A Surgeon's Heart: The Challenge

By R.W. Sewell, M.D.

After retiring to the Pacific shores of Nicaragua, Dr. Jack Roberts follows a new calling of his Surgeon's Heart. He is frustrated and angry with the growing restrictions, mandates, and penalties imposed on American physicians, so the accomplished pediatric heart surgeon vows to build a new and better health care system, far away from the forces of political power and corporate greed.
He teams up with others who are likewise on the verge of quitting to build a unique network of ultramodern hospitals, where the focus is on the needs of the patients rather than the profits of payers and investors. Jack works tirelessly to pull all the element together with an unspoken promise to change the world of medicine forever. He seeks to create an island of medical freedom amid the jungles of Central America, where inspiration, excellence, cooperation, and innovation are the driving forces.

As the story unfolds, Jack is challenged emotionally, physically, and spiritually, struggling to keep his dream alive, not just for himself, but also for his son. Dr. David Roberts, is a talented and ambitious surgical resident in a distinguished training program in Dallas, Texas, where he, too, experiences many of the same pressures and obstacles that drove his father from a successful practice in nearby Fort Worth a few years earlier. Having grown up watching his father openly display an unwavering devotion to his patients and the traditional code of medical ethics, David seeks to overcome his challenges as he follows his own Surgeon's Heart.

• Language: English
• Publisher: R.W. Sewell, M.D.
• Release date: Jul 16, 2016
• ISBN: 9781310728099

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 Challenge

by

R.W. Sewell, M.D.

Copyright © 2016 R.W. Sewell, M.D.

All rights reserved.

ISBN-13: 978-0990405160 (Robert Sewell, MD)

ISBN-10: 0990405168

DEDICATION

I would like to dedicate this book to all my personal mentors, beginning with those devoted elementary school teachers who never hesitated to give me a loving pat on the back when I deserved it, or paddle my butt when I needed it. Also, to those high school teachers who helped bridle my rebellious spirit and mold my character by offering a solid academic foundation and instilling in me the love of learning. To my college and medical school professors, at Lamar University and the University of Texas Medical Branch - Galveston, who kept me focused on my life’s goal of becoming a physician. Then, to the beloved faculty of the University of Texas Health Science Center in San Antonio, led by the late Dr. J. Bradly Aust, who molded me into an instrument of healing to be used for God’s purpose. To all of them I owe a debt of gratitude beyond what my words can express.

However, of all my mentors, the one who had the greatest and longest lasting impact on my life was my father, Chester Lee Sewell. He was my life teacher, and he did it by example. My dad was not a physician. He didn’t have a fancy education, but he was wise beyond measure in the common sense rules of the world. He taught me to respect myself as well as everyone else. He emphasized love of family and love of the Lord, but perhaps the greatest lesson he taught me was, Any job worth doing is worth doing well. He was a true craftsman and challenged me to be the best I could be every day. I miss you Dad.

INTRODUCTION

A Surgeon’s Heart: The Challenge is the fifth novel in this series, which started on a whim in March of 2013. A friend of mine, Hayden Knox, listened to my constant protests about how the practice of medicine was being systematically destroyed by a variety of outside influences. He patiently endured my often angry rants, nodding occasionally in agreement. Then, one evening following one of my more emotional outbursts about the unintended consequences of bureaucrats controlling people’s health care, he turned to me and said, You know what you should do? You should write a screen play about a group of doctors who go underground to stay one step ahead of the death panels. I laughed along with the rest of our small group of friends, recognizing that Hayden was gently tell me he was bored with my protests, and I reluctantly agreed.

Over the next few days, I thought a lot about what my friend said. I had written a number of short pieces about health care issues which I thought were important. I’d posted them on a blog and emailed them to friends, but that was the extent of my writing experience. I had coauthored a book with one of my patients, but that was more or less a how to manual aimed at a specific group of patients. I had no experience authoring a screen play or anything of the sort. Then my wife and I went to the movies to see Hunger Games, and I came away with a strange feeling. It was as though I’d been tapped on the shoulder and told, this is how you communicate a message to people. Tell them a story with characters they can relate to, and appeal to their basic emotions and their innate sense of right and wrong.

I had no way of knowing how the fictional story of a pediatric heart surgeon, Dr. Jack Roberts, would literally consume my life. What started in response to my friend’s challenge has grown into an epic tale, filled with inspiration, tragedy, passion, and hope. The telling of this story has become my personal calling, and I can only pray that it touches you, the reader, in a meaningful and personal way.

Please enjoy, A Surgeon’s Heart: The Challenge.

R.W. Sewell, M.D.

ACKNOWLEDGMENTS

A Surgeon’s Heart: The Challenge, like each of the books in this series, is a work of fiction. It is the product of my imagination and is based, in part, on my personal experiences as a practicing general surgeon for the last thirty-seven years. It is critical for the reader to understand that none of the characters described in this story are real people. Any similarities with any real persons, either living or deceased, is purely coincidental. Likewise, each of the facilities and specific situations portrayed in this story are completely fictitious.

Pictured on the cover is my friend and colleague, Dr. Howard Harris. Howard is an extraordinarily gifted orthopedic surgeon who graciously volunteered to serve as the visual image of Dr. Jack Roberts, a character who otherwise exists only in my mind. The background photo is a classic Central American sunrise, and was taken by my dear friend, and very special nurse, Jo Searles, RNC, BSN. When she took this incredible image in the spring of 2016, she had no idea it would be used to represent the hopes and dreams for a new health care system, one based on patients rather than payers. Thanks again, Jo.

