each of the characters in this story will eventually face the situations as will every reader.

The future of health care in America will depend on many factors, the most critical of which are up to each individual. First we must decide how do we respond to "The Calling". Second, can we resolve "The Conflict"? Then how will we cope individually and collectively when confronted with "The Crisis"? The first two novels in this series dealt with the first two questions, while this one takes on the third, and perhaps most critical question. Ultimately each of us will eventually be compelled to make "The Choice", but for now I hope you enjoy, "A Surgeon’s Heart: The Crisis".

R.W. Sewell, M.D.

ACKNOWLEDGMENTS

Over the course of the past eighteen months I have learned a lot about writing novels, but the most important lesson has been, you can’t do it by yourself. It requires others to do some of the heavy lifting. Perhaps the most important task that cannot be performed by any author is that of proofing the manuscript. Despite reading and re-reading every line, the author only sees what he or she wants the words to convey not what they actually say. And when it comes to punctuation, there is no substitute for a knowledgable English scholar. I am incredibly fortunate to have literally stumbled upon someone who has turned my ragged efforts into a readable work. Carol Jennings Peat is a retired pharmacist and literary expert whom I cannot possibly thank enough for her invaluable assistance.

The phenomenon known as writer’s block is real. From the beginning of my first novel the story flowed out of me like water from the garden hose. I thought this was the easiest thing I’d ever done. That is until it struck. I was mid-way through this manuscript and suddenly my mind went blank. Hopefully you won’t be able to see that brain cramp as you read this book, but I have to say it was like hitting a wall. Many of my readers asked, "When are you going to release The Crisis? My stock answer was soon despite not having written a single page in nearly a month. Ultimately it was the constant encouragement of dear friends like Davonna Kovalic, RN, Jo Searles, RN, Kris Held, MD and many others that got me going again.

During my brief hiatus from writing, I took a few days to read the wonderful true story "Special Heart" by Fox News anchor Bret Baier. In his book he relates the emotional account of how he and his wife Amy struggled with their own real life crisis surrounding their son’s serious congenital heart condition. The joy that accompanied the birth of their first child was suddenly interrupted by the reality that their newborn’s life was in immanent danger. As I read this heartwarming story, told from a parent’s perspective, it gave a whole new meaning to the similar yet fictional stories I’ve attempted to convey in this series of novels, told from the point of view of a mythical pediatric heart surgeon, Jack Roberts.

I must also thank the members of my office staff, not only for putting up with my moodiness that typically reflected the emotions of this story, but also for their timely encouragement. I have mentioned them in previous acknowledgements but their names bear repeating. They are the reason I have the opportunity to not only write novels, but also carry on a full time general surgery practice. Thanks to Nadine Collard who is the pleasant voice that answers our phone, Angie Gates, our patient representative, Stacie Bussey, RN, RNFA, CNOR, my first assistant and all around girl Friday, and Suzanne Jones, my office manager. She’s simply the best.

The photo on the cover features my good friend and colleague, Dr. Howard Harris. Howard has all the physical characteristics of Jack Roberts, and he has been a good sport to step out of his real life role as an exemplary orthopedic surgeon to pose as a retired pediatric heart surgeon.

All the situations in this book are fictional, but they reflect many of my own personal experiences. After thirty-five years of practicing general surgery I have encountered a great many individuals and countless situations that have collectively provided both the inspiration and the aggravation found in these pages. However, none of the characters in this book are based on any real persons. Any similarity or resemblance to any real individuals, living or deceased, is purely coincidental. Likewise, the organizations and facilities are the fictitious products of my imagination.

I would be remiss if I failed to thank my family for their love and inspiration. My children, Julie S., Julie L., Ashley, Tyler, Ryan and Chase, have each contributed to this work without their knowledge. And of course, my lovely wife Donna has been a constant companion and source of encouragement for more than thirty-two years,. It is her love that is reflected in the characters you encounter in these pages.

CHAPTER 1

It feels good to be back home, Elaina said as they walked into the living room.

Jack placed his briefcase in his office, as Federico brought their luggage in from the car. The caretaker, and all around handyman of their new home in El Transito, Nicaragua, had picked them up at the airport in Jack’s Land Cruiser. Federico’s wife, Lucinda, had prepared a welcome home meal of broiled grouper and fresh Mango slices. Elaina was exhausted after a full day of traveling from Texas back to Managua, followed by the eighty minute drive from the airport to what was now their home. At first she said she was too tired to eat, but when she smelled the amazing aroma that filled the house, she was suddenly starving.

The retired couple took their dinner out on the deck behind the house, watching the sun slowly fall toward the Pacific Ocean. They had both kicked off their shoes, truly relaxing for the first time since they’d left this house nearly two weeks earlier to attend their son’s medical school graduation in Dallas. Elaina had missed the sound of the surf breaking on the beach, just beyond the small lagoon, more than she’d realized.

Señor Dr. Jack? Lucinda asked, as she came out to retrieve the dishes. A man called for you yesterday and he asked me to give you a message. She placed a small note on the table, just out of his reach.

What was his name? Jack asked.

He said his name was Buzz, and he asked that you call him at that number when you got home. Lucinda spoke to her employer in Spanish, but she was beginning to understand at least some of their conversations in English.

