by Chris Bauer
“You are a liver specialist, Doctor?”
“I am a transplant surgeon who specializes in the liver, but I perform other organ transplants.”
Wally began. “I’ll pay you per transplant. Handsomely. Outgoing and incoming. I provide the donors, the recipients, the facility, and the support staff. You supply the scalpel. Magpie, your help here, please.”
“Sir?”
“Please pull up our operation on your phone and show the doctor.”
Magpie hit a few keys, a significant achievement considering how meaty his dark hands were. He reached across the desk to show an image to the doctor. On the screen was the picture of an exterior storefront in a strip mall, the marquee showing shadowy evidence of a sign for the prior occupant’s business, a local health services company. The tall windows were papered over except for the real estate “For Lease” sign in one corner.
“One of a few around the islands, Doctor. Short-term rentals from retail space lessors desperate for cash flow. Magpie?” A few swipes by Magpie’s paws brought up pictures of the empty interior.
“I’m renting it. As a warehouse for my planned Kauai import-export medical supply business.” Wally’s sardonic smile and air quotes betrayed the lie. “It looks quite different inside now. This one’s proximity to the airport sold me. Convenient for well-heeled clients who want easy and discreet island entry and exit. So let’s head to my car, Doctor, where we can talk about the specifics of the surgeries. Have you cleared your schedule for this afternoon?”
“Yes.”
“Excellent. Let’s head to Lihue so I can show you the operation, shall we?”
Wally being a good host, the ride south along the coastline in the backseat of his limo included snacks and beverages. Magpie drove, the window between the front and rear seats open so he could participate in the conversation if needed. Wally popped the cork on a bottle of champagne, filled a glass flute, and offered it to the doctor.
Dr. Rakoso hesitated—“Your celebration is a bit premature, Mr. Lanakai”—but after Wally’s second attempt to hand it to him, he accepted. Wally launched into his pitch.
“An operation small enough not to draw attention to itself. This one can handle the surgery on both sides, donor and recipient. The recipients are pampered. We treat the donors well enough, but not like my paying customers.”
“Then let’s talk about the recipients first,” Dr. Rakoso said. “I assume they’re on transplant lists somewhere.”
“Ha. Why yes, yes they are, and I’m tapped into them. But once I talk with them, they’re added to the only organ availability list that will get them results in the time they want, or need: my list. Very exclusive. One my group manages itself.”
“I don’t understand.”
“You will in a bit. Let me start by explaining that my transplant recipients are extremely wealthy, Doctor. They’re typically older and have led indulgent, visible lives. Many of them have lost a step or two, but not all of them. They travel in the best of circles in all walks of life. Industrialists, entertainers, politicians, financiers, former athletes, and interestingly enough, some are doctors like you. The only real requirements I have are they must be able to afford the cost of the transplant without financial assistance, and they must remain discreet.”
“So they’re recipients who are bypassing their health insurance. That sounds like their surgeries are elective.”
“For most, yes,” Wally said. “But a few are too sick to wait on hospital-curated transplant lists.”
“So they go to the black market.”
“An oversimplified explanation, but close enough.”
Dr. Rakoso studied the bubbles as they rose in his champagne glass while he assessed Wally’s answers. He took another sip, then set his half-full flute down in a cup holder, out of the way.
“No more with the twenty questions, Mr. Lanakai. Give me all the details start to finish in one summary. Whatever you think I need to know to get me to sign on.”
“Fair enough. First, call me Wally. May I call you Umberto?”
“I’d rather you stick with ‘Doctor’ for the time being. So tell me what this is all about.”
Wally stayed on the recipient side of the equation to start. He, Wally Lanakai, had created a clandestine market for liver grafts, for people who would die without them, but also for indulgent people with a different agenda.
“The living-donor liver replacement approach,” the doctor said, familiar with the procedure. “The donors give up only a portion of their liver.”