My friend, Carol Jennings Peat, of Flagstaff, Arizona, a retired pharmacist and literary genius, once again stepped up to the task of making this manuscript readable. She corrected more spelling, grammar, syntax, and punctuation errors than either of us dared to count. I appreciate not only her corrections, but also her recommendations for improving clarity along the way. She has truly been a godsend, not just for this book, but for each of the preceding novels.

I would also like to acknowledge and thank all my friends and fellow physicians for their continued support of my effort to bring this story of American health care to life on these pages. In particular I wish to thank Dr. Hisashi Nikaidoh, for his kind words of support, some of which appear on the back cover of this book. Dr. Nikaidoh is truly a living legend in the field of pediatric heart surgery, and his book, Healing Hearts, Ambassador International, Greenville, SC, 2013, has provided inspiration beyond words.

Finally, I want to thank my family once again for their love and inspiration. My children, Julie S., Julie L., Ashley, Tyler, Ryan and Chase, are each special to me, and are a source of constant pride. My wife, Donna, has been my constant support for the last thirty-four years, and she remains the center of my world.

CHAPTER 1

The distinctive smells of fresh paint and vinyl adhesives still permeated the hallways of the huge modern structure. The facility had been open for several months but the acrid scents of the ongoing construction had yet to be replaced by the typical medicinal aromas commonly associated with such buildings. The new Parkland hospital had been decades in the planning and was replacing the old Dallas landmark across Harry Hines Boulevard. It had taken more than four years to build at a cost well beyond the billion dollar budget. A number of areas were still unfinished and during the daytime hours men in dusty work clothes, topped with dingy yellow hard-hats, roamed purposefully among the white-coated medical students and residents as the young trainees scurried undeterred around the broad halls of the sprawling hospital. From the outside the building’s architect had done little to reflect the ancient art of medicine. Instead, the harsh geometry of simple rectangular boxes stacked atop one another offered a cold, almost sterile appearance, and reflected what American health care had become in recent years.

It was now after six o’clock as David stared angrily at the computer screen, waiting for it to refresh yet again. The twenty-seven year old, second year surgical resident was eager to log out for the day and go home to his young family, but the most recent upgrade to the vast electronic health record system had slowed everything down to a crawl. He had finished dictating his operative report and typed a brief note in the virtual chart, and all that was left to complete his obligatory tasks was to provide the proper billing codes for his last patient of the day. This was a chore that should have taken less than two minutes, but he’d been sitting in this small cubicle for nearly fifteen, and he’d been forced to reboot the computer twice. Each of his prior attempts to enter the diagnostic code had resulted in the client terminal freezing. He’d followed the steps he’d memorized during the hospital’s mandatory information technology training sessions, selecting what he was sure was the proper code from the more than sixty-thousand diagnoses in the ICD-10 database. He had no idea why the code he’d entered was not acceptable to the system.

I need some help, he pleaded in frustration when the evening shift worker finally answered the help-desk hotline.

Certainly, the woman agreed courteously. May I have your name, and your NPI?

I’m Dr. David Roberts, he replied, before supplying the technical advisor with his National Practitioner Identifier, which had been assigned to him by the federal government shortly after he graduated from medical school. David had quickly memorized the ten digit number after being told that it would be used to track his every action for the rest of his career.

Okay, I have your data pulled up. What seems to be the trouble? the pleasant woman replied.

I’m trying to enter a code for my patient and the system keeps giving me an error, then it locks up. I found what I’m sure is the right code using the standard search feature, but when I enter it the program says the ICD-10 code is not valid and then it freezes. David was trying to sound under control, but he was obviously frustrated and becoming uncharacteristically angry. He wanted to get home to see his seventeen-month-old son before Amy put him down for the night.

What is your patient’s ID number? the woman asked robotically. David read her the eight digit number then waited as she entered it in the system while reading it back to him.

My patient had an empyema, and the code that matches that diagnosis is J89.9, he offered confidently. The national standard for coding all the various medical diagnoses had changed only two months earlier by order of the Centers for Medicare and Medicaid Services. The older ICD-9 system, which contained fewer than twenty-thousand codes, was deemed to be inadequate to capture all the relevant data the government wanted, so it had been replaced by the much more complex ICD-10 list. Claims would no longer be accepted for payment under any government program unless they contained the new codes. Every hospital across the country now employed highly paid coding specialists and made them available around the clock to assist practitioners with the often confusing process, in an effort to ensure payment.

Did your patient have a pyothorax with fistula? she asked, obviously reading from the computer generated list and struggling with the pronunciation of the medical term.

No, David replied emphatically, having anticipated her question. That would have made it a J86.0. He just had a plain, uncomplicated empyema. J89.9.

As he heard her typing in the information he felt compelled to add, I just don’t understand. I’m certain I entered the code exactly the way it appears in the data search. His voice betrayed his overall irritation with the system.

Was this on the right or the left? she asked.

The left, he answered, then added defensively, but I didn’t see any place in the search where that designation was offered.

That’s your problem, she said, her tone turning a bit parental. For any code where laterality is at issue, it is mandatory that you specify which side. You must add a fifth character to the code: a one for the right, or a two for the left.

Why didn’t the coding module say anything about that? David asked, offering what he thought was a reasonable question.

The program assumes you know that, the woman replied sarcastically. It is one of the most basic elements of ICD-10 coding.

When David didn’t reply immediately she asked, Do you need any help with the procedure code?

No, he replied defensively. I entered the CPT code for thoracotomy and decortication of the lung, and the system accepted it.

So, is there anything else I can help you with, doctor? The woman’s condescending tone was now quite apparent as she repeated the phrase she’d been programmed to offer at the end of each help session.

