A young dad clings to his only hope after a destructive COVID infection. It comes with a heavy price.

This story is available in both English and Spanish. Haga clic aquí para leer la traducción al español de este artículo. Chapter 1: The diagnosis A doctor shouts a greeting to a weary Jesus Ceja Ceja, whose lungs have shriveled into scarred and stagnant red fists of tissue. He sucks in just enough air to squeeze out a response from his hospital bed, in the middle of a spacious yet lonely room in a Houston Methodist Hospital intensive care unit. “Somebody… somebody speak Spanish?” he asks, piecing together the little English he knows in his whispery voice. It is Sept. 17, 2021. Nearly six weeks after 29-year-old Jesus was admitted to Houston Methodist Hospital with a catastrophic COVID infection. His muscles, once bulging from long days of hard labor, have withered under heavy sedation. A life-support machine pulls blood from his 5-foot-7-inch body and pushes it back through the tubes that crown his head and snake deep inside his heart. His 28-year-old wife, Perla Munguia Ceja, enters the room to visit the man she met eight years ago in Cotija de la Paz in the Mexican state of Michoacán, where they grew up on ranches on opposite sides of the small city. Jesus has long been the head of their family — the strong, solid worker who frequently travels from Cotija to Baytown for temporary jobs insulating pipes at chemical plants and oil refineries throughout the Gulf Coast region. The family often visits the U.S., where they one day hope to live permanently, but still considers Cotija home. Two months ago, Jesus, a lawful permanent resident in the U.S., left Cotija for a job at a Louisiana natural gas plant while Perla and the kids stayed behind in Mexico. Now it’s up to Perla, a U.S. citizen who speaks limited English, to ask questions that will define their young family’s future. She turns to Dr. Ahmad Goodarzi, the lung transplant pulmonologist standing in the corner of the room. “He has been getting evaluated for a transplant, but they haven’t told me yet if he’s a good candidate or not — or what is going on,” she says. “He is under evaluation and testing, but we haven’t reached a final decision yet,” replies Goodarzi, who is having this conversation more and more with young families. At this point in the pandemic, 210 COVID-19 patients have received a lung transplant in the United States, including 16 at Houston Methodist — the most in Texas and third most in the country. These patients are on average 49 years old, 10 years younger than the average age of all other transplant recipients, and face devastating consequences. The operation carries the lowest survival rate of all solid organ transplants, which include the heart, liver and kidney. Only about 60 percent of lung transplant recipients survive after five years, according to the Organ Procurement and Transplantation Network, and 33 percent survive after 10 years. “Is there a chance he recovers without a lung transplant?” Perla asks, hopeful. “His lungs are so damaged that the chance of recovery would be very low,” says Goodarzi, slowing his words. “Every day that passes on this machine, a lot of complications can happen. I hope he recovers, but again …” Perla struggles to finish his sentence, “it’s not enough to …” Goodarzi nods, now confident she knows what he does: Jesus will never again use his lungs. A transplant is his only chance for survival. And Jesus does not yet qualify for the national organ waiting list. Vital sign monitors beep through the silence. Perla turns to her husband, her eyes welling with tears. Her voice quivers. “We had so many plans.” Lung transplants offer critically ill patients such as Jesus a second chance. But they wield an unending psychological toll through the long, complicated process of qualifying for the waiting list, matching with a donor and living a radically different post-surgery life. Jesus would be lucky to see his 7-year-old daughter, Victoria, and 3-year-old son, Erick, reach his own age. A heightened risk of infection means he could not continue his job as a journeyman pipe insulator. The first year with new lungs would require constant medical attention from Perla, a stay-at-home mother who would be left to shoulder a massive financial burden. And that’s if he gets the transplant. The decision of who makes the national organ waiting list at Methodist rests with a committee of more than a dozen professionals across a number of disciplines, including Goodarzi and the rest of the medical team. Together, they carefully select candidates deemed likely to survive the longest with a new organ, a precious resource consistently in short supply. Most COVID patients who need new lungs either become too sick or die before their evaluation. Goodarzi can see Jesus needs to be stronger to undergo the operation. But in order to become listed, Jesus also needs insurance coverage and additional people to care for him post-surgery. As Perla absorbs this new reality, she acknowledges that a lung transplant will steal her husband’s later years and fade their dream of growing old together, having two more kids and building a stable life in the