Olive green sheets draped the young woman’s body, except for a small area in the center of her chest. There, the sternal retractor spread apart the two halves of the sawed breastbone to reveal the beating heart. Dr. Joe Morales wasn’t assigned to this room, but he had to check on his friend Lourdes. So, he’d slipped into OR 19, the Mount Olympus of surgery, and staked out a position behind the curtain that separated the anesthesiologist from the surgical personnel.
Joe watched as Dr. Jacques De la Toure, head of the Houston Heart Institute, placed the last sutures deep inside the cavity. De la Toure put down his needle driver and looked to his faculty associate, Dr. Victor Carlisle.
“Good job,” Carlisle said.
De la Toure had closed an abnormal hole between two of Lourdes’s heart’s pumping chambers. Serious stuff, but on the spectrum of procedures, it anchored the low-risk end, and Joe encouraged Lourdes to proceed with surgery. She was his best friend, his only friend from the neighborhood. She respected him, admired him, adored him. So, when he told her she needed the operation, she acquiesced like a gentle lamb. Her father and his mother prayed to the Virgin for her recovery, but Joe did better. He arranged for her to have the finest heart surgeon in the world.
De la Toure turned in the direction of the heart-lung machine. “Start coming down on the pump, but don’t give any volume.”
“Yes, sir.” The muted voice came from Kim Chiu, the middle-aged, Asian heart surgeon that De la Toure had brought to Houston to serve as his head perfusionist, supervising all of the technicians. Her reserved, subservient demeanor belied an intensity that Joe had witnessed more than once.
“Oh, Lordy,” Marie Coleman, the scrub tech, said out loud.
Inside the chest, Lourdes’s heart was ready to burst.
“I told you not to give extra volume,” De la Toure said.
“I didn’t,” Chiu said. “I know how to run this machine.”
Joe realized that, in fact, she knew how to perform the operation as well as any of his attendings, but her attempts to obtain proper credentials had been thwarted by the Board of Surgery and its laws protecting American trainees. De la Toure ignored her words and looked to the anesthesiologist, Dr. John Allgood, standing next to Joe at the head of the table.
“Go up on your epinephrine,” De la Toure ordered.
Joe knew Allgood would pull Lourdes through if anyone could. Despite the double, right earrings and the ponytail stuffed under his surgical hood, this sixties holdout knew his medicine. Allgood glanced at the epinephrine pump and then leaned over the drape.
“We’re already at fifty ccs, Chief,” Allgood said.
“Then go to a hundred.”
Allgood let out a sigh but did as he was told. Minutes ticked by. She just needs time, Joe hoped.
As they waited, Joe noticed a band of sweat forming across the front of De la Toure’s surgical cap. Joe shivered as the air conditioning evaporated perspiration from his own skin. Finally, the increased epinephrine took effect. The heart began to contract vigorously.
From under his mask, De la Toure offered a deep, low “Thank you,” and Marie chorused with a soft “Amen.”
Allgood extended a congratulatory fist and Joe countered with his own. They bumped in midair.
De la Toure placed his open palms on Lourdes’s chest and pushed away, as if he needed her help to stand erect.
“Now let’s come down again,” De la Toure said. He straightened his back, growing in stature right in front of Joe’s eyes. “Slowly. And this time, Chiu, don’t give any volume.”
“Yes, sir,” she answered curtly. “Two liters. . .” “One liter. . .” “We’re off bypass.”
“Chief, you’re having some PVCs,” Allgood said. “And some short runs of nasty-looking V-tach.”
Joe turned to the monitor. Abnormally wide electrocardiogram complexes recruited others until groups of six or more filled the television screen: V-tach, a fatal rhythm. With these rapid beats, the heart produced no blood pressure. The arterial tracing flattened into a straight line.
“Check your labs,” De la Toure said. “This is a young woman with pristine coronary arteries. There is absolutely no reason for her to be having V-tach.”
“Everything’s normal, Chief,” Allgood said.
“Do not tell me everything is normal.” De la Toure threw down his instruments, leaned over the surgical drapes, and glared at Allgood.
Allgood moved forward to confront De la Toure, their faces inches apart, their bodies separated only by the expanse of faded green fabric that marked the boundary of the sterile field. Allgood’s right shoulder ticked to some internal metronome, a nervous habit Joe recognized.
