An Open Heart

by Harry Kraus

  Jace shrugged. “I’ve never even seen one.”

  “I guess I’ll just have to show you how.” His voice was pleasant, but his expression gave a clear message: Worthless subspecialist!

  As Dave went off to start the head-trauma patient, a nurse came out of the second operating room. “I have the patient’s spinal in. We are ready for you to drain the abscess, Dr. Rawlings.”

  Jace wished he’d had a chance to look the procedure up. He took a deep breath. Hey, I can do cardiac valve surgery. How hard can this be?

  He followed the nurse into the room to see the male patient up in stirrups as if he were ready to deliver a baby. At least the problem was obvious. An angry reddened swelling looked ready to burst. Jace nodded at a scrub assistant. “I’m Dr. Rawlings. First day,” he added, shrugging.

  “My name is Michael. The scrub sink is out there.”

  Jace stepped back into the hall and began scrubbing his hands at the sink. In a moment, Dave Fitzgerald joined him. “This ain’t heart surgery, Jace. You can stop scrubbing now.”

  He felt his face flush. He stepped to the door. Wow, he thought. If only my cardiothoracic surgery partners in Virginia could see me now. Big American heart surgeon draining a perirectal abscess. He chuckled at the irony. Surgery could be humbling stuff.

  He pushed open the swinging door. It’s just a test, Jace. They want to see what you’re made of.

  He positioned himself between the patient’s legs, and the assistant handed him a knife. Thank God for an assistant who knows what to do.

  He felt the skin, tense and stretched over the abscess. He stood with the knife poised over the skin. Here goes nothing.

  He stabbed the skin, releasing a large amount of pus. He smiled behind his mask. Just like riding a bike.

  He stood looking at the operative field for a moment, saying nothing. The tech asked. “Would you like to irrigate?”

  Sure, that’s the next step. “Irrigation,” he said.

  He irrigated the wound and applied a gauze dressing. Standing back, he mused how as a heart surgeon he had dreamed of coming to Kenya to do open-heart surgery—high-tech, critical operations. Yet here he was doing what many surgeons would consider the most basic and useful of operations: the evacuation of pus. His dreams were being downsized, one notch at a time. First, an overnight in the local jail, suspicions of local Kenyans inside and outside the government, and now, an opportunity to operate at last—and what do they give him to do? Butt pus, the bane of all surgery.

  He walked out and washed his hands again before walking into theater number one. There, Dave Fitzgerald was instructing the intern over a sleeping patient.

  “The dilated pupil indicates increased pressure inside the skull, likely from a bleed. Where do you make the first burr hole?”

  The intern was confident. “Temple area, above and in front of the ear.”

  “Which side?”

  “The side with the dilated pupil.”

  “Correct. What if both are blown?”

  “On the side with the pupil that blew first.”

  “Okay. If you don’t find blood at the first burr hole, where do you drill next?”

  “Occipitoparietal.”

  “The third hole?”

  “Frontal, at the hairline.”

  “Excellent. What’s the prognosis?”

  “If we are quick to drain the blood before there is serious damage, the reversal of symptoms and the recovery can be very rapid. If all we do is a burr hole, the intervention is quite minor. He could be normal in a week or two.”

  Jace listened intently. Yes, I know that from personal experience. He wished for a piece of paper. He needed to be taking notes. The intern knew more about head trauma than he did. The last time he’d treated a head-trauma patient, he was an intern at the University of Virginia—and there, they had a CT scan to show the surgeon exactly where to drill. Here, out in the middle of remote Africa, the surgeons had to rely on physical findings and the patient’s clinical course in order to decide when and where to drill. Without the advanced technology available in the West, the surgeons in Africa had to be better than their American counterparts. That thought was new for Jace.

  His gut tightened. How would he ever be able to face everything that came through the casualty doors when he was on call? Who was he fooling? Certainly not himself.

  When the surgery pair started drilling the first burr hole, Jace was mesmerized. He raised his hand and explored the tender scar well hidden beneath his hair.