David sighed heavily and politely thanked her for her help. He wanted to say that he had a lot more important things to learn during his five years of training than those damned codes and all the rules associated with them, but he knew better than to raise the issue with this non-clinical hospital employee. She didn’t care about his problems. She was merely fulfilling her own role, insuring the hospital received payment from the government. Parkland, like all American hospitals, relied heavily on government funding, and David had been lectured by every faculty member since his first day of surgical residency about the need to work with the central billing office. Maximizing reimbursement had become the major point of emphasis, especially for this teaching hospital, and this woman was almost certainly being paid more to oversee coding and billing than he was for performing the procedures. Despite being midway through his second year of surgical training, this coding process remained one of the most tedious and time-consuming parts of his job. He wondered if there would ever come a time when he could just take care of patients and leave all this accounting work to someone else.

It was ten minutes after seven when he wearily stepped through the door into the two bedroom apartment, only to find Amy lying on the sofa with her eyes closed. She had finished feeding their young son, and had just put him down for the night. She’d kicked the house shoes off her swollen feet and had fallen asleep with her knees bent in an attempt to take the pressure off her aching back. Dealing with an eighteen-month-old toddler was a full time challenge, now compounded by the burden of her second pregnancy in two years. Both were taking a toll on her young body.

Hey, Baby, David offered softly, prompting her to open her eyes in surprise. As she began the arduous task of shifting around the massive swelling in her abdomen, he added, Don’t get up.

He quickly moved to her side and knelt down as she sank back into the soft cushions. He leaned forward and kissed her tired smile as he placed his hand on her firm belly. How are my girls today?

David was excited by the prospect of adding a little girl to their young family, and for the last four months he’d referred to his pregnant wife as his girls.

She’s been kicking me all day, Amy answered. I don’t remember Jacky being this active. I think she really wants out of there.

Just two more weeks, he replied excitedly.

I keep telling myself that, she replied, but time seems to be slowing down. This second pregnancy had actually been much easier for both of them since Amy hadn’t suffered with any of the nausea and vomiting that plagued her during the first five months she carried Jacky. She’d been unable to work the final three months before he was born, but they managed to get by on David’s residents’ salary and the rental income from his grandmother’s old house in Hurst, Texas. Amy had gone back to work shortly after giving birth, but six months later they found out she was pregnant again, and David insisted she quit her job for good. For the last seven months she’d been a stay at home mom, a job she loved far more than she had ever dreamed possible.

Mom will be here next week, he offered reassuringly. She’ll take care of Jacky so you can get some extra rest.

Amy’s smile betrayed her exhaustion and the hope that this time things would be different. She’d anticipated her mother-in-law arriving a few days before Jacky was born in the summer of 2014, but a horrible accident had changed all that. Elaina had lost control of her car on the rain-slicked mountain pass near their home in Nicaragua, and she’d nearly died from a depressed skull fracture. David’s father had suffered a broken leg in the same accident, so neither of them had been present for the birth of their first grandchild. This time his parents were planning to arrive a week before Amy’s December 17 due date, and would stay in Dallas until after the first of the year.

So how was your day? Amy inquired, trying unsuccessfully to show some enthusiasm.

It was great, David replied, excitedly. I did my first thoracotomy. I drained an empyema.

What’s that? she asked innocently.

I opened up a guy’s chest to drain a collection of pus around his lung.

Oooh, yuck! she replied with disgust.

Yeah, it was kinda messy, but at least I got a chance to do a real chest case, he said. He was nearly six weeks into his thoracic surgery rotation and this was only the third procedure he’d been allowed to perform as the primary surgeon. The other two were thoracoscopic procedures, so this was the first time he had actually ‘cracked a chest’ as the senior resident described it.

David was the first resident to enter into the new accelerated heart surgery training program. Traditionally, becoming a heart surgeon required seven years of training after medical school; five years of general surgery followed by two years of cardiothoracic. Under the new program his formal training would be compressed into only five years by combining the general surgery and cardiothoracic modules. David had accepted the fast-track opportunity, but given what he’d experienced so far, he worried whether five years would offer sufficient training in this highly complex discipline.

*********

The sudden blast of cold came as a major shock to both Jack and Elaina as they got off the plane at DFW airport. A brisk north wind whipped the forty degree air through the narrow opening between the plane and the jetway, sending a shiver through each of the lightly clothed travelers. Coming from Managua via Miami, Jack had packed their coats in one of their checked bags, not anticipating they would need them immediately upon arrival in Texas.

The senior Dr. Roberts had retired rather unexpectedly two years earlier from his practice as a prominent pediatric heart surgeon in Fort Worth. A series of false accusations of Medicare and Medicaid fraud had prompted him to flee the country to avoid arrest and prosecution for things he obviously hadn’t done. He and Elaina had taken refuge in their vacation home on the Pacific coast of Nicaragua. While he’d ultimately been cleared of any wrong doing, he felt the time was right to pursue a different chapter in his life. He’d grown tired of fighting the constant pressures to accept the growing socialist movement in American medicine, so he and Elaina became permanent expatriates, living in the tranquil tropical village of El Transito.

Jack soon realized he wasn’t fit for retirement, and was inspired to build a new children’s heart hospital in Central America. He’d managed to persuade the Nicaraguan government to establish a free enterprise medical zone where he could create a health care system without government involvement. Providing state of the art care to children in that impoverished country had become his new calling. He was also actively involved in developing a revolutionary new surgical technique, and was using the government hospital in Managua to perform a series of clinical trials. For him to be away from his work for three weeks would be a challenge, but he’d promised Elaina she would be in Dallas for the birth of their granddaughter, no matter what.

