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Ruben’s Gift

Last December, a 12-year-old boy named Ruben Pena was shot in Fresno, Calif., and declared brain dead. While it was a tragedy, Ruben’s heart, kidneys and liver were used for transplants. In this special reprint from The Fresno Bee, we offer the story of how Ruben’s death helped to save the life of one Spokane woman.

The bullet flew straight and true, punching only a small hole near the high left side of his nose. But inside it stopped in the brain stem of a 12-year-old boy.



And 911 on the phone.

A 16-year-old boy cried to his little brother: “Don’t die!” But Ruben Pena would never speak again.

On a cold winter night on the poor side of town, his heart stopped instead. The first Fresno policeman on the scene gave him CPR. Then an ambulance whisked him, only a few city blocks, to the trauma unit at University Medical Center.

It was just after midnight on a Monday morning.

And Ruben Rena would not make school.

But by Thursday he would save three people’s lives, including a woman in Spokane.

The story was a true crime story. A 15-year-old charged with murder, bringing a rifle into an apartment, playing around, pointing it at people, and shooting Ruben Rena in the face.

But quickly, this .22-caliber tragedy consuming the world of headline news and homicide detectives also became a gripping medical story. A high-charged, dramatic, emotional story of a boy lying on a hospital bed with a crucifix and yellow rose on one side of his head and a wooden rosary on the other.

Then a great struggle inside UMC to keep his organs functioning long enough to transplant elsewhere.

But it was especially the story of his mother.

Rachel Pena.

And the hardest decision she ever made in her life. To make this whole senseless thing mean something.

Thirty-eight hours after her seventh-grade boy, a student in special education at Sequoia Middle School, had been shot, Rachel Pena sat in a small room at University Medical Center.

It was two o’clock in the afternoon.

Her son had just been declared brain dead.

And now as the early winter sun shone outside, Erin Gaylord-Sweeney of Modesto, transplant coordinator with the California Transplant Donor Network, asked her one simple question loaded with the finality of it all: “Do you want to donate Ruben’s heart?”

Thirty-five-year-old Rachel Pena, the third of eight children in her family, dressed in a sweat shirt and blue jeans, looked sorrowfully down at the green office carpet with her hands folded together inside her knees.

On her lap she held a legal form and in her hand a silver-colored pen.

She nodded yes.

And she put her initials “R.P.” inside the box on the form.

Her son would save lives. And in this he would be a hero.

“Do you want to donate Ruben’s lungs?” asked Ivan Monasterio, family services coordinator for the transplant network.

Rachel Pena started to cry.

A year ago her friend in Guadalajara had done this. Her 11-year-old son was shot and her friend donated his organs. Now it was her turn.

“It’s OK,” Gaylord-Sweeney told her.

The transplant coordinator held her hand.

“This is the hard part,” said Jin Kim, a hospital service coordinator.

But Rachel Pena wrote down her initials again.

And then again. With long pauses between each question. Her initials for the liver. The two kidneys. Her son’s pancreas.

At 2:27 p.m. she handed the form back.

She thought about her friend’s boy in Mexico, Ricardo.

And her own boy.

“I knew,” she said later, “that other people could live.”

Describing this kind of work in an earlier interview, Monasterio had used the word “nobility.”

“I see how they cry,” he said, “being in pieces. And they have the guts to say yes.”

Quickly then inside Room 3, the child pediatric trauma room in UMC’s burn center, there began an entirely different kind of medical drama.

Ruben Pena was officially brain dead.

This was the same as legally dead.

But it looked different. Machines could mimic the brain and the appearance of life, keeping his lungs breathing, his heart beating and blood circulating through the organs that surgeons would remove and sew into someone else.

Ruben Pena looked alive. His chest was moving.

He was wired to machines with blinking red and green lights. He had many clear plastic intravenous lines covering his chest and a breathing tube in his mouth. Still, he was dead.