  It had only been eight weeks since he’d been the patient in an identical operation.

  An hour later, after the lights in the operating theaters were out and the orders were written, Jace exited the hospital beneath the expanse of the African sky. He felt out of control. He longed for cardiac cases, where he knew what to expect and where he enjoyed ruling his small kingdom. But here, he felt alone and on unsure footing. Why does everything have to be so hard? He raised a fist to the sky.

  And listened.

  Around him, a chorus of crickets faded to background noise as he tilted his head, turning an ear to a silent, mocking sky.

  There were no answers beyond the accusations in his own mind—the guilt that drove him, occasionally with the sharpness of a surgeon’s scalpel, but always with a dull emptiness asking for satiety that never came.

  Then suddenly, he laughed. Not from joy, but from the irony of a tiny speck that dared lift a fist in the face of the universe.

  And Jace knew, as certainly as he understood the complexities of the physical heart, the muscle he’d dissected a thousand times, that the heartbeat of his soul had faltered along the way.

  He’d been avoiding a confrontation with the source. He lowered his fist and slowly opened his hand, watching an involuntary twitch and pushing aside a doubt about his readiness.

  Beneath the twinkling of the night sky, he again turned toward the cemetery.

  A few minutes later, he entered the graveyard via the dirt path leading from the hospital parking lot toward the housing units on the other side. As was so typical for Kijabe, cool wind rose from the floor of the valley and swept across the edge of the Rift Valley escarpment, battering the leaves into rhythmic applause. The grass was tall and needed cutting, something that would be done by hand with a Kenyan sickle. Gravestones, mostly small, some leaning as if they were burdened with age, stretched in rows on either side of the path. Rows of dead patients. Rows of the missionaries who came to serve on the African continent, lives given unfairly and prematurely to malaria, typhoid, and Rift Valley fever.

  This, to Jace, was the ultimate slap in the face. What kind of divine message was this—that sacrificing a life for God would mean the loss of loved ones in return? Parents had come to Africa, filled with glorious hope of converts; instead they had buried their children.

  He slowed his pace, aware of the moonlit shadows of tree limbs dancing on the ground in front of him. They swayed to a funeral march. Two-thirds of his way through the field of death, he paused, looking at the branches of a eucalyptus. Hands lifted high toward a distant God.

  Jace turned, his heart quickening. He moved forward, his legs parting the tall grass. Ahead of him, and to the right, a blur of fur startled him. A mongoose had been digging at the foot of a gravestone. He took a deep breath and continued, counting the stones from the edge of the path.

  At twelve, he stopped and leaned over a flat stone. He knelt in the tall grass and began to brush away the dirt from its surface, his hand trembling.

  “Janice Elaine Rawlings,” he whispered, tracing the letters with his finger.

  “O-okay,” he stuttered. “I’ve come back. Now what?”

  Twenty meters from the edge of the cemetery, Lydia Otieno leaned over the kitchen sink and squinted at the outline of a dim figure in the moonlight. “John,” she said. “I think you’ll wa
nt to see this.”

  The chaplain rose from his chair, switched off the kitchen light, and stared out beyond a row of bougainvillea. In the cemetery, a solitary figure knelt over a grave marker.

  “It’s Dr. Rawlings,” he said softly.

  His wife nodded and placed her hand on her husband’s shoulder.

  “The battle is beginning,” he whispered. “We need to pray.”

  Other than the day of her burial, this was the first time Jace had dared visit his sister’s grave, had dared to confront his painful past.

  He didn’t know what to expect. A voice perhaps? Another vision?

  Instead, what he experienced was an amplification of the jumbled noise he’d carried around for so many years. Guilt. His parents’ loss. He cupped his hands over his ears and rocked forward, with so many voices echoing within him. His father’s voice. All things work together for good. His ways are higher than our ways. Platitudes that spoke to the mind but not the heart. Janice’s scream as she fell.