“That is correct, Doctor. In this model, thirty-three percent of the liver is all we need. The donor’s liver will regenerate itself and return to its normal size. The alternative, full liver transplants, would leave the donors quite dead, if they weren’t dead already. This increases my pool of available livers. So aside from donors who suddenly check out, the ones in my business are all voluntary, and I pay them very, very well. And I would do likewise to the doctors performing the surgeries.”
The human liver. Also known as the human chemical factory for its ability to change internal substances into other substances that the body needed, by filtering the blood coming through the digestive tract. It also neutralized substances that the body needed to avoid.
“The recipient patient is taking a helluva chance,” the doctor said. “Grafting onto an existing liver doesn’t always work.”
“And in many instances,” Wally said, “there’s nothing wrong with the recipient’s liver.”
“Grafting onto healthy livers with other healthy livers? A big risk. Why do that?”
“It’s a risk worth taking for these people,” Wally said, about to drop the bomb. “Here’s why.”
No Alzheimer’s or other dementia, no polio, no measles, no mumps, no chickenpox, no AIDS. Pandemic-proof and disease-proof, generation after generation, Wally explained. The most enviable medical legacy on the planet in one small package, the human liver, as long as the liver graft came from someone native to one oddly idyllic Hawaiian island: Miakamii. Either from native islanders still living there, or from natives who emigrated elsewhere.
“Miakamii’s generational seashell thing,” Dr. Rakoso said. “I’ve heard it all before. A wonderful old wives’ tale. I admit the statistics are compelling. But medicine is far from embracing—”
“Medicine doesn’t need to embrace it,” Wally said, annoyed, “only my customers need to, and so far the reception has been outstanding. The statistics don’t lie, Doctor; the research bears it out. These organ donors don’t have these diseases, and they convey their immunity to the recipient. Apparently none of their Miakamiian ancestors had these diseases either. That’s what my customers see. And best of all…”
Dr. Rakoso sat transfixed. For the organ recipients, people who had money to burn, perception had become reality.
“… these livers can reverse age-related cognitive decline.”
“That’s preposterous. Cure patients of their Alzheimer’s?”
“You betcha.”
“Show me.”
Wally called to the front seat. “Pull over a moment, Magpie. Send me the list.”
Wally read from Magpie’s email. Four names, all prominent people who were highly visible: one old-money female socialite, one aging rock ’n’ roll diva, one retired senator, one actor. All had been on the slippery slope dementia-wise, well documented by family members. Over the past few months alone, all had come to Hawaii when called by Wally, and all left with partial liver grafts. “I have their contact info. I can get any of them on the phone. They will each vouch for their progress, or they have people who will do so for them.”
Dr. Rakoso studied the names. He knew these people. Media darlings plus other people who were very visible. Below the line were more names. “You have a waiting list?”
“Yes. Like I said, my own list. Separate, and very exclusive.”
The doctor counted the names; more than thirty, most of them public figures.
; Wally pushed. “I can keep you as busy as you’d like, Doctor. I could become your biggest financial crowdfunding supporter. This is cutting-edge stuff. Sometime after this business gets its legs, the medical community will learn about it, embrace it. At that point there will be no reason for physician anonymity. On the contrary. The doctors performing these surgeries might even get heroes’ welcomes.”
They crossed into Lihue’s town limits, passing through plantation farmland once ripe with sugarcane but repurposed into grazing lands for roaming livestock, the local sugarcane industry gone. The cattle huddled under a few trees to keep out of the sun, grazed while their tails swished, were disinterested in the passing limo. Dr. Rakoso mirrored their disinterest, remaining quiet.
“Tell me what you’re thinking, Doctor.”
“I’m doing the math.”
Wally had a good idea what was in his guest’s head. What it would take to accomplish a goal. The number of surgeries, price per, etc. Plus the risk.
“One other aspect to help you with your decision, Doctor, after we work out the financial details. If anything goes south—cops, loss of a patient—your response to law enforcement and the medical community would be that Ka Hui forced you into this arrangement. And we would validate that assertion. You have my word.”