Jack smiled as he reached for the slip of paper with the telephone number which he immediately recognized as that of his old friend and colleague, Dr. Horatio Buzz Jackson. He looked over at Elaina and said, I wondered how long it would be before Buzz called.

Jack and Buzz had first met at Wilford Hall Medical Center on Lackland Air Force Base in San Antonio, Texas in 1983. They were both pursuing careers in the military, Jack as a heart surgeon and Buzz as a pediatric cardiologist. They had clashed over who would take charge of the Air Force’s first, and only pediatric heart program, but soon became best friends as well as inseparable colleagues. Five years later they both left the Air Force to pursue private practice opportunities in Fort Worth, Texas, where they worked together for the next twenty-five years. Jack’s sudden retirement and move to Nicaragua eight months ago had temporarily separated the two.

Raised in southern Alabama, Buzz was a proud black man who was unwilling to admit to anyone how much he missed his long-time friend. His own practice was also no longer satisfying, in part because of Jack’s departure, but mostly because of all the changes that were occurring behind the scenes. He had spoken to his friend over the phone occasionally, but his life simply wasn’t the same without their weekly racquetball matches and regular collegial interactions as they cared for many desperately ill children.

Jack didn’t need the information on the note as he quickly selected Buzz’s number from the more than two hundred contacts in his cell phone. When he heard the familiar southern drawl say hello, his only reply was, Why didn’t you tell me you were planning to retire when I saw you at David’s graduation?

It took Buzz just a moment to orient himself in the absence of any greeting, before he replied, Well, mainly because I didn’t know myself until last Monday. I finally had enough, so I just quit.

It’s not like you to do anything on impulse, Jack stated matter-of-factly.

I know. That’s what Charlotte said, Buzz replied, referring to his wife who’d known him almost as long as he and Jack had been friends. So, how did you know I quit?

I stopped by the children’s hospital a couple of days ago and talked to Traci Bryan. She told me.

Yeah, Buzz said, she’s about the only one left up there that I’m gonna miss.

So what happened?

Oh, it was a combination of things, Buzz explained. All the hassles of dealing with Grady and his management team, being forced to justify everything I do to them and having to meet all those stupid best-practices protocols that were written by some asshole who doesn’t even treat patients.

Jack laughed softly as he listened to his friend rant. He thought Buzz was beginning to sound a lot like he did prior to his own sudden retirement.

Obviously, nothing had changed. Jerry Grady, the pediatrician who had become a full-time managing partner of the large multi-specialty physician group, had joined forces with the children’s hospital, forming an integrated Accountable Care Organization as called for by the Affordable Care Act. Grady had worked with two businessmen, Jim Fitzgerald and Michael Horvath, to create one of the largest children’s healthcare delivery networks in the southwest.

I understand, Jack agreed. Just the thought of all that stuff was what finally drove me out last fall.

I couldn’t stand working with that ridiculous electronic medical records program another day, the Buzz added, with obvious disgust. It kept me in a perpetual bad mood, but the final straw came last Monday when I showed up at the cath lab for my first case. I had scheduled a six-year-old kid with a very symptomatic atrial-septal defect to have an intra-cardiac patch graft. The little girl wasn’t exactly dying, but she had certainly become short of breath with even minimal exertion. Anyway, when I walked into the lab the head nurse told me my case had been cancelled. When I asked her why, she said that Grady’s office had called on Friday and cancelled it.

Jerry cancelled your case? Jack asked with surprise.

Yeah, Buzz replied, the anger growing in his voice as he recounted the event. The nurse told me he said I couldn’t do it until July because there was no money left in the Accountable Care Organization’s June budget.

Sounds like somebody exceeded their quota, Jack quipped.

Exactly! Buzz spouted. They had previously approved the procedure, but the prior Thursday I had another kid come in who needed an emergency cath, and since he was my fourth Medicaid patient of the month, that was all I was allowed to do until next month.

That would certainly have set me off, Jack offered, sympathetically.

I told my partners they could have it. I’m through trying to practice medicine with a choke collar around my neck.

This may sound strange, Jack replied, but, I’m really proud of you.

Charlotte said the same thing, until I explained to her that we would likely have to sell our house. I’ve put some money aside, but I hadn’t planned on retiring for a few more years.

Well, I can only speak for myself, Jack offered, having experienced many of the same frustrations. I’ve been retired less than a year now, but they couldn’t pay me enough to get me to come back to that rat race.

I understand, Buzz agreed, his voice softening a little. But don’t you miss taking care of those kids?

Of course! More than I ever imagined I would, and I’m certain you will too.

Throughout the last week of June 2014, Jack and Buzz spoke several more times over the phone. During their casual conversations Jack began to outline his idea for a project he had been formulating in his mind for several years. He asked Buzz repeatedly for his feedback, and all his friend would say is, That sounds like a great idea. You can count on my whole hearted support and participation, if you can pull it off.

The following Tuesday evening Jack called his friend, Franco Gutierrez, to ask if there was a time when they could talk. I have something I would like to discuss with you.

Franco was the wealthiest and quite possibly the most influential man in Nicaragua. He and Jack had become close friends after the American surgeon performed life a saving heart operation on Franco’s newborn daughter, Christina, nine years earlier. Franco said he would be tied up until Friday so Jack suggested Franco and his wife come to their home in El Transito that evening for dinner. Franco countered, saying, We do not wish to impose. I will make a reservation for Friday evening at the Voltes Restaurant in the Intercontinental Hotel.