Embarrassed, Joe turned away. He saw Chiu bowed low over the pump, pretending to check on the tubing.
The various operating personnel froze in their positions. There was dead silence.
Finally, Allgood broke the standoff. He pulled back a few inches and spoke slowly and forcefully.
“Dr. De la Toure, the pH, oxygen saturation, hemoglobin, potassium, calcium, and magnesium are all normal.” Allgood enunciated each item in a crisp rhythm, his right shoulder jerking upward with each word.
“Check them again. You are obviously missing something. And start some lidocaine. Or should I get another anesthesiologist in here?”
“Oh, Lordy,” Marie said, returning De la Toure’s attention to the patient’s heart, quivering inside the open chest.
“She’s in a sustained V-tach,” Allgood said as he turned to his drug cart.
“I can see that,” De la Toure said. “Give me the defibrillator.”
Marie turned to the stainless-steel stand behind the surgeon.
“Now!” De la Toure shouted.
“Yes, sir.” Marie handed De la Toure the two long metal lollipops, each connected by an electrical cord to the power source. Carefully, he slid them into the chest, and sandwiched the heart between the two paddles.
“Clear,” he ordered. Then, he pushed the red button on the handle.
Lourdes’s body jerked, knocking a tray of instruments onto the floor, making a cacophony of metal against metal. The suddenness and volume of the sound elicited an involuntary gasp from the OR personnel, followed by an immediate embarrassed silence, but, like De la Toure, Joe remained focused on the exposed heart, the bloated muscular pump drowning in a pool of its own blood.
Lourdes’s body lay still now. A sacrificial virgin at the apex of the pyramid, her chest split open, her heart exposed. For what purpose? To appease an unseen Quetzalcoatl, the feathered serpent? The idiocy that Joe’s Aztec ancestors accepted as fact was indeed as logical as any reason Joe could fathom. Whether you believed in the myth of a merciful savior or a vengeful deity, what difference did it make? Dead was dead.
Piercing illumination from the four OR lights bore down on the center of the surgical field. Each one, like a satellite dish with hundreds of mirrors, focused their halogen light source into a unified beam that spotlighted Lourdes’s distended heart. As Joe stared into the cavity, he couldn’t prevent his eyes from watering. Joe couldn’t look at it for another moment.
He raised his head, but was blinded by the overhead lighting. A supernova strobed inside his brain. Reflexively, Joe closed his eyes, but within his cranium, throbbing gray matter threatened to erupt like an overdue volcano. He opened his eyes to look at the monitor, frantically searching for signs of life, but the red, green, and yellow tracings from the plasma screen stretched and twisted and twirled around him like a time-delayed photo of the Southwest Freeway during evening rush hour.
Why had he pushed Lourdes to have the surgery? True, the VSD had prompted the beginnings of congestive heart failure, but there were medications. And now, she might die because of his advice.
Joe started to sway. His vision blurred. Stepping back from the table, he stumbled over a cable on the floor.
Allgood took hold of his arm, providing support. “Yo, Joe, you all right? Need me to sit you down?”
Joe looked at Lourdes, sweet and pure. Inmaculada. His knees wanted to buckle, but his mind wouldn’t allow it. He felt Allgood tighten the grip on his arm.
“Joe? Man, you okay?”
Joe pulled away. He had to be strong. Professional.
“I’m fine. Look, I have to get to OR 15. It’s where I’m assigned today.”
Without turning back, he rushed out of the room, his hand covering his mask in case he couldn’t control the bitter fluid rising in the back of his throat.
When the mechanical doors opened into the ICU, Jacques De la Toure faced his head nurse, by no means a young woman, but still sensuous, who only weeks before had served to recapture his lost youth.
“Delia, where is Lourdes’s father?” De la Toure asked.
“In the consultation room,” she answered. “Do you want me to come with you?”
“Yes, that would be helpful.”
“We heard she barely came off pump.”
De la Toure didn’t respond. As he walked, he felt Delia’s hand gently grasp his elbow, guiding him past the waiting area where families congregated. He avoided eye contact with anyone.
Stopping outside the closed door to the consultation room, Delia turned to face him. “You remember that Mr. Sanchez works as an orderly here in the ICU?” she asked.
“Yes, I know Raúl,” De la Toure said.
