Rishi Nair sits at the edge of a hotel swimming pool, his feet dangling in the water, while his three older siblings splash and play.
He can't join them.
Tubes implanted in his belly help keep him alive despite chronic kidney failure, but they could become infected if he jumps into the pool.
This summer, though, the whole Birch Bay family might get to swim together.
Rishi's mother, Mary Lyn Nair, is giving her 5-year-old son a kidney as a Mother's Day present to them both.
"When you bring a child into the world, that's a gift of life," she said the day before surgery to remove her left kidney. "Giving my kidney to him is a way of giving the gift of life again."
In a choreographed two-hospital operation, a UW Medical Center surgeon pulled Mary Lyn's kidney out of a small incision in her right side, packed it in ice and sent it by ambulance to Seattle Children's Hospital and Regional Medical Center. There, Rishi was waiting for surgeons to make his mother's kidney his own.
But it might take months to learn if the boy's body will accept the gift, and if he will have a functioning kidney for the first time.
PRAYERS FOR RISHI
Resting before Wednesday morning's surgery, Mary Lyn's face shows none of the strain her body will endure that day. She reclines beneath what looks like an air mattress, a whirring machine filling it with warm air.
One good reason to donate a kidney, she jokes, is that it feels like going to a spa.
Mary Lyn, 35, had called her father that morning. Everyone in his church was praying for her, he told her. Don't worry, she replied.
"I think the divine has a lot more that he wants me to do in this life," she told her father. "I don't think I'm going anywhere."
For Mary Lyn and Mahen Nair, faith in the divine has been as important as faith in modern medicine in helping their son survive chronic kidney failure. They are practitioners of Sahaja Yoga, which has roots in Hinduism but celebrates the divine in all the world's major religions.
Before Mary Lyn's first ultrasound revealed the Nairs' fourth child wasn't developing normally, and before she knew she was pregnant, Mary Lyn dreamed of seeing a baby in an incubator in an intensive care unit. She and other parents held and caressed their babies through heavy rubber gloves attached to the clear plastic boxes.
"There's another baby coming," she told Mahen when she woke up. "And it's not normal."
But those babies in Mary Lyn's dream weren't just protected by medicine. As she and Mahen prayed over the sick child in her dream, she watched as the energy from the prayers burst around the room.
"It was like streaks of lightning," she says.
Rishi was born with chronic kidney failure; his kidneys never developed to serve their function as the body's filtration system. Anemia plagued his bloodstream. Rickets threatened his bone development. He couldn't eat enough to keep himself alive, and survived on nutrients delivered through a tube to his stomach. Another tube was attached to a whirring, beeping dialysis machine 10 hours each night to filter the toxins from his body.
His parents have been taking him to medical specialists - and praying for him - his whole life.
MARY LYN'S SURGERY
By 10 a.m. Wednesday, Mary Lyn lies on an operating table in a darkened surgery room. Dr. Ramasamy Bakthavatsalam has begun the laborious process of moving Mary Lyn's other organs out of the way to reach her kidney near the left side of her back.
Bakthavatsalam, known in the hospital as Dr. Baktha, will remove Mary Lyn's kidney with "hand-assisted" laparoscopic surgery, which means he'll spend the next several hours with his left hand in her belly, his right hand operating cutting tools and cauterizers through a small incision in her navel.
Standing next to Baktha, Dr. Edie Chan pushes a tiny camera through a small tube inserted in Mary Lyn's belly, and everyone clustered around Mary Lyn watches the surgery on video screens on both sides of the operating table.
The field of vision is small, and performing laparoscopic surgery seems like looking through a hose to find your car keys. But Baktha is in familiar territory, meticulously trimming away the tissue surrounding Mary Lyn's organs bit by bit. Trained in India, Baktha was a transplant surgery fellow in Ireland before coming to UW Medical Center in 1999.
Removing a kidney through laparoscopic surgery isn't easier than doing it with a larger incision, Baktha says. But the recovery time is shorter, he says, encouraging more people to donate a kidney.