  He shook his head in a vain attempt to silence the memories. “Janice. I’m so sorry, I’m so sorry, I—” his voice cracked— “am sorry.”

  A world away in America, he had pushed hard in pursuit of career and professional reputation. As long as he did, his guilt withdrew into the background, a nuisance, nothing more. But all of that changed when he met Anita Franks. Something about her brought Janice to his mind. She was fresh, different from Heather, and apparently open for play. And so, guilt slipped off its background perch and began an assault for recognition.

  He wouldn’t have recognized that he’d planned a medical mission to Kenya to soothe his conscience. But it wasn’t always easy for Jace to see the obvious.

  The grave marker in front of him was flat, with little to distinguish it from the others. But for Jace, it seemed to loom like the Washington Monument over the Mall.

  “Dr. Rawlings.”

  Jace recognized the bass voice of John Otieno and looked up.

  “I live just over there and saw you. Is everything okay?”

  “Sure.” He stood. He wanted away from the big man, but the chaplain stood between Jace and the way back out of the cemetery. He stepped to the side, but John moved to block him. Jace sighed and looked back down at the grave marker.

  “I remember Janice,” Otieno said. “I used to chase her out of the hospital after hours. She was always hanging around watching your father.”

  “From the time she was in the first grade, she always said she wanted to be a surgeon.”

  The chaplain nodded and smiled.

  “She wanted to come back here, be a missionary surgeon.”

  “And you?”

  “My desire to enter medicine came later in life. In college.”

  The old chaplain chuckled. “When you were here, all we heard about was Jace and rugby. We thought you’d anchor the first American team in the World Cup.”

  Jace smiled and looked at the large Kenyan. A fine spray of wrinkles dignified his face. Whatever wear and tear his skin showed, he’d earned the right to wear it through years of hard work and his share of tears over the troubles of his people.

  “This is it, isn’t it, Jace?”

  “It?”

  “The reason you came back.” He knelt beside the grave. “The answer is right here.”

  Jace choked on the apple in his throat and swallowed hard. “Janice asked—” he paused, then rephrased his thought—“would have wanted me to do this.”

  10

  When Jace finally went to bed, his mind refused to rest. He thought about all he’d seen in the operating rooms, especially how deftly the surgeons had dealt with the intracranial bleeding for the head-injury patient. And that brought back a mental rehearsal of all that led up to his own similar injury not long before.

  He’d been on call the night governor Stuart Franks felt sudden chest pain and collapsed at a fundraising dinner for Virginia’s Special Olympics. By the time Jace was called, the governor was clearly in a fight for his life. Jace walked past the bodyguards on his way into an ICU room crowded with two nurses, a respiratory therapist, and two cardiologists.

  Dr. Robert Hawthorne looked up. “Hey, Jace, thanks for coming.”

  Governor Franks was fifty-five, overweight, and lying in a tangle of monitoring cables and drainage tubes. He was unresponsive except for the rhythmic rise and fall of his chest with the mechanical ventilator. His blood pressure, recorded on the monitor, was seventy systolic.

  Cardiologist Hawthorne pointed at a portable echo machine at the bedside. “He’s had a massive MI. I cathed him, was able to open up a 90 percent LAD lesion and a second 80 percenter of the circumflex. Problem is, he’s developed an acute mitral regurgitation. Seems to have ruptured attachments to his mitral valve.”

  The second cardiologist, James Green, nodded. “With maximal pressors, we just can’t get his pressure up to snuff. He’s barely staying out of heart failure. As it is, we had to sedate him and put him on the ventilator just so he could be oxygenated.”

  Jace studied the monitor screen on the ultrasound machine. Slowly, he replayed the video. “Wow. Look at this,” he said, pointing at the screen. “You can see his mitral valve leaflets just flopping in the breeze, totally uncoordinated.”

  “He needs a new valve. Tonight. I’m afraid he won’t last the night if we let this keep on.”

  Jace took a deep breath. “Agreed. Has anyone talked to his wife?”