Jack knew that his friend was accustomed to having his way, and quickly decided it didn’t really matter where they met. He just needed a couple of hours of Franco’s undivided attention, so he agreed to meet at the landmark hotel in Managua.

For the next two days, Jack paced up and down the beach by day, and sat in front of his computer every evening, organizing his thoughts. The concepts he was attempting to crystalize into a coherent strategy had been rattling around in his head since that night, several years earlier, when the Nicaraguan Minister of Health first asked his opinion on how to improve the quality and availability of healthcare in this third world country. The question had taken on a more personal meaning, now that he and Elaina were actually living in Nicaragua. He found it tempting to get caught up in creating a comprehensive healthcare system, but decided it would be best to focus only on what he knew, and that was pediatric heart surgery.

The irony of the fact that Friday was the Fourth of July was not lost on Jack. America’s Independence Day had no significance in this Central American country, but it was important to him, and he would miss taking Elaina downtown for the fireworks display at Fort Worth’s Sundance Square.

Jack and Elaina left their house a little before six on Friday afternoon for the hour-long drive into Managua. He’d decided to take her six-year-old BMW rather than his big Toyota Land Cruiser. He thought the luxury car would be more appropriate given the occasion and the upscale Intercontinental Hotel. As they walked into the restaurant, the maitre d’ immediately recognized the American surgeon and his wife and quickly escorted them to a secluded table which was always reserved for Mr. Gutierrez. The man pulled out two chairs for Elaina and Jack, making it clear that the two seats on the far side of the table, facing out into the room, were reserved for their hosts. Franco would surely have this man fired if he were asked to sit with his back toward the entrance.

In less than a minute a waiter arrived with a glass of champagne for Elaina and a double scotch on the rocks for Jack. He started to ask what kind it was, but thought better of it. He knew it was a fine old single malt, ordered specifically by their host.

Elaina laughed and said, Isn’t it nice to have ridiculously wealthy friends?

Jack silently nodded in agreement, but he was still uncomfortable with the way Franco seemed to take every opportunity to spoil them. Over the last nine years he’d come to the conclusion that it made Franco feel good to provide for others, so he simply indulged him. On this night, he was actually counting on his friend’s generosity to help move his idea forward.

Good evening, Franco said as he approached from behind Elaina’s shoulder. Please keep your seat, he added, then leaned over to kiss her politely on the cheek before stepping around to shake Jack’s hand who had quickly stood. Gabriella, Franco’s elegant black-haired wife of more than twenty years, was an incredibly beautiful forty-three-year-old woman. She followed her husband in embracing Elaina warmly, then hugging Jack as he stepped around to greet her.

I trust you haven’t been waiting long, Franco said as he sat down across from Jack. Almost simultaneously the waiter placed a glass of scotch on the table in front of him. The bartender had poured his favorite drink the moment he saw him enter the front door of the hotel. Gabriella, likewise, accepted the flute of champagne.

No, we just got here, Jack said raising his glass. Barely enough time to sample this Macallan.

I assume you approve?

Of course, Jack said with a satisfied smile.

And is the champagne to your liking? Franco asked Elaina.

Yes, it’s delicious, she said with a broad smile.

Crystal is Gabriella’s favorite.

Jack raised his glass and looked first toward Gabriella and then back to Franco, as he said, Here’s to fine wine, old scotch, and good friends.

They all raised their glasses in agreement before taking another sample of the expensive liquids. Then, almost as if part of a scripted evening, Franco said, I would like to propose a toast of my own. He raised his glass and continued, To our future venture. Elaina and Gabriella were neither one sure what he was talking about, and Jack also had a surprised and questioning expression on his face. He tentatively raised his glass, but didn’t bring it to his lips.

After taking a generous sip of his drink, Franco asked, Aren’t you going to drink to your plan?

How do you know what I want to talk with you about?

I don’t, but you arrived here slightly early and you began the evening by proposing a toast to friendship, Franco said, then paused as a sly smile came to his face. Am I not correct in assuming you have an idea for which you want my help?

Jack smiled sheepishly as he dropped his chin and shook his head slowly. I had no idea I was that easy to read.

Franco laughed heartily, then replied, It’s not you, my friend. It is the situation. Anytime someone calls and says they have something they would like to discuss with me, it invariably involves some kind of business venture.

So, do you always toast to a venture even before you know what it’s about? Jack thought perhaps he’d discovered a weakness in Franco’s logic.

No, only when I know the individual, and I’m certain it will be a success.

I appreciate your confidence, but I’m afraid you may change your mind when you hear what I’m proposing. I’m not even sure it will work.

I have every confidence in you my friend. Now, why don’t you tell me what it is you want to do.

*********

It was approaching eleven o’clock as Jack finished explaining his intricate plan over a second after-dinner drink. Franco had remained more quiet than usual throughout the evening, listening intently to every detail and asking questions only when he didn’t immediately understand something. Elaina and Gabriella talked about Christina’s private schooling as well as the imminent arrival of David and Amy’s baby back in Dallas.

As they all rose from the table, Jack stumbled slightly over the leg of his chair, revealing the effects of the considerable alcohol he’d consumed.

Are you okay my friend? Franco asked.