United States. But they refuse to let each other go. They want to piece together what’s left of their dream. Their only hope is to make the list. The infection The symptoms hit Jesus gradually at first, then with sudden force. On a humid Friday night in mid-July, he feels a wave of fatigue wash over him as he and his brother, Gabriel Alejandro Ceja Ceja, sip beers and work on Jesus’ F-150. Gabriel, the oldest of eight siblings, had traveled from California to work at the well-paying pipe insulation gig Jesus had wrangled in Cameron, La. Two weeks into the job, they take a break at Jesus’ Baytown trailer, just as they learn a co-worker tested positive for COVID. When Jesus’ exhaustion doesn’t end by Saturday, the brothers seek out nasal swabs. The results: positive for Jesus and negative for Gabriel. Gabriel brews his brother tea when Jesus’ fatigue gives way to a cough. And the elder brother returns to Louisiana to continue working while Jesus quarantines. When Gabriel returns to the small, cluttered trailer the following Thursday, Jesus is feverish and short of breath. “Why didn’t you call me?” Gabriel asks, exasperated. “I didn’t want you to have to stop working,” Jesus replies. “I don’t feel that bad.” Gabriel calls Perla in Mexico and siblings in California. But when he insists on taking Jesus to the hospital, Jesus bucks. “No, no, no,” Jesus protests. “Just make me another tea, like the one you made me before, and I’m going to be OK.” But Gabriel has lived this nightmare before, and he knows the truth. Their father, 64-year-old Jose Ceja, died of COVID in Cotija five months earlier, at a time when the virus was rapidly infecting friends and neighbors in the small ranching community. The loss hit Jesus, the youngest of the eight children, especially hard. But despite his lingering grief, he cannot overcome his longstanding fear of hospitals. He is young, he reasons. Healthy and strong. Why risk a hospital? Like the vast majority of those who suffer the worst consequences of the virus, Jesus is unvaccinated. He is not against the shot; he is just busy. When he arrived from Mexico, where the vaccine was still available only to the elderly, he absorbed himself with work, as he always did. But COVID is mounting another attack. New cases have doubled in Texas and the Houston area within a week, as Harris County tallies 595 and Texas reports 6,400 the day Gabriel returns. Back in Cotija, Perla gathers the children for the 19-hour bus ride to Baytown. Jesus deteriorates rapidly after she arrives, and she persuades him to go to a freestanding emergency room. After three days, Jesus is transferred to Houston Methodist Baytown Hospital, where chest X-rays reveal a thick haze of fluid between the layers of thin membrane lining his lungs, resulting in dangerously low oxygen levels — full-blown COVID pneumonia. Jesus is sedated and connected to a mechanical ventilator that pushes air into his lungs through a tube lodged in his windpipe. Still, he does not improve after several days. He needs ECMO — a scarce life-support machine seeing unprecedented demand due to the pandemic. It draws oxygen-starved blood from a main artery, removes the carbon dioxide and pumps oxygenated blood back into the body. Doctors apologize to Perla as they explain: They don’t have the resources to operate the machine for Jesus, and the hospitals that usually would, including Houston Methodist in the Texas Medical Center, are at capacity due to a 50 percent increase in COVID patients that week alone. Jesus’ family leans on faith, praying the rosary through two days and nights in Mexico, California and Texas. A week into Jesus’ stay, Dr. Aditya Uppalapati, a critical care specialist, calls Perla. “There’s nothing more we can do if he does not get an ECMO machine,” he tells her. “I have two kids,” she cries. “He’s the only person who works for this family. We might not be able to live without him.” “I’m sorry,” the doctor says, assuring her the medical team will keep trying. Perla calls her parents in Mexico and sobs, alone, at Our Lady of Guadalupe Catholic Church in Baytown. She lights a candle at the altar. The next day, she writes a Facebook post: “Don’t give up my love. Your family, our children and I need you so much and you have thousands of things to do, most of all to see your children grow. They love you with all their hearts and so do I.” ‘Beautiful eyes’ Jesus was 21, on a break from studying architecture at a public university in Morelia, when he first saw Perla at the cellphone store where she worked. “You have beautiful eyes,” he told her. She blushed. Jesus traveled from Morelia to her ranch in Cotija every weekend to visit her. As their love blossomed, Jesus considered leaving school to work in the U.S. and start a family. He introduced Perla to his parents, and his father predicted their lifelong union. “Oh boy, you’re stuck now,” Jose told Jesus. Perla reflects on those days while Jesus dangles over death in Baytown. Two days after she pleaded with the doctor to save her husband, Houston Methodist Hospital’s medical director of critical care, Dr. Faisal Masud, huddles with his colleagues in the Texas Medical Center. They face a difficult