At fifty-six, Elaina was eleven years younger than her husband, but neither of them looked or felt their age. They’d both become tanned and comfortable with their new life on the shores of the Pacific, but today she was more than willing to brave the North Texas winter for the chance to be beside her son and his wife for the birth of her second grandchild.

Their luggage finally appeared on the carousel and Jack quickly opened the largest of the three bags. He retrieved their coats then headed for the bus that would take them to the Avis facility several miles away.

I’d forgotten how cold the wind could be here in December, Elaina said as she sat shivering on the passenger side of the mid-sized rental car.

I’m just glad we came a day early, Jack offered as he started the engine. The forecast is calling for freezing rain later this evening and for the next couple of days.

Elaina smiled, as her silent shivering offered her only reply. It had been her idea to move their trip up several days, but Jack had resisted based on his work schedule. He’d reluctantly agreed to taking a flight the day before they were originally scheduled, and now it seemed he was taking credit for having gotten them to Dallas before the winter storm hit.

A thick blanket of slate-colored clouds added a shadowless coldness to the familiar, yet somehow foreign environment. Jack remained very much an American at heart, refusing to even consider applying for Nicaraguan citizenship despite the urgings of many of his new friends. He loved his homeland, especially Texas, but like the weather, America seemed to be a colder and less hospitable place than the one he’d left. He’d made a point of keeping up with the news and the politics of the day and he’d grown increasingly discouraged by the overall political direction of his native country, even before his retirement. The next round of elections were a year away, but the campaigns to win the presidential nominations of the two main parties were in full swing. The level of anger and animus among the contenders seemed to penetrate every aspect of American society, with the greatest impact being to increase racial tensions. It was like nothing he could remember. Every news story seemed to involve violence as mobs of protestors took to the streets in opposition to civil authority. It bordered on anarchy in many parts of the country.

The most recent wave of violence had started with looting and destruction of private businesses in a St. Louis suburb almost a year earlier. The violent protests came on the heels of the fatal shooting of a black teenager who had robbed a convenience store, assaulted a police officer and attempted to take the officer’s weapon. The riots had since extended to nearly every major city as allegations of police brutality against blacks prompted racial confrontations even in cases where the accused officer was also a black man. The situation had escalated to a point where the police were being charged with brutality even in situations where victims were caught in the act of committing a serious crime. The slightest suggestion of excessive force by any authority figure resulted in mobs of angry black teenagers and twenty-somethings, arising seemingly from nowhere to burn cars and businesses in a display of random rage. In many cases large numbers of protestors were bused in from hundreds of miles away and paid to stir up violence within the local communities. The national guard had been called out to quell uprisings in eight different states over the last six months. Thus far the rioting had not extended into any Texas cities, but it seemed only a matter of time.

Jack was convinced that this civil unrest had more to do with the collapse of the country’s basic moral foundation than it did race or income inequality. As a youngster in the sixties he’d witnessed what people referred to as public demonstrations against the war in Viet Nam. He recalled vividly watching a news program on his parents’ old black and white television as scantily clad girls with painted bodies were running barefoot through the streets of New York, throwing flowers at passing cars and shouting make love, not war. Those protests were in sharp contrast to the race riots of that same era, which were similar to what the nation was experiencing now. Rioters abandoned all respect for other people’s property and displayed no regard for authority. However, there was one fundamental difference between the protests of the sixties and what was happening now. For the most part, the earlier protests were not aimed directly at the police the way these more recent uprisings were. The rioters of 2015 had made it clear that they were now targeting police officers for what they claimed was rampant racism in every department across the country.

What Jack found most worrisome was the way things were being handled by federal officials. The President along with other high ranking elected politicians seized every opportunity to blame rank and file officers for what was happening rather than supporting them. The effect had been to create an increasing reluctance on the part of law enforcement to take action for fear of being criticized, which only emboldened the rioters. Young black males were now fueled by the knowledge that they no longer needed to fear being arrested or prosecuted. Several left-wing media pundits had gone so far as to suggest the President would be justified in declaring martial law to control the protests, while others were actually recommending nationalizing all state and local police forces.

Are you okay? Elaina finally asked, as she watched her husband sitting motionless, staring out through the light mist that was gathering on the windshield.

Yeah, I’m fine, he said, not willing to trouble her with his fears about the future of both the weather and the nation.

*********

Amy was beyond uncomfortable one week before her due date. She answered the door and was excited to see David’s parents.

Come in, she insisted. I’m so glad you’re here.

Elaina hugged her warmly then asked, Where’s my baby?

He’s taking a nap, Amy replied. He should be awake soon. Take off your coats and make yourselves at home. Can I get you something to drink?

No, we’re fine, Elaina replied as she handed her coat to Jack. You sit back down. Take a load off your feet.

Thanks, Amy replied. I think I will. Whenever I’m up more than just a few minutes my feet swell up like balloons.

Amy laughed softly as she returned to the sofa. She no sooner propped up her feet on the coffee table than she heard Jacky rattling the side of his crib.

He’s awake! Elaina shouted excitedly as she ran quickly into the baby’s room. She greeted her grandson with her usual cooing as she quickly changed his diaper then brought the child into the living room to see his grandfather.

I can’t believe how much he has grown, she said, as she held the confused child away from her body to perform a proper inspection.

You haven’t seen him in six months, Amy reasoned.

Jacky started whimpering and began kicking his legs in protest, prompting Elaina to put his feet on the floor. She’d watched him walking on the videos David and Amy had posted on Facebook, but seeing his four-inch long, curly blond hair bouncing around his ears as he stumbled the few steps to his mother’s side made her giggle with excitement.

He looks so much like David did at that age, she said.