LIFE WITH LIMITS
Doctors first suggested a kidney transplant when Rishi was 3, Mary Lyn says. But she already had spent too much time trying to comfort her little boy during medical procedures. He'd learned plenty about fear and confusion, and it was time for Rishi to learn about optimism.
"It was important for his character," she says, "for him to feel that life has a sense of joy and wonder."
So Rishi joined his three older siblings, sister Shanti, now 10, and brothers Kamal, and Nirmal, now 9 and 7, in home schooling, filling his days with reading and music, karate lessons, gymnastics classes, ceramics painting and walks on the beach. Monthly trips to see doctors in Seattle included trips to the aquarium.
But Rishi had started to complain about his nightly peritoneal dialysis treatments, in which the fluid in his belly is exchanged. He had grown tired of waiting in bed for the dialysis to finish while his siblings raced downstairs for breakfast.
"Sometimes we all jump into his bed and start playing with him," says Mahen, 44. "But he's still stuck on the machine."
Rishi also has to take care that the tubes implanted in his belly won't become infected.
When his siblings jump into the hotel pool on road trips to see family in California, Rishi can't join them.
"Rishi just goes and dangles his feet," Mahen says. "I know he must be thinking, 'Gosh, I can't go in the water.' "
Rishi's siblings are now at a school in India, where they'll stay for the next several months. There, they'll benefit from an international experience, Mary Lyn says, while she and Rishi recover from their surgeries.
When Rishi first began dialysis, about a year and a half after he was born, the machine needed adjustment about every 15 minutes all night long. Even now, it still beeps when he rolls over onto a tube.
"I told him, 'Rishi, you can sleep on your head if you want to (after the surgery),'" Mary Lyn says.
After more than two hours of surgery, Baktha has moved aside Mary Lyn's large intestine, spleen, pancreas, adrenal glands and other organs. The only things attached to her kidney are the ureter, which delivers urine from the kidney to the bladder, and renal artery and vein, which deliver blood to and from the kidney. The vessels pulse in time with a beeping machine monitoring Mary Lyn's heartbeat.
Baktha won't cut those until the very last minute.
"We're still at a point, I can stop it right now," he says. "If, for some reason we need to abandon, I can preserve this kidney."
Baktha asks nurse Vicki Sandeen to call Rishi's operating room at Children's Hospital to announce the kidney is ready for the last cuts. Wait another 10 minutes, he's told. They end up waiting a bit longer. The special fluid brought over from the other hospital to preserve the kidney isn't cold enough. They must find more.
For the first time in more than two hours, Baktha removes his hand from Mary Lyn's belly and steps away from the table. Removing a kidney isn't a complicated procedure, he says, but removing a kidney from an organ donor, who doesn't need the surgery for her own health, makes the procedure a bit more intense.
Sandeen calls the hospital's pharmacy and asks them, with urgency in her voice, to track down cold fluid. She soon reports that it will arrive via the hospital's pneumatic tube delivery system.
Baktha suits up to finish.
A BOY'S HOPES
Rishi knows that kind of urgency. When asked what life will be like after his surgery, he talks about getting rid of the tubes in his belly and about going swimming.
"I'll feel stronger," he says.
Rishi's parents have tried to temper his expectations about how he'll feel after the surgery. The tubes in his belly won't come out right away, they remind him.
"Remember, you're going to give your body time to adjust," Mary Lyn told him a few weeks before the surgery.
In some patients, transplanted kidneys begin to work immediately, producing urine right there on the operating table. But some take up to eight weeks to produce any urine, Baktha says.
"Never say a (transplanted) kidney's not working," he says.
A CAREFUL RIDE
Soon after the preservation fluid arrives, Baktha clamps the vessels and cuts Mary Lyn's kidney free.
"Get the time, please," Baktha says.
It's 12:33 p.m.
He slips the kidney, barely a handful, from her body and places it in ice water in a metal bowl. He connects a tube to one of the vessels to flush fluid through. As a nurse squeezes the bag with both hands, the kidney lightens to a pale pink.
Baktha pours the kidney and ice water into a plastic bag and puts the bag, surrounded by ice, into a plastic cylindrical container. The container, with still more ice, is put into a foam container. That container goes into the cardboard box.