“And with him is Dr. Morales’s mother, Lupe. She works in the hospital, too.”
“I know her, but I didn’t realize she would be here.”
“They’re cousins,” Delia said. Raúl is the reason Lupe got her job here. Years ago, when I was a student nurse.”
“I remember when he brought Lourdes to me to consider for surgery.”
“Yes. Raúl and his wife took care of her and since Raúl’s wife died, they’ve been very close.”
Delia pulled open the door, but De la Toure paused at the entrance. He detested this place. He’d complained so much about the industrial, cold space that one week ago his wife Susan marshaled the auxiliary to perform a complete, while-you-were-out makeover. They accomplished a luxuriant transformation, but the antique Persian rug and the Mary Cassatt reproduction failed to soften the space. Neither did the faux-stucco walls with trompe l’oeil accents diminish the distress of the messages to be delivered here.
For years, De la Toure came to this tiny space, not much larger than a modern confessional, to convey unpleasant news, and these last weeks he had to offer apologies for results that he couldn’t explain. He admitted his failures, but there was no reconciliation. He never left feeling forgiven or renewed, and today would be no different.
De la Toure felt Delia’s firm hand in the hollow of his back, as if to push him across the threshold. The family conference couldn’t be avoided.
Inside, he found the couple huddled in the center of the settee, a mauve, velvet Queen Anne sofa with curved cherry legs. The two squeezed in tightly, as if to draw comfort from their closeness, to form a shield against the anticipated storm. They sat underneath a copy of Cassatt’s Two Children at the Seashore. His wife knew how much he admired the impressionist who renounced a privileged existence in America for a lifetime of study in Europe. For a moment, he relished the copy of the lush oil work that hung in the National Gallery of Art. This reproduction captured the strong brush strokes, vivid hues, and lustrous light of the original.
On the canvas, two girls played in the sand. In the background, a sailboat floated on calm water. All was serene. De la Toure looked at it and could smell the salt in the air.
From behind, Delia cleared her throat, bringing De la Toure back to the reality of his mission. He wondered how long he’d stood entranced in front of this pair, their bodies interlocked, the terror in Raúl’s eyes reflected in those of Lupe’s. And then they turned to him. He held their gaze for only a moment before looking down. At their feet, the vivid pigments and the stylized design of the wool rug seemed inappropriate. Maybe it would have been best to leave the room with its linoleum floor and vinyl-upholstered furniture. Before, there was no misrepresentation.
De la Toure moved between two of the wing chairs among the several scattered in studied randomness around the carpet’s perimeter. He sat on the front edge of the one closest to Raúl. De la Toure leaned forward, cupping his hands on Raúl’s knee, and looked straight into the desperate eyes.
“Mi preciosa, she is dead?”
“No. Lourdes isn’t dead.”
“Gracias a Dios.”
“Gracias a la Virgen,” Lupe said.
“Sí, tomorrow is her special day,” Raúl explained to De la Toure and Delia. “The feast of the Immaculate Conception. The Inmaculada will protect my innocent one.” Lupe put her arm around Raúl and they both cried.
De la Toure waited for them to regain composure. He still had bad news to deliver. He cleared his throat to gain their attention.
“But she is critical. I do not know if she will survive.”
“What happened to my little girl? You told me not to worry.”
De la Toure felt Delia’s reassuring hand on his shoulder. Her scent sparked in him a wave of memories. He recalled the way she rejuvenated him at this point in his life—the time when children leave home and husbands look at wives and feel old, used, wasted. His Susan was everything he wanted in a wife and mother, but Delia was everything he wanted in a woman and lover. Even now, she made him feel invincible. He could handle this.
“Raúl, any time in cardiovascular surgery—.”
“But you said she had a good heart. Just a little hole inside, and you would fix it.”
“Yes, and I did, but when we tried taking her off the bypass machine, she began to have difficulty.”
“I do not understand.”
Delia gently massaged the surgeon’s shoulder, and he drew a deep breath. How could he explain a procedure that took years to learn? Moreover, how could he explain a complication that he himself didn’t understand? Here was another patient with unexpected, unrelenting V-tach. How many had there been this last month? Too many.
“Raúl, it is very complicated. Lourdes developed a dangerous heart rhythm—.”
“She will live, no?”