You realize he’s only a few months younger than David was when you and I first met, Jack offered, recalling the circumstances of their initial encounter. He’d been called by his good friend and pediatric cardiologist, Buzz Jackson, to help care for David. At age two, David’s heart had begun to fail rapidly due to a congenital defect. Elaina had recently divorced David’s father, and was raising her son as a single parent with the help of her mother. It was that medical crisis which brought the couple together more than twenty-five years earlier.

I’m so grateful that Jacky is healthy, Elaina replied as she moved quickly over to pick up the young child again, holding him tenderly in her arms.

Me too, Amy added. I hope this little girl will be as well. She looked down and she patted her swollen abdomen.

What did your last sonogram show? Jack asked.

They say she is perfect from all they can see, Amy replied. David made them take an extra careful look at her heart, and he says it looks fine.

Jack knew that most major heart defects could be identified by ultrasound examination well before birth, but two of the more common problems, patent ductus arteriosus and atrial septal defect, could not be diagnosed until after birth. These openings were naturally present in the fetal heart and normally disappeared within a few days after birth. David’s problem had been a persistent opening between the upper chambers of the heart, which eventually worsened and led to his heart failure and the need for urgent surgery.

When do you expect David to get home? he asked.

What time is it now? Amy inquired as she strained to see the clock on the kitchen wall.

Three-thirty, Elaina answered after glancing at the new Apple Watch Jack had given her back in September for her birthday.

He was on call last night, so he should be home any time.

It was nearly four-thirty when David came through the door, exhausted and hungry.

Mom! he exclaimed, as he hugged his mother. I didn’t think you guys were coming until tomorrow.

I talked your father into leaving a day early. I just had to see my little guy again. Elaina said, as she looked lovingly into the innocent face of the child she had been carrying around almost continuously since they’d arrived.

How are you, Buddy? Jack said as he embraced his son warmly.

I’m okay, David replied, without much enthusiasm. A little tired. It was a long night. How ‘bout you?

Jack smiled as he said, Never better.

So how are things going with the new hospital? David asked, eager to hear about his father’s project.

Well, we broke ground last week, so we’re actually slightly ahead of schedule, Jack replied. The rainy season ended a couple of weeks early, so Franco’s road crew was able to complete the first bridge from the highway across the ravine in late October and they finished building the first stretch of the new road that runs in front of the hospital just a month later. He also had another crew clearing the jungle and preparing the pad site, so we were able to have our formal ground breaking ceremony last Tuesday.

How is Mr. Gutierrez?

Same as always, Jack replied, referring to his friend Franco, who was not only the owner of the largest construction company in Central America, but also Jack’s partner in the massive health care project.

Franco had all the news media there for the ground breaking, Elaina added. It was a big deal.

Like everything else Franco does, Jack added with a laugh.

When do you think it will be finished? David asked.

If everything goes as planned we should be able to start seeing kids in the heart hospital in early 2017. Franco said he expects it will take no more than fourteen months, and hopefully the pediatric neurosurgical hospital will open a few months after that.

Wow! It took longer than that just to build the foundation of the new Parkland hospital where I’m working.

Jack laughed and said, Well, our facilities aren’t going to be anywhere near that size, but I suspect we will be able to compete with them, and anybody else when it comes to children’s heart surgery.

How about the MATRICS trials? David asked. He was aware of the clinical research his dad had been performing in the government hospital using a revolutionary new technology called MATRICS. The technology got its name because it was a minimal access totally robotic intra-cardiac system, and was being used to repair problems inside the heart without the need for heart-lung bypass. It had the potential to change the way virtually all heart procedures were performed. The system had been developed by Jack’s brother, Ben. As one of the most brilliant bioengineers in the world, Ben had worked for more than a decade, refining his system, but when it was finally ready he’d been unable to find anyone willing to perform the clinical trials. The legal and economic environment in both the US and Europe made surgeons and hospitals reluctant to even try his new revolutionary system, so Jack had agreed to perform the MATRICS clinical trials in Nicaragua, starting in the old government hospital.

We’ve done a total of ten procedures so far, Jack replied. They’ve all gone very well, and we haven’t had to convert any of them, but I haven’t tried anything all that difficult yet.

How is that kid doing with the transposition of the great vessels? You know, the one that was on your YouTube video. David was referring to the first time his dad had used the MATRICS platform on an actual patient. A local child had been born with a congenital abnormality where the two main pumping chambers of the heart were connected to the wrong arteries. The little girl would have died without some means of ensuring oxygenated blood from her lungs could mix with the blood flowing out to her body. Jack had worked inside the miniature heart using the tiny robotically controlled catheters and the unique camera system to widen the opening between the two upper chambers and place a stent in the ductus arteriosus to keep it open. All this was done while the infants heart was still beating. Although the treatment was only a temporizing measure, it was extremely successful. The extraordinary technology made it possible to accomplish the procedure through a simple needle puncture in the infant’s groin. The following morning the baby appeared healthy and was discharged from the hospital. The local media had hailed the procedure as a modern medical miracle, and Ben’s wife, Elizabeth, had posted a video on YouTube of the television news interview with the child’s parents and local hero, Dr. Jack Roberts. She’d added a link to their new web site designed to promote the pediatric heart hospital which was still in the planing stages. The video had immediately gone viral with tens of thousands of reposts on Facebook and countless retweets on Twitter, spurring intense worldwide interest and financial support for what had come to be known as the Pan American Research Cooperative project.

That baby is doing very well, Jack replied, but we’ll have to go back and correct the defect once she’s big enough. Jack was hopeful the definitive repair could wait until their new hospital was completed, but he also knew that most kids require permanent reversal of the abnormally developed vessels before their first birthday. Fortunately, he now had the ability to do an open heart procedure in the existing government hospital, if necessary. The only question that remained was whether they had sufficient support staff.