Sandeen carries the box from the room, followed by Makayla Blank, a transplant coordinator from Children's Hospital who will accompany the organ on its short ambulance ride to Children's.
Before handing it off to Blank, Sandeen stops in the business services office on the surgery floor to grab some tape to close the box.
"It always makes me nervous, carrying these," Blank says.
At 1:03 p.m., Blank is in the back of an ambulance, the box wedged between her feet for the short ride to Children's Hospital. As transplant coordinator, most of Blank's job involves working with transplant recipients and their families, not carrying their organs between hospitals. But she's not complaining.
"It's nice to be a part of this," she says.
Blank carefully watches her footing as she steps down from the ambulance and walks into the hospital's emergency room, down the hall, and into the operating room where Rishi lies on the table. His X-rays on nearby computer screens show faint outlines of the tubes in his belly, the ones that keep him from swimming.
Sometimes it is hard to believe, looking at Rishi, that he needs such drastic surgery.
He's an active, inquisitive kid who loves to play, paint ceramic animals and read books. He's learned to sing in Sanskrit, Hindi and English. And he plays Indian tabla drums, keyboards and an accordion, on which Rishi may someday learn Cajun songs from his mother's native Louisiana.
"If you see him, he doesn't look as if anything is wrong," Mahen says. "He is so normal."
But the fatigue of his illness is written on Rishi's face the evening before surgery. What's wrong, his mother asks when he lets out a small whimper. He motions to the intravenous needles in his arms. They keep him from playing the drums.
"After the surgery, you won't have them anymore," his mother says softly. "You're going to cherish (having two free arms) even more, because you'll know what it's like to not have it."
By 1:25, Mary Lyn's iced kidney sits in a bowl - kidney shaped - on a table between Drs. Pat Healey and Andrew Schulman. They carefully turn the kidney over in the bowl, snipping away excess fat and tissue. Rishi lies nearby, draped in blue surgical cloth, about 2® hours into his own surgery.
Within a half-hour, the surgeons begin carefully stitching the kidney to Rishi's blood vessels. Even after it comes out of the ice bath, they will keep the kidney cold as long as possible, says Healey, the attending surgeon, to help prevent injuring the organ. Free of blood now, the kidney is a pale, bland pink.
Their foreheads nearly touch as Healey and Schulman bend over Rishi, making tiny stitches with blue filament. Both wear magnifying lenses on their glasses. Schulman wears a light strapped to his forehead. They don't remove Rishi's own defunct kidneys, and Mary Lyn's kidney is placed right above Rishi's right hipbone.
"Fits perfectly," Healey says.
At 2:51 p.m., Rishi's kidney is ready for its first real test. Surgeons remove the clamps from his blood vessels, letting his blood flow through his new kidney.
"Getting pinker," Healey reports.
The doctors hold a small microphone to the kidney, filling the operating room with the rapid whooshing rhythm of Rishi's heartbeat. Schulman rocks his head back and forth, swaying to the beat.
Soon, Rishi's new kidney is bright, bubblegum pink.
But doctors won't know the kidney is really working until it starts to produce urine. They see his ureter pulsate a bit.
It looks like the kidney's trying to work, Healey says.
Healey and Schulman lay the ureter on a swath of white sponge, preparing to attach it to Rishi's bladder.
Tiny droplets of urine hit the sponge.
Rishi just might get to go swimming this summer.
"PART OF ME"
Doctors told Mary Lyn to expect to stay in her hospital bed three to five days to recover. Try two, she told them. She checked out Friday to be with Rishi at Children's Hospital for his fifth birthday.
After Rishi leaves the hospital, he and Mary Lyn will stay in Seattle at Ronald McDonald House, for near daily checkups to ensure Rishi's body is accepting his mother's kidney.
Mary Lyn is optimistic.
"He lived in my womb once. If my body didn't reject him, why should his body reject part of me?"
Mary Lyn Nair checks on her son Rishi Nair, 5, on Tuesday night before the kidney-transplant operation at Children's Hospital in Seattle.-->