Dr. Rakoso retrieved his champagne glass from the cup holder.
The doctor might have thought he was still on the fence, undecided, but his sips from the glass, embracing his host’s hospitality, told Wally his pitch had connected.
The Escalade claimed a parking space that faced a storefront window papered over from the inside in brown, like an overnight package. They exited the limo, straightened themselves out, and entered the shade of the overhang. The storefront was wider than it appeared in Magpie’s cell phone photo, looked to be about the size of…
“An urgent care facility?” Dr. Rakoso said.
“A pain management clinic. Hell, why bother with the charade, it was a pill mill. A few sensational ODs by former patients put them out of business. Before we go inside”—Wally’s congenial expression turned serious—“tell me here and now that what you’re about to see, you will share with no one.”
“A verbal non-disclosure? Sure, no problem.”
“Too cavalier. You must remain discreet, Doctor. Otherwise…”
“Fine. Dire consequences otherwise. I get it. You have my word.”
They pulled at the glass-door entry and filed inside the single-story building. Two large men worked the lobby’s front desk, their attire casual: loose-fitting tropical shirts, gabardine trousers, boat shoes. How much of what the clothing covered was girth and how much was concealed weaponry was indistinguishable. The men nodded, their expressions blank; they returned to their phones.
“Nurses’ station, coming right up,” Wally said.
The station functioned as a nerve center, its three walls cloaked with medical supply parts hanging on pegboards, standing oxygen tanks, shelved respirators, and more, outfitted to look like a parts desk at a warehouse yet it still performed its original duties.
“’Sup, gentlemen?” A tiny, elderly Hawaiian woman in a pink smock over nurse scrub pants looked away from a desktop computer. She rose to greet them from behind the counter.
“How is our patient doing today, Nancy?” Magpie said.
“One day into post-op. Our associate madam justice is doing splendid. And at her age, mind you,” Nancy said, beaming. “She leaves tomorrow for the medical spa. No signs of organ rejection, and she’s convalescing well. Her children are beside themselves at how much more coherent she’s already become. And she’s stopped having lengthy discussions with her deceased husband. All appears well.”
Dr. Rakoso’s eyebrows rose. “Am I supposed to believe you have Supreme Court Justice—”
Wally held up his hand. “No names. You may believe whatever you want, just don’t share it with anyone. Let’s move on. I’ll show you the operating theater, then we’ll come back out here and talk.”
He stopped them with a raised hand in front of a set of swinging doors. “All surgeries are performed here. It’s a sterile environment.” He pointed to bins on a table next to the entrance. “Gloves, masks, footies. Let’s suit up, Doctor. Nothing is in session, but keep your hands to yourself when we get inside.”
What was once a spacious meeting room had been repurposed with operating room essentials, intensely bright lighting, and two sets of everything. Wally gestured left, then right.
“A simple arrangement,” he said. “Donor surgery on one side, recipient surgery on the other.”
“Screening?” the doctor asked.
“For recipients, it’s based on family physician statements and recommendations. The donors are prescreened at another Kauai clinic. A standardized evaluation process including a psych eval. They’re one hundred percent voluntary.”
One very noticeable machine sat in a corner. “A hotdog cart?” Dr. Rakoso said. Transplant surgeon parlance for a heart-lung machine. “You’re doing other transplant surgeries here?”
“Exclusively livers, but shit happens. As circumstances present themselves, the surgeons may need to improvise.”
“Which means you’ve lost patients,” Dr. Rakoso said, his wince noticeable, “and you’ve harvested other organs.”
“Yes. So far, not here. On the mainland, in Philly. The nature of the beast, Doctor. You know that.”
The doctor moved onto a different topic. “Tell me about post-op care.”
“Some patients receive it right here, on site, from a few surgeons beholden to me. Most patients prefer getting it from their own doctors, privately, elsewhere on the islands.”
“The donors?”