Is there any chance you could fix the problem using MATRICS? David asked.

I’ve been racking my brain trying to figure a way to do that, but I haven’t been able to come up with a way to swap the two major vessels while the heart is still beating, Jack admitted. This is one of those defects that we need to find a way of preventing before it happens.

Is that possible?

Theoretically, if we could identify the gene that causes the heart development to become confused, we might be able to fix it in utero, but, like I said, that’s theoretical.

That would be so cool, David replied as he nodded his head.

Maybe that’s something you can take on, his dad offered.

I think I will, David said with a smile, accepting the implied challenge.

Jack returned his son’s expression with his own crooked smile and said, I believe you will.

So what about the other patients? David asked.

They’ve all been pretty straight forward catheter based procedures. We’ve closed a couple of sizable ventricular septal defects and five ASDs in local kids, Jack explained. I guess the most interesting case we’ve done so far was a mitral valvuloplasty on a forty-year-old guy.

You repaired the mitral valve while the heart was still beating? David asked in astonishment.

Sure, his dad replied. Catheter techniques for opening tight valves have been around for a long time, but those blind techniques just tear the valve open by inflating a balloon. What makes this so different is the ability to actually see what we were doing and use a laser to very precisely separate the scarred areas. It was really pretty cool to watch as the value began opening wider and wider, and eventually was functioning normally.

Wow! I would really like to see one of those MATRICS procedures some time.

You will get to do more than see one, Jack replied. Next time you come down I’ll have you help me do one.

David’s face broke into a toothy grin as he said, Really?

Sure. Our hospital isn’t going to have all those stupid restrictions controlling who can come into the OR, like they have here in the states.

I can’t wait, David said excitedly. I’m so tired of watching videos and training on the simulators…

You can watch procedures all day long, but it’s just not the same as doing them, and that’s especially true with the MATRICS platform.

Maybe I should just come down there to do my training.

No, his dad laughed. I think you’d better get the basics here. Makowski knows his stuff and I’m sure he’ll see to it that you get the experience you need over the next three and a half years.

Leo Makowski was the chief of the adult cardiothoracic surgery section at Southwestern and as such was a well respected academic surgeon. Jack was very comfortable knowing David was now under his wing. He didn’t really care for the chairman of the department of surgery, Dr. Steven Wilkinson, but David’s cardiac surgery training in the new accelerated program would mostly fall to Makowski.

So who is managing your patients while you’re up here? David asked.

Dr. Jackson and Dr. Ferguson are minding the store, but I don’t suspect they’ll be doing any clinical trial cases with the MATRICS while I’m gone. George has assisted with a couple of cases, but he’s still getting his feet wet.

Horatio Buzz Jackson was Jack’s oldest and dearest friend. The Alabama native was an exemplary pediatric cardiologist and he and Jack had teamed up back in the mid 1980s during their days in the Air Force. Buzz had followed his friend to Fort Worth in 1988 to develop the children’s heart program there, and more recently he too had moved to Nicaragua, fed up with the direction American medicine had taken. While it had been years since Buzz had cared for any adults, he was certainly capable of handling most routine situations, and if any patients required emergency surgical care George Ferguson could almost certainly provide it in Jack’s absence.

Although George was twenty-five years younger than Jack, the two men had briefly been partners prior to Jack’s sudden retirement. In Jack’s absence George had assumed the role of the primary pediatric heart surgeon in Fort Worth, but he soon found the stress more than he could bear. It hadn’t been the work of caring for patients that had made him quit; he loved operating on babies with congenital heart defects. It was the unrelenting pressure to follow a constantly changing set of financially motivated rules that tore at his own heart until he finally left medicine. He’d returned to Pine Bluff, Arkansas to manage his ailing father’s Ford dealership, but soon found himself in the even more miserable role of businessman.

Jack had urged his younger colleague to come back to the practice of surgery and join him in Nicaragua. He’d promised things would be different, so when George’s father died back in July, it didn’t take him long to sell the dealership to a national consortium and come to Managua. His wife refused to move the family because there weren’t any American schools for the two young Ferguson children, so she remained in Pine Bluff. She reluctantly agreed to let him resume doing what he loved with a man he trusted and admired, provided he come back home every other weekend.

Did I understand you to say that a pediatric neurosurgical hospital is going to be built at the same time? David asked. He knew that a second specialty children’s hospital had been discussed, but the last he’d heard they were still only in the preliminary planning stages.

Yes, Jack replied enthusiastically. We have raised more than enough money to build both hospitals along with a third utility building, which will house our emergency department, all the general radiology and laboratory services, a cafeteria and the laundry. It’s turning into a much bigger project much quicker than I anticipated, Jack added with a sigh.

I’m sure Raphael must be fired up, David offered, referring to the young neurosurgeon who had saved his mother’s life following her accident. Dr. Raphael Ramirez, the son of Jack’s long time friend and local pediatrician, Domingo Ramirez, was seven years older than David. He returned to Managua after completing his training at Johns Hopkins University in Baltimore in the summer of 2014. The young physician had promised his father that he would come back to Nicaragua for at least two years, but he was now a permanent fixture in the local medical community. He was beyond excited by the opportunity to plan and build a state-of-the-art children’s neurosurgical hospital as part of the Pan American Research Cooperative in his home country.

You bet, Jack replied. Raffy and Arielle are both very enthusiastic about building the PARC Children Neurosurgical Hospital.

Did they get married? David asked.

Oh my goodness, yes! Elaina interrupted. You should have seen it.