Yeah, sure, he replied, I’m fine.

Don’t worry, Elaina said, I’m going to drive us home.

No, you’re not, Jack protested a little louder than was necessary, again suggesting he’d had a bit too much scotch.

Well, you sure aren’t driving, she stated boldly.

Franco placed his hand on Jack’s shoulder and said, Your wife is right. I think you had better do as you are told.

Jack started to object again, but he recognized he was outnumbered. Instead he suggested, We could just spend the night here in this fine hotel. He flashed his signature crooked smile, hoping she would take the hint.

Elaina just laughed, knowing her sixty-five year old husband would likely be asleep by the time his head hit the pillow. No, we need to get home tonight. I have a bunch of stuff to do tomorrow before I leave for Dallas on Sunday. Their only child, David, and his young wife, Amy, were due to have their first baby in less than a week. Elaina was going back to Texas a few days before the anticipated delivery to make sure she was there for the arrival of her grandson.

The valet pulled the white BMW up behind Franco’s black limousine as the group said their good-byes. Franco kissed Elaina’s cheek and suggested, You should follow us to the Pan American Highway. Once you reach the turn off to Leon, the road should be very familiar to you.

That sounds like a great idea. She was not accustomed to driving through the streets of Managua at night, and wasn’t sure whether Jack would be of any help navigating the unfamiliar city streets. As the limo pulled away from the hotel she followed closely behind. Franco instructed his driver to proceed slowly and keep her in sight, at least until they got out onto the highway.

Jack was uncomfortable being the passenger, and despite the slight lingering effects of the alcohol, he was watching every turn very closely. You know you’re going to need to merge onto the highway just ahead, he said, offering directions she didn’t need.

I know exactly where we are, she insisted. I’ve driven this way before, you know. After a brief pause she added, I don’t tell you how to drive.

He knew he had hurt her feelings, so sheepishly said, I’m sorry. I’ll shut up.

They reached the fork in the road where a small, poorly lit sign read Carretera Vieja a Leôn. The limo proceeded on to the south, while Elaina turned the BMW to the west, toward home. This time of night the road was almost deserted, with only a rare oncoming vehicle, and none going in their direction. They steadily climbed the east side of the mountain toward the ridge. Just beyond was her favorite place with the incredible view of the ocean where they had stopped to take photos of the Pacific on multiple occasions. There would be no such view this evening. A thick layer of clouds now shrouded the mountain in complete darkness except for the penetrating headlights illuminating the road. As they passed through Monte Verde, the last town before reaching the summit, a steady rain began to fall, prompting the activation of the automatic windshield wipers.

You should probably slow down, Jack offered, with a hint of concern in his voice. This road gets a little slick when it rains.

Elaina didn’t take her eyes off the road, but heeded her husband’s suggestion, slowing down to ninety-kilometers-per-hour from the posted limit of one-hundred. She felt the tires slip ever so slightly when the road made a sharp bend to the right, causing her to grip the steering wheel a little tighter. As she crested the hill and began the long descent down toward El Transito the rain intensified significantly, causing the wipers to automatically adjust to high, but they weren’t able to keep up with what had quickly turned into a tropical downpour.

Suddenly the oncoming lights of another car appeared, seemingly out of nowhere, heading directly toward her. She swerved to the right to avoid hitting the other car head on, while the other vehicle turned sharply back into the proper lane. In the darkness she felt the rear end of the BMW start to come around causing her to instinctively hit the breaks and turn the wheel hard back to the left. The response to the over correction was instantaneous. The car swerved back across the highway, spinning and sliding sideways on the slick surface. Jack reached across in front of her with his left arm in a reflex attempt to help her regain control, but it was too late. As the wheels on his side of the car made contact with the loose gravel of the shoulder, the momentum caused the left side tires to lift effortlessly off the pavement. Elaina’s sudden scream seemed like a strange musical accompaniment to a violent dance as the car quickly rolled over and the steel roof immediately above Elaina’s head struck forcefully on a volcanic boulder. The sound of the rock crushing metal, caving in the roof, instantly silencing her scream. The rotating motion continued until it suddenly stopped when the right side of the car slammed into a large tree, crushing Jack’s door into the passenger compartment. He cried out, as he instinctively reached toward his reach his right leg, the source of his excruciating pain.

He looked back over toward Elaina and saw her slumped forward, resting against her seat belt, motionless. He attempted to reach out to her, but remained constrained by his own seat belt and shoulder harness. He worked feverishly to release the buckle near his left hip, ignoring the pain in his leg which rapidly subsided under the influence of the sudden rush of adrenaline. The desperate scene was illuminated by the dim lights of the dashboard and the eerie reflection of the one remaining headlight off the trees in front of the mangled car.

Oh my God, he said softly to himself, this can’t be happening. He reached over to touch Elaina’s face, lifting it carefully in the palm of his left hand. The soft skin of her cheek was moistened by a small stream of blood flowing down from the left side of her head. The unacceptable thought that she might be dead raced through his mind, causing him to instinctively move his fingers to the front of her neck. Her pulse was still present, faint, but palpable. Her breathing was shallow, but like her pulse it, too, was barely perceptible. Perhaps she wasn’t badly injured after all. People get knocked out all the time. Surely she would regain consciousness any second.