“I don’t know. She is requiring a large amount of support: pacemaker, ventilator, and an excessive amount of vasopressive drugs.”
Raúl nodded, but De la Toure wondered if this simple man understood the precarious nature of his daughter’s condition.
“So, she’s just like my wife was.” A wave of hopelessness flooded Raúl’s face. “Only the machines keep her alive?”
“In a manner, Raúl.”
Five days later, December 12, the Hispanic community celebrated the feast of Our Lady of Guadalupe. Joe felt obligated to join his mother at church, but first he wanted to check on Lourdes.
Hours before sunrise, he entered the rear stairwell of the Houston Heart Institute and climbed the pock-marked concrete steps to the second-floor landing. Soggy, pungent air filled his lungs. Drops of condensation spotted the surface of the industrial door that opened into the ICU. He reached for the metal handle and recoiled at the gritty sensation that shot through his palm and bolted up his arm. He returned his hand to the stainless-steel ball, worn from years of use, twisted the knob, and shoved the heavy door open.
Inside, Joe found a different world—one that was bright, modern, immaculate. Leaving behind the thick, humid, Houston air, he encountered the unnaturally clean and odorless atmosphere of the ICU.
In these predawn hours of the graveyard shift, the back patient bay of the ICU, the section for “long-termers” was quiet. Except for the patients, the space was deserted. He saw a bald-headed male in scrubs at the secretary’s desk and assumed he was in charge. He probably had briefly stepped away, but it irritated Joe that no one was watching Lourdes. These patients were all stable, here for the long haul, on autopilot, but they—including Lourdes—needed attention. Lourdes deserved the best of care. She wasn’t just another dead-head going nowhere. She was . . . she was special.
Joe moved to Lourdes’s bed, alone with her except for the eight other patients in this open ward, all on ventilators, oblivious to the world around them. Not even their individual curtains had been drawn to offer the illusion of privacy. At each bed, air flowed in and out of the respirators. Like a scene from the movie Coma, bodies were suspended in animation. They were cold, calm, motionless. He could have been in the morgue except for the discordant beeping from the monitors, like back-up warnings from nine dump trucks, all headed for him, ready to roll over his body. He wanted to shout at them, “Stop!”
Joe looked down at his friend. The word friend seemed so inadequate to describe their relationship. No one else in the world understood his origins. No one else appreciated his need to reinvent himself. When he’d chosen an Anglo wife, she negotiated for him with his mother. He married in the Church but absent the mariachis and the lasso ceremony. She accepted not only who he was, but also who he wanted to become. Unlike his mother, she didn’t feel rejected as he attempted to move up in society.
“I’m here, Lourdes,” he whispered. “We’re all praying for you.” Yet he wasn’t. He didn’t believe in the power of prayer. How simple if the Virgin would appear next to them, and he could ask her to save his friend, but she wouldn’t and he couldn’t. He relied only on science. Unfortunately, Lourdes hadn’t fared well under his guidance.
Joe kissed her forehead, but Lourdes lay motionless, the distinction between life and death obscured. Pavulon, a paralyzing medication, prevented her from fighting the ventilator. An endotracheal tube in her windpipe was securely taped to her mouth. Its flexible hose connected the clear plastic tube to the breathing machine. Bottles of intravenous fluid were connected to her arms via a number of thin plastic lines. Cables came from everywhere. Wires and tubing tangled like spaghetti. Lourdes’s face had swollen to the size of a basketball. It was not the face of the former princess of the festival of Bellas Artes.
Then, she walked down the staircase in long black velvet with a rhinestone tiara that held her hair back to frame exquisite features. She took away Joe’s breath, and then she stole his heart. He never looked at her that way before, and it terrified him. He knew in that moment that he couldn’t allow himself, couldn’t condemn himself to the future they would share. What hurt most was that Lourdes understood, and yet she still loved Joe, but she couldn’t hide the sadness that filled her deep, dark eyes.
Now her eyelids were taped closed for protection. She couldn’t even blink on her own. Her arms were marred by bruises, the work of needles with which nurses had jabbed her during the last five days. The glistening skin covering her swollen hands and feet was stretched taut with blisters starting to form. Their color was a marbleized purple and blue.