*********

The mid-October morning held little promise for the kind of weather Arielle had hoped for on her wedding day. The mountains to the East were shrouded in low hanging clouds and a fine mist was falling on the recently erected event tent. She’d planned the ceremony to take place down on the beach with the reception to follow inside the large canvas structure, but if the weather didn’t cooperate it would need to serve both purposes.

Arielle had purchased this prime piece of oceanfront real estate fifteen kilometers south of El Transito shortly after selling her opulent mansion in Managua. The house had belonged to her deceased husband, José Benavides, a wealthy banker and former partner of Jack and Franco in the Nicaraguan Medical Development Corporation. José had been murdered eight months earlier, making the twenty-six-year-old heiress one of the wealthiest women in Nicaragua. Originally she’d planned to buy a smaller beachfront property near Pochomil where she and Rafael had strolled secretly more than nine months earlier. It was there where she had first allowed herself to dream of one day running carefree alongside the man she truly loved.

The shy and hauntingly beautiful Arielle had been miserable before meeting the dashing young neurosurgeon. She had never really loved José and he certainly didn’t love her. He had married her for social convenience and she had foolishly agreed to his proposal at her family’s urging. Her life changed abruptly at a gathering at the Gutierrez estate where the charming Raphael first swept her off her feet. She knew all too well seeing the young bachelor even casually was far from acceptable, but she could not help herself. For the first time in her life she felt alive, and it was Raphael who made her feel that way. She had agreed to go with him on that memorable afternoon, and as they strolled hand in hand along the water’s edge, she finally understood what it felt like to be in love.

Her husband had died along with his mistress in what was originally reported as a murder-suicide. It turned out to be a double homicide during an attempted extortion, but she didn’t care how, she only knew that she was finally free. Her mother had urged her to observe a mandatory period of public mourning, but privately she and Raphael were finally going to be together, and they had been for more than four months.

All the controversy and secrecy was behind her now. She was ready to build a new life with her one true love, and her first thought had been to purchase that stretch of deserted beach. Unfortunately, that property was no longer available. Instead she found this five hectare estate which was much closer to Managua and offered a far superior option for building their home. She imagined a large two story house built high on the cliff above the crashing surf. The site, now occupied by this large tent, was one of the highest points along this part of the Nicaraguan coast, and commanded a spectacular view of the Pacific to the West.

A local crew had erected the tent and built a wooden stairway off to the North side which provided access to the private beach some fifty feet below. Arielle had everything planned out in her mind, if only the weather would cooperate.

I knew we should have waited another couple of weeks, Arielle said in frustration. The timing of the wedding had been the source of considerable debate between the young couple. He had wanted it as soon as possible, but she had wanted an outdoor wedding on the beach, and naturally her biggest concern was timing the event to coincide with the end of the rainy season. Fortunately the region had been rain-free for almost two weeks, signaling the beginning of the dry season earlier than usual. However, this particular Saturday threatened to offer one final exception to the otherwise predictable annual climate change.

I’m sure it will stop raining by noon, Elaina said reassuringly, as the two women arrived back at the Roberts’ home in El Transito. Elaina had offered to help Arielle with her final preparations and the Roberts’ home had become the bride’s unofficial headquarters. That morning Elaina had driven Jack’s Land Cruiser across the eight miles of dirt roads to the sight of the ceremony, which had been strategically scheduled for five-fifteen that afternoon. It had been Arielle’s final opportunity to check on the preparations of the caterer, the florist and the photographer.

As they stepped out of the car, Elaina pointed to a shaft of sun light which had broken through the clouds over the water. It created a shimmering circle of silver on the still waters of the bay. You see, she said excitedly. It’s going to be a beautiful afternoon and evening. Now let’s start getting you ready.

Following Raphael’s proposal, Arielle sold her home to a local banana exporter, along with all the furnishings, walking away with only her clothes and a few personal items. She wanted desperately to rid herself of anything and everything that reminded her of that miserable time in her life. She moved into a suite at the Intercontinental Hotel where she would stay until they were married.

She had initially planned a very simple wedding ceremony with only family and a few close friends, but the invitation list ultimately grew to more than one-hundred. Like all brides, Arielle wanted to look perfect for her husband, so she arranged for a local stylist to do her hair and makeup, and she’d hired Gabriella Gutierrez’s personal Italian dressmaker to create a magnificent custom wedding gown. Elaina had turned their guest room into a temporary salon, and for the next six hours the two women primped and giggled and sipped champagne as the attendants saw to every detail.

Raphael began his day with a trip to the government hospital to discharge his one remaining patient. In preparation for taking a two week vacation for the wedding and honeymoon he had avoided scheduling any surgery. However, five days before the wedding he’d admitted a young boy who had fallen off his bicycle and hit his head on the broken pavement. The eight year old had been unconscious for nearly an hour at the scene, having sustained a linear skull fracture and a major concussion. Fortunately the boy had not suffered any intracranial bleeding and had required only careful observation.

With more than seven hours to kill before he needed to be on the beach in his tuxedo, Raphael found himself pacing aimlessly around his apartment. Eventually he sat down at his computer to check his email, looking specifically for any new correspondence from Dr. Bert Jennings. The older man had told him he would contact the list of surgical vendors to request donations of equipment and supplies for their yet to be built PARC Children’s Neurosurgical Hospital.

As he waited for his computer to finish booting up, his cell phone rang and he immediately recognized the number.

Hello, Dr. Jennings.

Well, are you about ready to take the plunge? Bert asked cautiously.

Yes, sir, Raphael offered with confidence.

She is a very lovely woman, the older man offered. I know you will both be very happy together.

Thank you, sir. Raphael replied, continuing to show his respect for the man who had been his most influential professor during his training at the Johns Hopkins University Hospital.