He reluctantly reached up to touch the top of her head for the source of the bleeding, and as he did he thought his own heart would surely stop. There was only a small laceration in her scalp, but as he ran his fingers over the left side of her head there was a strange softness to her skull. A portion of the bone seemed to be floating up and down with his gentle touch, and he could feel a definite depression along the far edge. He knew the meaning, and was once more filled with a near-paralyzing fear.

Memories of those countless nights on trauma call at the county hospital in San Antonio raced through his mind. As a resident rotating on the neurosurgery service, he had cared for several patients with depressed skull fractures, and he couldn’t recall a single one that had done all that well. Almost robotically he found himself going through the list of clinical signs the staff surgeons had instructed all the residents to look for, findings that would indicate increased intracranial pressure. Instinctively he reached for his cell phone in the left front pocket of his trousers, but found it a challenge to retrieve it with his right leg pinned awkwardly between the side of his seat and the crumpled door. Eventually he was able to work the electronic device out of his pocket and saw that it was still functioning. He activated the flashlight application and used it to examine Elaina’s eyes. As he spread the index finger and thumb of his left hand, opening her right eye lid, the brilliant green iris that had captured his heart more than two decade before came into view. With his right hand, he shined the bright light directly into the dull and almost lifeless eye. Instantly the pupil constricted down reflexively in response to the brightness. He breathed a sigh of relief, then repeated the same process on the left side, praying for the same response. This time the pupillary reflex was sluggish and incomplete. As he had feared, her life was very much in danger.

Jack closed his eyes and prayed for cell service, knowing it was always spotty along this stretch of the road. He touched the screen to bring up his contact list and quickly found the name he was searching for, then touched the number and held the phone up to his ear. The silence seemed interminable as the phone searched for a signal. Finally he heard a ring, followed by another and still another before the familiar voice finally answered.

"¿Hola?"

Domingo! This is Jack! We need your help!

The cellular connection was tenuous but Jack was able to convey what had happened and the approximate location of the accident.

You need to have your son meet us at the hospital. Elaina has a depressed skull fracture, and I’m certain she is going to need a neurosurgeon.

Just before the connection was lost he heard Domingo say, Help is on the way, and Raffy and I will meet you at the hospital.

Thirty-two-year-old Rafael Ramirez had arrived back at his boyhood home in Managua only two days earlier. The brilliant young neurosurgeon had been in the United States for the previous fifteen years. The first four were spent in

Houston, where he attended Rice University. The next eleven years he had lived in Baltimore, where he completed medical school and a seven year neurosurgery residency at Johns Hopkins University. Raphael had reluctantly turned down a job offer to join the faculty at that prestigious hospital because he had promised his physician father that he would return to Nicaragua to help the people of his country once he finished his training. There was no way either of them could have imagined that his first patient would be the wife of Domingo’s longtime American friend.

As Jack sat silently, looking over at Elaina’s motionless figure slumped over the steering wheel, he suddenly felt incredibly alone. He wondered if life could offer anything more cruel than this. Being forced to sit helplessly next to the woman he loved so deeply, watching her die. It was beyond any physical torture imaginable. He tried once more to free his leg, ignoring the pain of his broken fibula, but it was impossible to release himself. He was reminded of a book he’d read a couple of years earlier. He couldn’t recall the title, but it was the gruesome account of a young rock climber who had amputated his own arm in order to free himself when his hand was crushed between two immovable boulders. That was an option he would gladly accept if only it were possible.

In the soft greenish glow of the dashboard lights he could see Elaina’s slow and shallow breathing and his consciousness was once more flooded with long-forgotten clinical training from his internship. Her minimal breathing would certainly lead to a rise in the level of carbon dioxide in her blood, and the reflex physiologic reaction would cause her circulatory system to shunt more blood to her brain. The increased blood flow would cause the swelling in the brain to be magnified, hastening her death. To delay what he feared might be inevitable, he had to find a way to increase her breathing and lower the carbon dioxide level in her blood. He had to reach her somehow.

He tried in vain to stretch his torso across the console between their seats, but nothing he tried brought him any closer to her. He unbuckled her seatbelt and cast it sharply toward her door then pulled her gently by her right arm toward him. He knew full well that moving her in this way could cause further injury if any vertebrae in her neck or back were broken, but that was a risk he’d have to accept at this point. Her upper torso turned gradually, exposing her back allowing him to place both his hands under her arms. As he attempted to lift her shoulders up and over the center console it became obvious that the steering wheel across her thighs was blocking the movement. The air bag had deployed from the center of the steering column and now deflated, it gathered loosely across her lap, obscuring his view of precisely where her legs were being held. Jack let out a deep sigh in frustration and released his hold on her, allowing her limp body to slide back into the driver’s seat.

The thought of giving up his plan never entered his mind. Instead he contorted his body forward using the center gear shift lever in his right hand to pull himself as far over as his trapped leg would allow. With his left arm fully extended he reached through the opening between the wheel and the column and with the tips of his fingers he found the small nob that controlled the position of the steering wheel. As he pushed it up, the mechanism responded, raising the wheel more than six inches above Elaina’s legs. Then he pulled the nob back, causing the wheel to extend further into the cabin, creating even more room. Perhaps there would now be enough space to allow him to free her flaccid body.