  “On and off all evening,” Hawthorne said. “She’s in the waiting room with her husband’s chief of staff, Ryan Meadows. Come with me, I’ll introduce you.”

  The cardiologist led Jace down the hall from the ICU to a private seating area that they used for patients’ families. When he pushed open the door, Jace peered in to see a young, fit, bottle-blonde Anita Franks leaning forward and holding hands with Ryan Meadows. Jace’s first thought was that this was the governor’s daughter.

  “Mrs. Franks,” Dr. Hawthorne began, “I’d like to introduce you to Dr. Rawlings. He’s a heart surgeon.”

  This was the wife, then. She released the hand of the chief of staff to reach out to Jace. “Anita Franks.” Her voice trembled. “A surgeon?”

  Jace nodded. “Your husband’s heart attack has damaged his mitral valve, the valve between the main pumping chamber, the left ventricle, and the left atrium, the chamber that receives the blood back from the lungs.” Jace unfolded a laminated card he kept in his coat pocket and pointed. “Here,” he said. “The heart attack has injured the valve so that it is now incompetent. What that means is that blood is allowed to flow in two directions across the valve instead of just one.”

  Anita Franks nodded.

  “Instead of allowing blood to flow only into the main pumping chamber, the left ventricle, blood sloshes back and forth across the valve, so that extra blood is pushing back out into the lungs.” Jace paused, searching her face for clues of understanding.

  “That’s why he’s having such a hard time breathing?”

  “Exactly.” Jace sat across from the duo so that he would be at eye level. “We need to replace the valve with a mechanical one.”

  “When?”

  “As soon as possible. The heart doctors are doing everything they can, and your husband’s heart is failing. I fear that if we don’t replace the valve soon, we may lose the only window of opportunity we have.” Jace paused again. “Without surgery, he may not survive the night.”

  “And with surgery?”

  “I won’t sugarcoat it. This is very risky. But I’d give him a fifty-fifty chance with surgery.”

  Anita looked at Ryan.

  He touched a graying sideburn of his perfect hair. “It’s your choice, Anita.”

  She squirmed and tugged at the edge of a too-short skirt. “I have to give him the chance.” She looked at Jace, her eyes pleading. “Do what you h
ave to do to save my husband.”

  On Monday, Jace went to the hospital early and found his assigned intern on the Wairegi ward, the men’s ward named after a generous male patient. Dr. Fitzgerald had divided his service, handing Jace a few post-op patients so he could share the load.

  Jace looked into the bright face of his intern, Dr. Paul Mwaka. Paul held out his hand. “I hope that you will allow me to assist in heart surgery.”

  Jace found himself chuckling. “I only hope we’ll be given the chance.” He paused, looking at a stack of charts. “Can you introduce me to the patients?”

  Paul nodded and lifted the top chart. Lean, mostly legs and lungs, he was built like he’d be at home running a marathon.

  As they worked through the list, Jace couldn’t help noticing the reversed role. He was the attending surgeon, but the intern was teaching him. Fortunately, Paul was experienced, and Jace deftly stepped around his own lack of knowledge by assuming the role of teacher: He questioned the intern. But instead of testing him, Jace was learning.

  The first patient on their rounds had had prostate surgery the day before. Jace felt his gut tighten. He’d had a total of one month’s training in urology years ago during his own internship. “Do you want to stop the bladder irrigation?”

  Paul shook his head. “Not yet. We’d better wait until the urine isn’t so red.”

  “And what might happen if you stop the irrigation too soon?”

  “The catheter may get clogged with a clot, causing the bladder to leak through the suture-closure.”

  Jace nodded as if he’d known the answer all along. “Of course.”

  The intern handed Jace a chart. Jace reached for it with his left hand, and the chart slipped from his grip and landed on the floor, opening the two-ringed binder and spilling the papers. As Paul hurried to collect the papers, the intern apologized. “Pole sana,” he said softly. I’m so sorry. It was Kenyan custom. Apologize even when it’s not your fault.