Don’t worry about anything while you’re gone. I’ll take care of everything until you get back.

The sixty-four year-old Jennings had recently retired from what he referred to as the rat race of academic medicine. He was one of the most experienced and highly skilled pediatric neurosurgeons in the country, yet he was no longer able to mentor the residents and students the way he once had. Mounting federal regulations and university budget constraints had changed his role dramatically over the last few years, making him more an administrator than surgeon, and he hated it. As a full professor he had commanded a great salary with tenure at one of the most prestigious medical schools in the world. He had accomplished a great deal in his career, but like many others he detested what was happening to his profession. He wanted desperately to get back to doing what he loved, and Raphael’s invitation to come to Nicaragua had come at a time when he was particularly frustrated. He and his wife had visited the region several months earlier and he’d heard all about Jack Roberts’ plan to build a group of highly specialized hospitals on the western slope of the Maribios mountains. Initially the whole idea seemed rather far-fetched, but when he learned that Raphael had secured the funding necessary to build a state-of-the-art pediatric neurosurgical hospital, he made his decision to leave Baltimore and follow his own heart.

Bert and Barbara had moved to Nicaragua a month earlier and had taken up temporary residence in an apartment in the same complex where Raphael lived. Dr. Jennings had no problem obtaining a temporary work visa from the Ministry of Health based on Jack’s recommendation, and he immediately started helping Raphael, both in the government hospital and in the private hospital across town. He also volunteered to assist his young protégé in developing a working plan for the new hospital to be built in the free enterprise medical zone, now known simply as the PARC. He’d personally contacted a number of surgical manufacturers in the United States and Europe to secure the latest equipment they would need to bring twenty-first century pediatric neurosurgery to Central America. He’d even convinced two more American companies to relocate their factories to the PARC.

Raphael had found a local woman to serve as both a housekeeper and interpreter for the older American couple, since neither of them were comfortable with the local language. Twenty-five year-old Nadine Montoya arrived at their apartment every morning at eight o’clock sharp and worked until eight each evening, six days a week. She was an extremely bright young woman, having graduated from high school at the top of her class. She had also completed two years at the John Paul II University of Applied Social Sciences in Managua. Unfortunately, her dreams of becoming a social worker had been dashed when the scholarship money she was receiving from the local parish ran out. Born into poverty, as was the case for so many Nicaraguans, her opportunities to rise out of the barrio were limited, even with an education. In addition to her domestic chores, she tutored her American employers as they learned Spanish, and for this she was paid the princely sum of fifteen dollars a day.

I discharged that boy with the skull fracture this morning, Raphael stated. So I don’t have any patients in the hospital for you to worry about. He spoke to his old professor just as he had when giving his daily reports throughout his years as a resident.

Do you need me to see him back in your office next week?

No, sir. That family lives about twenty kilometers east of Managua, and they have no means of transportation.

How did he get to the hospital to start with? Bert asked.

The boy and his mother hitched a ride into the city in the back of a produce truck, Raphael replied. He should have come by ambulance, but there aren’t any emergency vehicles in the community of Tipitapa where they live.

Sounds like that may be one of the first things we need to address, even before we finish the hospital.

When Bert first arrived at Hopkins thirty-five years earlier, ambulance services were beginning a critical transformation. For decades most communities had only one or two small privately owned ambulance services, and the personnel were often poorly trained and functioned as little more than pick-up and delivery drivers. As a result, a significant percentage of major trauma victims received little or no care at the scene and often rolled into the hospital emergency room only to be pronounced dead on arrival. Hopkins, like many other training hospitals had developed their own ambulance service back in the 1950s to bring emergency patients into their facility from the surrounding communities. They also trained their drivers and technicians in advanced first aid, many of whom had served in World War II as medics. The result had been a significant increase in the number of patients arriving in conditions that were at least treatable.

The nearby University of Maryland teaching hospital had taken the process a step further. Dr. R. Adams Crowley helped create the Shock Trauma Center, the first dedicated trauma center in the United States. Other hospitals, like Hopkins, responded by developing their own trauma teams, headed by either a general or thoracic surgeon, and supported by all the various surgical sub-specialists. Eventually, trauma surgery developed into an accepted specialty as major hospitals across the country sought to become recognized trauma centers.

That’s going to be a major challenge here, Raphael said. Currently there are only three or four ambulances in the whole country, and they are all here in Managua.

Well, like I said, Bert replied. That is something that will have to be addressed if we are going to treat kids with head trauma.

*********

Amy shifted her body awkwardly on the sofa, as her facial expression revealed a new level of discomfort.

Are you okay, dear, Elaina asked, as she paused momentarily from delivering her account of the recent events in Nicaragua.

Yeah, the young mother replied tentatively. I think this little girl has decided it’s time to stretch her legs. She’s kicking like she wants out, now.

Can I get you anything? her mother-in-law asked, clearly concerned for Amy’s comfort.

No, she replied. I just need to move around a little and she’ll settle down.

The twenty-seven year-old leaned back against one of the throw pillows and moved her swollen feet from the edge of the coffee table over to the sofa, trying unsuccessfully to find a more comfortable position. She arched her bulging abdomen forward as David placed another small pillow under her back in a vain attempt to relieve the pressure.

Thank you, she said with a forced smile before turning back to Elaina and asking, So, did they get married on the beach?

CHAPTER 2

As Elaina had predicted the dreary overcast began clearing before noon, and soon the deep blue sky was interrupted by only a few scattered puffs of white. Elizabeth arrived at the house with Ben at one o’clock so that she, too, could get her hair and makeup professionally done in preparation for her role in the ceremony.