He repeated the same steps he’d employed in his previous attempt, and this time with a final firm tug, he was able to lift Elaina’s hips, sliding them up until she was sitting on the center console. He leaned her shoulders forward, holding her firmly with his right arm, then carefully pulled her legs out from under the steering wheel until both her feet were resting in the seat. With some additional adjustment to her position he brought her blood stained face directly in front of his.

Holding her head steady with his right hand behind her neck, he used his left hand to pull her chin down, forcing her mouth to gape open. He placed his mouth over hers and blew his breath forcefully into her, causing her cheeks to bulge slightly, but more importantly he felt her chest expand forward against his. When he removed his mouth he could feel the air escaping from her lungs as he turned his head, drawing in a breath of fresh air before repeating the process.

Over the next ten minutes Jack assisted Elaina’s breathing by forcefully blowing his own breath into her mouth as rapidly as he could manage. His objective was to achieve a controlled but vital state of hyperventilation, but he hadn’t counted on the effect this had on his own physiology.

After less than three minutes he began to see tiny flashes of light in his peripheral vision. He tried to convince himself they were of no consequence, as his own hyperventilation began to influence his rational thinking. He looked down into his wife’s beautiful face, which now appeared to be sparkling from the imaginary stars he was seeing. He was suddenly reminded of the first time he had placed his mouth on hers, kissing her tentatively as they sat in a horse drawn carriage on that dark Fort Worth side street. His mind drifted back to that moment and how she had taken his breath away that time as well. Spawned by his rapid rhythmic breathing, his hallucinations continued, as he saw her slowly opening her familiar green eyes with their golden highlights. In his mind they were very much alive and seductive accompanied by the melody and lyrics of The Wedding Song that her friend had sung at their wedding ceremony. Amid his self-inflicted dizziness he silently prayed that his love for this woman would allow her to draw life from him and give it back again.

In the distance he thought he heard the faint sound of an approaching siren through the soft patter of the rain on the windshield. It brought back the vivid image of an ambulance carrying his baby brother, as it raced ahead as his father chased it down the highway toward the hospital. As the sound grew stronger, his thoughts returned to the reality of this emergency, wondering just how long it had been since he’d spoken to Domingo, and whether his efforts would make any difference or not.

Suddenly, the brightness of a search light penetrated the darkness, causing him to recoil. He wasn’t sure whether what he saw was real or not until he heard a man pounding on the windshield and shouting to him in Spanish. Before Jack realized exactly what was happening the glass of the window in the driver’s side door shattered under the blow of the rescuer’s hammer. The tiny fragments of glass suddenly covered Elaina’s legs and torso, but none were not sharp enough to cause any further injury. The man reached inside and unlocked the door, and after several attempts he was finally able to jerk it open.

Trained emergency responders were few and far between across Nicaragua, but Domingo had known the appropriate people to call on the west side of Managua, and it was by pure coincidence that the local emergency team was one of several currently undergoing training by a visiting group from Ottawa, Canada. The private Canadian ministry, called the Paramedic Partnership Bridge, consisted of a group of ten volunteer paramedics, scattered across the country conducting training classes as part of a three year program designed to train three-hundred-sixty Nicaraguans in first responder skills. One of the Canadian paramedics was conducting a week long course at the nearby Nicaraguan Christian Academy International, which also housed the only ambulance team Domingo knew of in the region.

The paramedic spoke quickly in English, explaining that he needed for the passenger to release the victim. Jack reluctantly loosened his hold but continued to cradle her head in his hands as the Canadian carefully pulled her limp body , feet first, out of the mangled vehicle. Another man took her legs as the paramedic gently lifted her shoulders, then placed his hand behind her neck. When Jack could reach no further he finally allowed her head to leave his grasp, and as the other men laid her carefully on the wet ground, Jack shouted, She has a depressed skull fracture.

Immediately the paramedic checked for himself and what he felt on the left side of her head confirmed Jack’s diagnosis. He called for one of the Nicaraguan men to bring him the intubation box out of the back of the old ambulance. In less than a minute he expertly placed an endotracheal tube in her windpipe, and began squeezing the oxygen filled bag, resuming Jack’s life saving measures in a more efficient manner.

Please breathe her as fast as possible, Jack called out through the rain, now little more than a light drizzle. It’s critical you hyperventilate her.

Another man tried to pull Jack out of the car through the driver’s side, but his right leg remained pinned, and each time he tried to move him Jack cried out in agony. Leave me here, he insisted, Please, just get my wife to the hospital before she dies.

It was clear there was no way they were going to get Jack out of the car without the help of a wrecker or other heavy equipment that could pull the car away from the tree where it was lodged. The crushed passenger side door would have to be opened before his leg could be freed. One of the local trainees used the ambulance radio to call for additional help, and at Jack’s insistence the ambulance crew finally agreed to leave the scene without him.

Dr. Rafael Ramirez should be waiting for you in the emergency room of the government hospital, Jack explained. Please go quickly, please!

One of the men volunteered to stay behind with Jack while the others loaded Elaina in the back of the ambulance and quickly sped away. The rise and fall of the blaring siren slowly faded into the darkness, and the surreal scene was once more wrapped in an eerie silence as Jack lost consciousness.

*********

He opened his eyes slowly to the sound of a chain being hooked to the underside of the BMW’s twisted frame. As the fog of unconsciousness began to lift, he once more became fully aware of the excruciating pain in his right lower leg.