The sight was every parent’s nightmare.

“Our primary goal here,” said Gaylord-Sweeney, “is just to keep things normalized.”

A former emergency room nurse, it was her role now to coordinate hours of tests, from chest X-rays to sonogram pictures of the heart to repeated blood checks. There were HIV and hepatitis tests that took eight hours to read. There were tissue samples flown out to distant labs to seek the best possible match.

They were buying time.

The time to match supply with demand.

There were thousands of people, many desperate and running out of time, trying not to die before organs like these became available.

On this very day almost 50,000 people waited across America.

And over a year’s time, more than 3,000 of them would die.

While this medical drama played out in Fresno - typically gunshot wounds where it used to be auto accidents - the people waiting wore pagers and carried cellular phones. And three lucky ones - a man from the San Joaquin Valley, a teen-age girl from the Bay area, and 40-year-old Gigi Preston from Spokane - hadn’t a clue yet their lives were about to change.

Truly, it was one of the great ironies of the 30 years of organ transplanting: the worst despair on one end created opportunity for the highest elation on the other.

‘Mucho paz,” the Rev. Phil Van Linden said in Spanish to the boy who was dead, but lying on his back, hooked up to many tubes.

“Much peace.”

After the priest finished the last rites, Rachel Pena stood sadly for a long time holding her son’s hand. She had five other sons and one daughter. She rubbed his forehead. And she did not cry. Even though all her life she thought: “I was going to have all my kids with me.”

It was 40 hours since all this started.

His stepfather said in Spanish:

“He is very small to die.”

Outside Room 3, the winter daylight had turned to night. From hallways and a waiting room outside the burn center, visitors streamed into the room in pairs. Family. Relatives. Friends. A younger brother carried a color picture of Ruben Pena in the foothills wearing a baseball cap.

Despite the senseless shooting that put him in here, the family put an upbeat face on the boy. Happy. Helpful. A good boy. A 49ers fan. Born in Guadalajara. Raised in Fresno. He liked to joke around. A playful child.

His grandmother, Herminia Martinez said, “I still love him. And even though God has taken him, for me, I still think he’s alive. I’m very sorry for what happened to him.”

He played soccer at Winchell Elementary School. They would miss his smile. He always tried his best.

Then someone brought two red carnations to his room.

The hours went around the clock fast now. Transplant Coordinator Erin Gaylord-Sweeney read test results and faxed a stream of material to the transplant network offices in San Francisco.

There was no HIV or hepatitis.

The nurses were weaning Ruben Pena’s body off the heavy drugs they called “the big guns.” These were the drugs that kept the body going when the trauma of the gunshot wound was fresh in its memory. They were also the drugs necessary after brain death to keep the blood pressure up.

Finally, about midnight, 48 hours after being shot in the face, Ruben Pena’s little 85-pound body began to stabilize.

“This is what surgeons like to hear,” Gaylord-Sweeney said in the early morning while most of the city slept. “It’s a good indication of his condition.”

So in the network’s San Francisco headquarters, they started making “offers” to transplant centers in the Bay Area.

Computers matched organs against lists of people who needed them most desperately. Considering that demand for organs exceeds supply almost three to one, this was no easy task. It was further complicated by limits of distance and time.

It had always been embroiled in ethical controversies.

About who was most deserving.

In the first half of the 1990s, 16,300 Americans died waiting for that dearest wish that never came true.

Among the waiting someone would always die.

And someone else would live.

Wednesday morning arrived with a bright orange sun rising over the hospital. It had been 57 hours since Ruben Pena was shot.

Everybody changed shifts again.

A new transplant coordinator on the scene, Julianna Schug, said the “liver team” at California Pacific Medical Center in San Francisco was “chomping at the bit” to come get the boy’s liver. First, the heart must be placed.

At 2 p.m. that day, Schug cried out suddenly over the phone: “Yes!” “Yes!” She cried again.