Every six seconds, the girl’s chest moved, thanks to the ventilator. On the monitor a sharp spike preceded each electrocardiogram complex, thanks to the pacemaker. Underneath the EKG readout, the arterial tracing indicated her blood pressure to be normal, thanks to the medications dripping into her veins.
This semblance of life was a grotesque tribute to modern technology. Lourdes looked like her mother did when she lay in the ICU suffering from gallstone pancreatitis. Raúl wanted every possible intervention and the surgeons had operated on her seven different times. In the end, her mother’s body bloated beyond recognition. At Lourdes’s insistence, Raúl agreed to give the do-not-resuscitate order. But his wife didn’t die until after many more days of torture. Now, Raúl had again agreed to the DNR status for his daughter. And again, the patient hadn’t cooperated. This semblance of life would not yield.
Two miles away, Joe pulled into the driveway that circled in front of St. Anne’s, the mission-style church and school that commanded the corner of Shepherd Street and Westheimer Boulevard. To the west stretched River Oaks, a bastion of the rich. To the east there was an eclectic neighborhood with a number of Hispanics, many here without documents. This dichotomy typified Houston, a city that both prospered and suffered from the effects of unbridled growth without zoning limitations. Both ten-million-dollar mansions and adult book stores stood within a few blocks of each other.
Inside this sanctuary, Houston’s wealthiest worshipped side-by-side with those whose only assets were determination and desire. His mother had worked nights at the school in lieu of his school tuition, and each day she taught him a new word from the S.A.T. prep list, words she could neither define nor pronounce, but Joe could memorize every one.
In the outside courtyard, hundreds gathered for las mañanitas, the predawn celebration of the feast day of Our Lady of Guadalupe. They sang to the Virgencita. In the cold, December air, their words were made visible by the light from the candles they each cupped in their hands.
Zipping up his windbreaker to hide his scrub top with its Heart Institute logo, Joe waded through the crowd. Thanks to his father’s genetic contribution, he towered over the mass of short, dark-skinned people—men in denim and work boots, women in servant uniforms, children of every age darting in and out. The familiar smell of working people pervaded the crisp, morning air. The mellow tones of their voices comforted the many babies wrapped in bright-colored blankets, snuggled against their mothers’ breasts.
At the entrance to the building, Joe struggled to open the heavy rustic door. He stepped over the threshold onto the hard Saltillo-tile floor of the vestibule and let the door close behind him.
Blackness enveloped him. Blindly, he moved forward, and his outstretched fingertips found the lead grouting of the stained glass inset into the doors leading inside. His fingers read from left to right until they reached the wooden frame, and then they moved down to the brass door handle.
Inside, exit signs provided soft red light that extended only to the first stone columns supporting the vaulted roof. Along the walls, arched voids in the stucco replaced the multicolored windows, invisible without sunlight. At the end of the center aisle, a single candle burned in the sanctuary lamp. The amber flame danced with its reflection in the gilded tabernacle.
Joe stopped at the third pew from the rear entrance, genuflected, and sloppily made the sign of the cross, bringing his right thumb to his lips, a substitution for kissing the crucifix of a rosary he no longer carried. He knelt next to a middle-aged woman with a brown complexion and prominent bone structure visible beneath plump cheeks. She wore a freshly ironed, sky-blue uniform, stretched at the waist by her generous hips. He imagined her mind was filled with thoughts of gratitude to the Virgin Mary and with petitions for assistance.
Joe leaned down, placed his arm around the woman’s shoulder, and kissed her cheek. “Buenos días, Mamá.”
She turned to him. “Thank you for coming, mi corazón,” she whispered.
“Mamá, I got to first assist Dr. Carlisle on a heart.”
“That’s nice, José,” she said softly.
“It was great. The cardiac surgery fellowship with De la Toure is as good as—.”
“Shhh,” she said, bringing her index finger to her pursed lips.
“Shhh,” she repeated. “You tell me after Mass.”
Joe sat back in the pew. As his eyes grew accustomed to the darkness, he could perceive the baldacchino, four, twenty-feet-tall pillars that supported an intricately carved marble canopy over the tabernacle, and he could see the outlines of a framed image hanging from the two rear columns.
Joe shivered as a gust of wind swept by, accompanying other early arrivals who were escaping from the elements. To make space, Joe and Lupe scooted down the well-worn wooden pew.