We’re going to get you out of there very soon, came a stranger’s pronouncement.

Jack could feel the car moving sideways as he heard the metal groaning under the force of the electric winch. He could see the strange lateral movements of the trees and underbrush visible through the shattered windshield, as the car was slowly pulled away from the massive Caribbean pine responsible for his entrapment. The outside movements were illuminated by the sole remaining headlight, causing the scene to jerk and slide mysteriously away to his right.

Move your head away from the door, the man shouted, again, but this time from just outside his door. Jack complied as much as he could manage, once again using the gear shift lever to pull his torso forward, and turning his shoulders to the left. He heard a loud crack of metal on metal as the rescuer drove the crow bar under the back edge of the door. As the man put his weight against the bar, the car wobbled several times, but the door remained unyielding. He heard two men speaking rapidly to each other, seemingly arguing about how the task should be accomplished, but he was powerless to assist. Then he heard the powerful sound once more as the crow bar was again thrust under the edge of the door. As the car rocked rather violently again, the door popped open a couple of inches. Despite their aggressive efforts to pull it open further, the mangled metal would not move any more.

Although the pain was now even more severe, Jack found he could finally move his leg forward slightly, freeing it from where it had been held between the base of his seat and the crumpled door. He wondered how his foot could have ended up in that spot during the roll-over, but at this point it didn’t matter. He was finally free and he shouted to the men that he thought he could get out through the driver’s side. The rescuers quickly ran around to the open driver’s door and began to pull him out by his shoulders, as he cried out in pain again.

The three men laid him across the back seat of one of their old cars for the trip to the hospital, which took nearly twenty minutes. Throughout the ride, the man who had remained behind when the initial rescue crew left with Elaina, kneeled in the front seat, and leaned over the back of the seat to attend to his patient. He attempted to stabilize Jack’s leg by holding it up, his arms functioning as a sling, while Jack faded in and out of consciousness. When they arrived at the emergency room he was fully conscious once more.

Where is my wife? he demanded of the nurse who came to check on him.

Was that her they brought in a couple of hours ago with the head injury? she asked as she began setting up to place an IV in his arm.

Yes! Where is she? Could it have been that long, he wondered.

The new doctor, I think his name is Ramirez, took her to surgery, she replied, as she expertly stuck the needle in his arm and connected the clear plastic tubing. I don’t know anything other than that.

Can you please find out for me? he pleaded.

She taped the IV in place and continued her assessment. I will ask one of the assistants to check on her status, but right now we need to see about your leg.

Jack started to protest, still frantic to learn what was happening to Elaina, but before he could say anything more, the nurse left the room and a young male technician entered. He quickly rolled Jack’s stretcher out of the emergency room, and down the hallway to the radiology department. He carefully moved him over to the hard x-ray table, and within a couple of minutes he had completed the task of obtaining two views of Jack’s broken leg. As the young man returned and prepared to push his patient back to the ER, Jack stopped him and asked, May I see those x-rays?

The technician hesitated, looking quizzically at his patient.

It’s okay. I’m a doctor, Jack assured him.

The man tentatively handed him the two mostly black films, then watched as Jack held them up to the light, assessing the damage.

It doesn’t look as bad as it feels, he admitted. The distal fibula is obviously broken, and there’s a small hairline fracture in the proximal end as well, but the tibia looks fine.

The technician retrieved the films and rolled Jack back to the ER.

I found out your wife is still in surgery, the nurse announced, and the doctor’s name is Ramirez.

*********

The walls of the old operating room were covered with ceramic tiles, once a brilliant gleaming white, but now a dull shade of yellow from decades of being wiped down with antiseptic solutions. The room was deathly quiet except for the rhythmic beeping of the heart monitor, and the slow but steady cycling of the ventilator. Both were under the watchful eye of the young anesthesiologist. It was three-thirty in the morning, and the surgical team, headed by the newest member of the medical staff, Dr. Rafael Ramirez, had been working for just over an hour.

Wrap this in a saline soaked sponge and place it somewhere safe on your back table, Dr. Ramirez instructed as he handed the irregular piece of Elaina’s skull to the scrub nurse. I’m going to need it back once I finish picking these fragments out of her brain.

The crushing blow to the left side of Elaina’s head had resulted in an irregular oval fracture, and Dr. Ramirez had expertly removed the broken section. The top edge of the bone had been pushed nearly a quarter inch into the soft cerebral tissue it was designed to protect. The brain, like all soft tissues, responded to the injury by retaining fluid, causing it to swell, but unlike other organs, the brain is housed inside a bony casing. As it swells, the pressure inside the rigid confines gradually increases. The unyielding housing offers only one natural point where the pressure can be released, the large circular hole near the center of the base of the skull called the foramen magnum. The opening encircles the base of the brain where it joins the spinal cord. The brainstem is the very center of the neurologic system, where breathing, heart rate and other vital functions are controlled. Rising intracranial pressure can quickly push the brainstem down through the narrow opening causing blood flow to this most vital area becomes compromised. This was the most common mechanism of death following traumatic brain injuries, a process that could take only a matter of minutes.

Keep her respiratory rate around thirty. Rafael barked his instructions toward the inexperienced anesthesiologist. The neurosurgeon was well aware of the need for hyperventilation to slow the swelling, but he was totally unaware of the incredible measures her desperate husband had taken to ensure she would survive long enough to reach the hospital.