“Cedars-Sinai accepted our heart.”

The last hurdle had been cleared.

The heart and one kidney would go to a San Joaquin Valley man in Los Angeles. The liver would go to Preston, waiting in San Francisco. Another patient there would receive the second kidney.

The San Francisco liver team chartered a jet to Fresno Yosemite International Airport.

Surgery was scheduled at 7 p.m.

But first came one more time for Rachel Pena to say goodbye to her son.

She was exhausted, approaching three days of grief.

Little Ruben was dead.

But the body of her seventh grader, whom they’d called “Linge,” (for sweet little boy) still breathed artificially on the bed.

It was 6:43 p.m.

And Rachel Pena wanted to hold him.

She said days later she never thought he would really die.

The nurses, Denise Daniel and Catherine Snyder, looked at one another. They could try. So they got on two sides of the bed, held the IV lines, and lifted the boy’s shoulders up.

Rachel Pena slid in behind him.

He rested back on her. His head against her neck.

And she started to cry.

Somewhere else, in San Francisco and Los Angeles, three people had hope now they might live. They’d received phone calls. They were crying. They were happy. They were overwhelmed at the enormity of being called.

Finally. A beginning.

But on this end, Rachel Pena held on for 37 minutes. She sobbed softly and rocked back and forth with her child and whispered to him. When the gun went off that night they wouldn’t let her in the bedroom. So she wouldn’t see.

The heart team arrived from L.A.

Then the liver team from San Francisco.

They waited in a room down the hall.

Manuel Felix put his hand on his wife’s shoulder and whispered they should go. She shook her head no. Not yet.

And then her husband put his head down and cried.

At 7:20 p.m. it ended. The two left for home.

And 10 minutes later the staff wheeled Ruben’s body up to the fifth floor and into the operating room.

It was time.

What began then at UMC happens about 5,000 times a year in America’s trauma hospitals. There was a pre-operation flurry of preparation by nurses.

And doctors “scrubbing in” at the sinks.

Then a brief hush.

In Operating Room 2 someone called it out:

“Start time eight o’clock.”

And for two hours came the meticulous, uneventful tissue dissecting that always in surgery precedes the big moment.

The liver team led the way.

Two doctors and a third-year medical student, all from the University of California at San Francisco, opened Ruben’s chest and abdominal cavities. And 11 minutes after beginning, the lead doctor, Dr. Robert Isorio, pronounced his verdict: “The liver looks good.”

Before long, he also revealed the beating heart.

This was it: The dramatic high-wire surgical work behind all the organ donation billboards, the donor dots on drivers’ licenses and Saturday mornings in transplant support groups.

All the grim pronouncements that started in doctor’s offices with strange symptoms, the weakening conditions and long waits - months and even years with silent pagers and phones that didn’t ring - all came down to this:

With seven heads hovering right over the chest cavity.

“I need another pair of DeBakeys.”

“Co-ag down to 20.”

In hours, the body would go to the Fresno County Coroner’s Office for an autopsy.

There was a charge of murder relating to it.

The dissecting plodded on. Then suddenly, approaching 10 p.m. there was a sense of the tide changing and something big building.

Dr. Isorio, still leading the way, said: “Get the ice ready.”

The team’s donor technician, Timothy Chan, poured clear saline solutions into blue tubs filled with melting saline ice.

“Ice please.” Dr. Isorio said at 10:05.

Then Dr. Carlos Blanche, the heart team leader from Cedars-Sinai Medical Center in Los Angeles, called out the two biggest words in organ transplanting.

“OK. Crossclamp!” They removed the organs from their blood supply.

Then everything happened fast.

The surgeons filled Ruben’s chest and abdomen with slush and chunks of ice. The heartbeat monitor stopped and the machines went quiet.

It was over. It had worked. They’d made it.