“Paid for by the organ recipient, even lost wages. A week at a special health spa with medical oversight. No heavy lifting for—”
“Six to eight weeks. I know.”
More stops, at a scrub room, a kitchen with a freezer, and a rear storage room with access to an alley, then came Wally’s redirection as host and tour guide: “Let’s head back out front so we can talk.”
Wally’s arm found its way around the doctor’s shoulder as they walked. He made a final push.
“I won’t ask you what you think, Doctor, I already know. The site is basic, the equipment minimal. The clientele, however, is impressive. You are intrigued, you like the trailblazing surgical procedures aspect, the potential long-term medical community recognition you will receive, but you’re still apprehensive. So let me make this simple.” A friendly shoulder squeeze. “I will pay you a hundred grand for each surgery, donor or recipient. You do both ends of the transplant, that’s two hundred K in donations for maybe eighteen hours of surgery, tax-free. That should put a dent in your legal fees. Sound good to you?”
They emerged from a hallway, passed tiny Nancy at her nurses’ station, and reentered the lobby secured by its two casually dressed guards who perked up at their entrance. Wally put his hand out there for the doctor to take, confident a deal was only a handshake away.
Dr. Rakoso accommodated him. The doctor’s congenial smile became a straight face. “This isn’t a yes, Mr. Lanakai. I’m going to need more time.”
They were sharing a moment, their hands pumping, the guest trying to remain gracious, the host doing his best to remain calm after not having closed the deal. An ear-piercing car alarm blared—honk, honk, honk—ending the mood. Magpie hustled to the front door and jammed his face into the slice of sunlight visible through a separation in the paper. In his line of sight was Wally’s gold Escalade, in the parking space fronting the store.
“The hood of your car, boss… someone left something on it…”
Magpie blasted through the entrance door with enough bad intent it should have left its hinges, his handgun out of its shoulder holster. His head swiveled as he scanned the perimeter, soon resettling his focus on what sat on the car’s hood: a cheap white Styrofoam cooler.
Wally and Dr. Rakoso followed him outside,
the three of them staring the cooler down. Magpie holstered his gun, then pulled the cooler off the car. They surrounded it on the blacktop. Wally grunted an order at Magpie. “Open it.”
The loose lid aside, inside was pretty much what Wally expected would piss him off: dry ice, chunks of it, enough to protect its contents. The edge of a clear plastic zip-lock bag poked through the top layer, the contents submerged. Magpie lifted the bag out with a bare hand, quickly laid it on top of the dry ice. They leaned in.
“A human liver,” Dr. Rakoso said. “Complete, not a partial.”
Magpie drew his handgun again, used the barrel to check through the dry ice chunks to see if there were any other gifts inside. He found a yellow envelope clasped shut against the side, nothing else.
“Give me the envelope,” Wally said.
Magpie complied. Wally slid out a single piece of paper and read the message aloud. “TYPE O. UNIVERSAL DONOR. TWO HOURS FRESH. HAVE A NICE DAY — Y.”
This secret-admirer-organ-donation bullshit had run its course for Wally, with him being a beneficiary now two times over. “Who the fuck is ‘Y,’ goddamn it!”
On cue his phone chirped. He read what was on the screen in silence.
“What is it, boss?” Magpie asked.
“A news story and a text. This SOB took out someone in Kapaa,” Wally said. “This is his liver. The bastard’s taunting me, Magpie. He’s got my phone number and is playing me…”
Magpie pulled up the news story on his own phone. “A street performer. The story’s an hour old. Someone tossed his body out of a moving car”—Magpie paused—“outside a restaurant. The report says he’s a native islander from—”
“Miakamii,” Wally said. “The text says he’s Miakamiian.” He exploded, throwing his phone with severe malice against the asphalt, its plastic frame splintering. When it stopped bouncing he jammed his heel into it, crushing what was left.
Magpie read more of the story. “Already the news people are making a connection, boss. ‘Second Miakamiian murder in three days.’ ‘Miakamii bodies are piling up…’”