decision. They had selected Jesus and a handful of local patients as candidates for the hospital’s one available ECMO machine. But only the person most likely to survive will receive it. It’s a choice the team confronts every day during the worsening COVID surge. And the knowledge that patients who don’t make the cut will likely die weighs on Masud. Used in more than 11,300 COVID patients worldwide, ECMO, or extracorporeal membrane oxygenation, is the highest form of life support for patients with irreversible lung damage. But it’s an imperfect fix. Extended use can lead to severe blood infections, and about half of all ECMO patients die in the hospital. Methodist can operate up to 12 ECMOs at once. But the explosion of severe COVID patients, combined with a shortage of trained ECMO operators, forced hospitals nationwide to ration the device. As Masud and his team analyze their best ECMO candidates, Jesus meets three critical criteria: He is young and otherwise healthy with the damage isolated to the lungs. A nurse calls Perla at 7 a.m. Jesus has been accepted. Perla exhales. It’s a miracle. Medical staff wheel Jesus to a 10th-floor COVID-surge unit, to a room along a hallway with a grim moniker: ECMO alley. Goodarzi is the first to assess Jesus for a possible transplant. The doctor places his stethoscope against Jesus’ chest and hears the sound of total organ failure: nothing but the faint hum of the mechanical ventilator. He checks the rest of his body. No other infections. The rest of his organs perform well. He glances at Jesus’ chart. “Wow,” Goodarzi thinks. “Twenty-nine.” Before the pandemic, the vast majority of Goodarzi’s patients were older people with late-stage lung disease who rarely needed extended life-support. Now, the virus is sending him a rush of otherwise healthy young people with lungs scarred beyond repair, on a last-ditch machine that can cause further damage. The pattern is a unique feature of the delta surge, now rising with Texas reporting up to 16,900 new daily cases. While the older population largely took advantage of vaccine availability in early 2021, young people are dragging their feet, leaving them more vulnerable to hospitalization. The sickest ones often suffer from prolonged COVID pneumonia, which, if left untreated, can lead to severe scarring that lingers well beyond the COVID infection. In Jesus’ case, the pneumonia became so relentless that it caused permanent and widespread scarring, essentially transforming his lungs into nothing more than shells. Goodarzi darts across the sky bridge over Fannin Street to discuss Jesus’ case with Dr. Howard Huang, medical director of the hospital’s lung transplant program. “It’s going to be a long road for him,” Goodarzi tells Huang in a 26th-floor hallway. “But still, I’d like to evaluate him.” Huang agrees. The doctors are unsure Jesus and his family have the resources to pay for an operation that could cost up to $1.2 million, including the hospital and recovery expenses, much of which won’t be covered by insurance. The Kiewit Corporation, which owns the construction company that hired Jesus, has not yet approved his coverage. But the clock is ticking. Jesus is malnourished, causing his body to eat his muscles and fat to stay alive. If he does not improve enough to rehabilitate, they will be forced to consider disconnecting him from ECMO, to offer the machine to someone with better odds. Nightmares Immobilized on the machine, the strength through which Jesus supported himself and his family — muscles that first budded during long, hard summers harvesting sugarcane on his ranch in Cotija — disappears completely. A week after Goodarzi’s first assessment, Jesus struggles to sit up in bed. He cannot stand without nurses and physical therapists propping him up. Still supported by a ventilator, he can only nod “yes” and “no” during video calls with Perla, who is not yet allowed to visit in person. During a strength test, in which Huang asks Jesus to squeeze his hand, the doctor notes a feeble grip. At least he is awake and following commands, Huang thinks. That’s enough progress to keep Jesus in the transplant conversation. Huang reminds himself to be patient. In his 16 years in critical care, he’s never dealt with this many young people who need extended ECMO treatment, and it’s forcing him to learn more about the amount of abuse the human body can take. Under the surface, Jesus is breaking down mentally. When he closes his eyes at night, he sees himself at the bottom of a pit filled with dead bodies. Monsters chase him. His medication blurs the boundary between nightmares and reality. For Perla, the boundary no longer exists. Sleep eludes her. So do answers. She does not fully understand what is happening to him. She lights a Virgen de Guadalupe candle and prays. Her mind races, and she worries what to tell the children. “I’m not strong enough for this,” she tells herself. When a COVID survivor's lungs are permanently damaged, it's not just medical decisions that decide whether they get a transplant. Slow steps Three weeks later, nurses and physical therapists scurry around Jesus, adjusting IV lines and wires growing like vines from his gown. Perla