Thirty years ago, this nonchalance of putting a liver inside a red Igloo ice chest on the Southeast side of Fresno would have been unthinkable. Even five years ago, some insurance companies still considered liver transplants “experimental.”

The first successful liver transplant made history in 1967 - and even then, a 1-1/2-year-old girl survived only 13 months. Early heart transplants showed such unpromising results that Life Magazine called them - in 1970 - a medical failure.

Now it was routine.

The anti-rejection drugs are better.

And surgeons have plenty of practice.

So in Fresno now, at 12:20 a.m., Timothy Chan wheeled an ice-packed liver and kidney down a hallway and put both in the trunk of a white limousine.

It was raining.

The medical team piled into the car and the driver left for the airport, where a charter plane was waiting. At 12:28 a.m., it took off.

The ice chest and cardboard box sat in the back of the passenger section.

And the team was jolly and talkative. These trips cost between $1,500 and $2,200 and would become part of the bill.

At 1:28 a.m. the plane landed at San Francisco International Airport, where the wind blasted sideways and the sky poured rain.

And there, a white van waited.

Eight hours after leaving San Francisco, the team came back to town with a liver and a kidney.

Another transplant team would sew Ruben Pena’s liver into Gigi Preston, then sitting up with her husband in a quiet hospital room.

“He’s had the worse,” Gigi Preston would say.

“‘Now it’s time for the better.”

At 12:28 a.m. the white van stopped at the emergency entrance of California Pacific Medical Center, not far from Japantown on top of a hill in Pacific Heights.

Chan jumped out.

He wheeled the Igloo ice chest inside. Immediately, an operating room staffer, setting up the room for a 4 a.m. start, wheeled it away.

The liver was in the building.

Upstairs on the third floor, Gigi Preston of Spokane prepared to trade in her liver - which had given her trouble for half of her life - for a new one.

Preston had been in the hospital since Halloween night. She was on leave from her job as office manager for public relations at Gonzaga University.

A bag sat by the bed with a stuffed animal inside.

It was a moose.

Gigi Preston also had lots of flowers. And cards every day.

Her situation was desperate. And there were three more just like her on this floor. It was either get a transplant or maybe die inside the hospital waiting.

And she waited almost two years.

Gigi and John Preston, married 4-1/2 years, had no children.

“We haven’t had kids because of this,” Gigi Preston said.

This meant slowly dying.

She was exhausted. She had fallen down in the street once. And no one could tell her she’d live to raise her kids.

“Maybe now,” she said.

She was calm.

“This is a moment I’ve been waiting for for a long time,” Gigi Preston said. “I really am at peace. It’s like the adrenaline has worn off. I have total faith in my doctors.”

But her husband fidgeted.

John Preston is tall and thin, director of athletic development at Gonzaga. That day he was wearing a dark blue sport coat with gray slacks.

Even though California Pacific Medical Center’s survival statistics were the best in the country with 83 percent of its liver transplants surviving past three years, it was still tough for a husband to face six hours in a waiting room alone. Anything might happen. You just never know.

Finally, at 3:33 a.m. nurse Marvin Weinstein came into the room and said: “We need to go.”

Gigi Preston gave her husband her glasses.

She joked about how high the gurney was.

And slid herself on backward.

“OK, here we go,” Weinstein said.

They all got on the elevator and went down two floors. And at the heavy metal doors leading into the surgical suites, John Preston bent down and kissed his wife. He whispered a few things to her and then he straightened up.

“Obviously, I’ll be right here,” he said.

Then Weinstein wheeled her through the doors.

It was 3:43 a.m.

Dr. Jean Emond made a big T-shape cut across Preston’s lower abdomen at 5:38 a.m. And on a gray San Francisco morning, 5-1/2 hours of transplant surgery began.

What was happening inside the California Pacific Medical Center operating room, and afterward for the first year recovering, typically costs between $150,000 and $250,000.

How much money depends on how sick the patient was.

But nobody at the moment was concentrating on the dollars.