Joe watched as Lupe returned to her prayers. He doubted he believed in the Roman Catholic Church anymore, doubted he believed in anything. After all, he had graduated from Rice University, founded by an atheist when being an atheist wasn’t fashionable. Having majored in biochemistry, he understood the theories of evolution and the origin of the universe. There was no need to bring God into the picture. Yet here he knelt, surrounded by a group of poor, uneducated Hispanics who gathered to celebrate the feast day of Our Lady of Guadalupe, the dark-skinned Virgin Mary, their protectress. In Joe’s mind, the emphasis was on their. He felt little community with these people.
Joe’s thoughts were interrupted by the arrival of Raúl Sanchez. The short, stocky man, like his mother, also came dressed in hospital garb. It seemed to Joe that Latinos cleaned the whole city. Joe glanced at his own surgical scrubs. How many times had he been misidentified as an orderly?
Joe looked toward Raúl for an acknowledgment, but found only a vacant face with swollen eyelids barely open.
Raúl knelt and bowed low, burying his face in his open palms, muffling faint sobs. “Mi preciosa . . . ¡Qué horror! . . . that face. O, Dios mío. Dios mío. Por favor. . . .” His mutterings continued, indistinct amid his tears.
Joe tried not to listen, not wanting to share in such immense grief. Yet the frost of the damp, dark morning penetrated to his core and sadness covered him like a shroud. Joe felt the bone-cold air from outside as the doors were opened wide for the procession of worshippers to assemble inside. Fortunately, the wave of chill dissipated with the arrival of the crowd. The familiar sounds of Spanish hymns now filled the cavernous space, and the golden glow of candlelight illuminated the rear of the church. The smell of burning wax mixed with that of incense and rose to the ceiling. His mother believed that prayers rise with the smoke to heaven. Joe turned to view the gathering crowd. Down the pew, Raúl raised his head from his hands and looked toward the altar.
“O Virgencita, mi Virgencita,” Raúl pleaded.
Suddenly, Raúl stood. He kicked up the kneeler but it bounced off the wooden stop and clanked on the tile floor.
“I can’t stay here,” he said to no one in particular as he moved into the aisle, jerking his head from side to side, a series of staccato nos. “Basta! Enough.” Pushing his way past the celebrants waiting to start the worship service, he exited the church.
Lupe watched their friend leave and then returned her focus to the altar. Joe knew she prayed for both Lourdes and Raúl.
Mass began. From the rear of the church, a legion of priests and altar servers led the crowd of believers, the decorated appliqué of the priests’ garments contrasting with the simple black-and-white dress of the altar servers. Each member of the procession carried a large votive candle to place in the sanctuary. Their luminaries covered the altar and overflowed onto the marble floor.
The entire apse glowed, revealing a large portrait of the Virgin as she appeared to the Aztec Juan Diego in the hills outside modern-day Mexico City. Juan pleaded with her to cure his uncle. The lady answered Juan in his native language: “Do not worry, my little child. Put it in your heart.”
She instructed him to gather roses from a snow-topped mountain and she arranged them in his tilma, a poncholike, cactus-fiber cloak, to take to Bishop Zumárraga. As Juan stood in front of the cleric, the flowers fell to the floor revealing the miraculous image of the Virgin imprinted on the fabric of his cloak.
Later, the bishop who had led a campaign to evangelize the indigenous population, interceded on their behalf and excommunicated Beltran de Guzman, the president of the first Audiencia of New Spain. Unfortunately, Bloody Guzman merely moved his conquest westward. Ironically, one of Acapulco’s prominent families proudly traced their unspoiled lineage to this European-born despot.
Joe stared at the sacred figure hanging from the two rear columns of the baldacchino, a reproduction of the image magically imprinted on the coarse material that had cloaked a poor peasant. The Aztec Virgin, clothed by the sun, looked down on her children. Thoughtlessly, Joe began to recite a prayer from his childhood.
“Santa María, Madre de Dios . . .”
His mother taught him that English was the language of science and education. To be successful, you became proficient in English, but when you prayed, you prayed in Spanish, the language of love.
Like the hundreds of other Hispanics gathered in St. Anne’s and the millions who kneeled in churches throughout the Americas, Joe prayed to Mary.
Could the Virgin come to their assistance? But that wasn’t possible. Or was it?