*********

Have you seen Dr. Domingo Ramirez? Jack asked the nurse as she locked the wheels of the stretcher.

Are you talking about the pediatrician? she asked with a questioning smile.

Yes, Jack replied abruptly. He is my friend and the father of the neurosurgeon who is operating on my wife.

I have not seen... Her response was cut short as Domingo stepped into the small examination room.

Jack! Domingo shouted. I’m so glad you are okay.

My leg is broken, but otherwise I’m all right.

I heard, Domingo replied, I have called my good friend, Miguel Soto. He is the best orthopedic surgeon in Managua, and he is on his way in to fix your leg.

Did you see Elaina when she came in? Jack asked, once more ignoring his own condition.

Yes, I was with Raffy when he examined her. You were right, she had a depressed skull fracture, so Raffy took her straight to the operating room. He’s been working for nearly two hours now.

Was she conscious at any point? Jack asked.

No. Not that I’m aware of, Domingo replied as he looked over at the nurse. She shook her head, confirming what Jack already suspected.

Good, he replied. At least she wasn’t suffering. Did she have any other injuries?

I don’t believe so, Domingo answered. Raffy performed a quick cervical spine series of x-rays before taking her upstairs. He said they looked okay, but he plans to get a CT scan as soon as possible after surgery.

Jack silently hung his head as he muttered, This was all my fault.

Nonsense, Domingo replied. It was an accident.

No! Jack insisted. None of this would have happened if I hadn’t had so much to drink at dinner. I should have been driving...

Then it would have been you up there in the operating room, Domingo interrupted.

Better me than her, Jack replied sadly.

There isn’t anything you can do about it now, Domingo reasoned, hoping to change his friend’s focus. The important thing now is to get that leg of yours stabilized.

Jack looked down at the old metal splint that had been used to temporarily immobilize his ankle, and the large ice pack that was sitting on top of his foot, well away from the sight of the fracture. Normally he would have been quick to point out the obvious misplacement, but he didn’t seem to care.

Please go check and see how things are going with Elaina, would you?

I spoke to Raffy just before I came down here and told him that you were here in the ER. He will be down as soon as he is finished.

Thank you, Jack replied, softening his tone. I really appreciate your being here.

I wish there was something more I could do, but you’re both a bit beyond the age of my typical patients, Domingo laughed, again attempting to lighten the mood, and this time with some success.

The curtain across the entrance to the small examination room was suddenly swept back by a very large Nicaraguan man who looked to be in his mid-fifties. He didn’t speak initially as he made eye contact first with Jack and then Domingo.

Miguel, Domingo offered as he moved quickly to embrace his colleague. Thanks so much for coming.

Of course, the other man replied with a smile, although it was obvious from his appearance that he’d just recently been awakened.

Miguel, this is my very good friend, Dr. Jack Roberts, Domingo said as he motioned toward the stretcher.

Excuse me if I don’t get up, Jack said as he raised up on his elbows before extending his right hand.

It’s a pleasure to meet you Dr. Roberts, the burly man said as his huge hand seemed to swallow Jack’s. I’m just sorry it had to be under these circumstances.

Yeah, me too, Jack replied as he laid back down on the stretcher, now resigned to being treated.

I looked at your x-rays, and you have a broken fibula, Miguel said without the slightest emotion.

Yeah, Jack replied, In two places.

Miguel looked surprised by Jack’s observation. Most people would likely see the break in the lower end of the smaller of the two bones of the lower leg, but the crack up closer to the knee was far more subtle. How did you know that? Miguel inquired.

I saw it on the films, Jack replied as if it were simply understood. I was always told to look for a second fracture, away from the obvious one. That crack on the proximal end wasn’t all that hard to see.

You are quite perceptive, Miguel said. And I suppose you understand that means I’ll need to place you in a long-leg cast, immobilizing your knee.

Yeah, I was expecting that. Just as long as you don’t think it needs surgery.

No, the distal fracture is not significantly displaced. In about eight weeks it should heal just fine.

Okay, Jack said without further discussion. He was eager to get on with the process so he could get back to seeing about his wife.

One of the nurses wheeled in a cart with all the materials Dr. Soto would need to apply the cast. As he began wrapping Jack’s leg with a roll of soft cotton material to protect the skin from the rough plaster, he said, The long-leg cast will only be necessary for about three weeks, then we’ll switch you to a shorter one that will allow you more mobility, and some weight bearing.

Jack noticed the long cast became quite warm as the plaster began to dry. Once it had hardened, Miguel used an oscillating power saw to cut through the chalky white material down the full length of the inside of Jack’s leg. He then repeated the process on the outside of the cast, saying, Your leg is going to swell, so I’ve split the cast so it won’t cut off the circulation. I’ll need to put you in a more rigid one in a few days.

Miguel wrapped a series of elastic bandages around the split cast, before saying, I have arranged for you to spend the rest of tonight here in the hospital so we can make sure your pain is under control. Hopefully you can go home around noon.

Thanks, Jack replied, but I don’t intend to go home until I can take Elaina with me.

Domingo looked over with a questioning expression. Jack, that could be weeks. You can’t stay here in the hospital.

"Well, I can’t very