Eighty minutes went by like a flash.

Then suddenly Dr. Emond lifted out Preston’s liver.

Outside the hospital, the city woke up and traffic jammed. Inside, the surgeon put the worn-out diseased liver that was killing Preston into a steel pan.

It was brown and rough. It looked like a roast.

At 7 a.m. Dr. Emond pulled Ruben’s liver off the side table and slid it into Preston’s abdominal cavity.

Watching this, an operating room nurse, Gerrie Davis, said: “That’s the new liver. Look at how pretty it is.”

The doctor started threading immediately. Quick, short strokes with thread for a couple of hours - tying together five major connections between the liver and Preston’s blood vessels and bile duct.

“He’s flying,” Davis said.

The liver was getting color back into it.

It was turning pink.

In eight days Preston would be out of the hospital.

A blur of moving hands carried the morning. And at 11:15 a.m. the job was finished. It had been uneventful.

They wheeled Preston out of the room.

“Her chances are quite good,” Dr. Emond said. “She’s young and strong. And the new liver came from a young person, so it was all healthy and nice. There’s a 95 percent chance,” he said, “that a year from now she’ll be fine. Then in the long run, she should do really well for a long time.”

This was great news.

And it has stayed so.

In southwest Fresno, five days after that surgery, the Rev. Phil Van Linden said a noon funeral Mass at Our Lady of Mount Carmel Catholic Church.

And a 15-year-old still was in jail on a charge of murder.

In his sermon, the priest, standing before the family and friends, relatives and Ruben Pena’s fellow students, explained that “God loves us.” Then he pointed to a small casket and he thundered into the microphone:

“I HATE guns. And GOD hates guns. I think God hates guns more today than a week ago. I do. I hope you do, too.”

Outside, it rained.

When the Mass ended, a woman sang a hymn about the angels welcoming Ruben into heaven. And everyone sang the song his mother, Rachel, said was his favorite “church song.”

It was “De Colores.” And 30 minutes later they buried Ruben in St. Peter’s Cemetery west of the city.

That same afternoon in San Francisco the conflicting emotions of organ transplanting couldn’t have been more apparent.

Gigi Preston was ecstatic.

“I am doing great!” she said. “It’s been wonderful. I feel really good. I’ve got my color back and I’ve got so much energy. There are no signs of rejection.” she said. “It’s just the perfect one for me.”

A week ago Preston had been on the national waiting list for livers with 7,329 others. Now she was re-energized. She was feeling her future, living inside a “fairy tale.”

“It’s amazing. I have the rest of my life,” Preston said. “I’m 40 years old and I plan on living a long time now. I can live as long as I want to, as long as I take care of myself.”

Then she got weepy.

It was the medicine. And the emotions.

“I have these feelings,” Gigi Preston said, “of joy, and gratefulness to the donor and the donor’s mom. I’m adopted. So to me, that’s extra special. I’ve got a mom and she loves me no matter what I do. And I’m just so grateful to her and to the donor, and I can imagine how hard it must have been for her.”

And finally, nothing about any of this, the whole story from beginning to end during one week in the lives of four families, was unusual.

It was, in fact, typical.

Ruben Pena had died.

And his mother, Rachel, had made him a hero.

By Thursday, in one of the last weeks of school before Christmas vacation, he had saved the lives of three people.

And his mother took comfort in that. Life had been hard. She spent some time in foster homes. She didn’t go to high school. Her first husband was dead. And now her son. Like her friend’s.

“I thought of her,” Rachel Pena said. “I thought: my son died from the same thing. And I did the same thing as her.”

It was her gift.

Ruben’s gift.

“It’s a happy beginning for me,” said Gigi Preston inside California Pacific Medical Center, tears choking her voice.

“It’s the beginning of the rest of my life.”

MEMO: See related story under the headline: Transplant recipient continues to do well

See related story under the headline: Transplant recipient continues to do well

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