holds his hand, whispering encouragement as he sits in a chair next to his bed, preparing to walk. “One more day of this is one day closer to getting out,” she says, her long black hair draped in a ponytail over her shoulder. Jesus nods and stares at his running shoes. Jesus and Perla promised never to leave each other at their 2014 wedding in front of more than 400 family members and friends at an ornate Catholic cathedral in Cotija. So when Jesus tested negative for COVID in early September and transferred to a ninth-floor ICU, where visitors were permitted, she made the hourlong drive to the hospital every day from Baytown. Jesus’ mechanical ventilator has been removed, but a breathing mask covers his mouth. A man of few words even before COVID stole his breath, he communicates mostly with his eyes and subtle head movements. His usually short, tidy hair twists around the ECMO tube, which surgeons had plunged into his heart through his jugular and strapped to his head. He grips the handlebars of a standing frame — a mechanism that will help him stand and stay balanced. He’s done this before. He started walking last week, after a brief bout with a bacterial infection, but made it only 20 feet outside of his room. Today, he has bigger plans. “How far are we going?” asks the physical therapist, Catherine Stolboushkin. “As far as I can make it,” he mutters into his mask. “Hey, I’m down,” she says. “Let’s go.” Perla watches the rolling circus as Jesus gingerly advances on calf muscles as skinny as forearms, surrounded by medical workers, oxygen tanks, the ECMO machine, a chair, his IV bags and vital sign monitors. He barks empty coughs as he arrives at his usual stopping point — and presses on. “You OK?” Stolboushkin asks. Jesus nods. “Are you sure?” Another nod. Jesus creeps past other rooms — 25 feet, 35 feet, 40 feet — around the main desk at the end of the hallway before resting about 50 feet from where he began. “What was that?” Stolboushkin shouts. “Where did that come from? Are you kidding me? Very nice!” “Muy bien!” Perla cheers, over and over, her eyes watery and crinkled at the edges by a smile. She bumps her forehead against his, then pecks a kiss through her mask. Later, in Jesus’ room, with the medical staff gone and the celebration over, exhaustion sets in. Jesus thinks about Victoria and Erick. He turns to Perla. “I just want to get out of here.” Denied With Perla at his side, Jesus improves dramatically. He walks in circles around the ninth-floor ICU, blaring Imagine Dragons and norteño music from a small speaker dangling from his rolling IV. He no longer needs the full support from his ECMO machine. He sketches Perla and the house he one day wants to build. The color slowly returns to his face. Jesus’ mother, Evangelina, signs on as the additional caregiver needed for him to make the list. By the end of September, the transplant committee is notified that the Kiewit Corporation has approved his health insurance coverage. For the first time in months, the road seems smooth. Until Perla receives a phone call from a Kiewit representative. Jesus has not worked for the company long enough to be eligible for insurance, the representative tells her. “Craft employees,” like Jesus, are eligible for medical benefits and short-term disability only on the first day of the month following 60 days of active employment, according to company policy. Jesus had worked for two weeks before he became sick and did not inform Kiewit his absence was related to the virus, the company said. Gabriel is angry and confused. He remembers texting his supervisor about Jesus’ positive test in July. In one instant, the news demolishes the significance of Jesus’ physical progress. Without insurance, Jesus cannot remain on the waiting list. Plus, he and Perla need the money desperately. Perla qualifies for federal assistance to feed herself and the kids, and Jesus’ family sends money, but that barely covers the ceaseless stream of bills for rent, car insurance, credit cards and phones. “What are we going to do?” Perla asks Gabriel during one of their regular phone calls. “He needs this insurance.” ‘It’s so big out there’ Money. The thought that after everything he’d seen Jesus accomplish — peeling himself from bed and inching across the ICU with a tube snaking from his body — could be discounted because of money frustrates Huang. He knows social or financial factors often hold up the process, but Jesus is among his most physically capable candidates. Doesn’t he deserve a shot at the American dream that called him to that Louisiana factory in the first place? Huang wishes for an easy fix. But there are rules. Jesus is placed on a hold, meaning he won’t be active on the transplant list until the insurance issues are resolved. Perla spends a day making frantic phone calls to Jesus’ company and public insurance providers. As the transplant committee discusses options, Huang stresses the medical urgency of Jesus’ situation. Every minute Jesus is inactive on the list could mean a missed opportunity for the perfect pair of lungs. After days of purgatorial pleading, Perla receives a call from a Methodist social worker: The hospital will pay for Jesus’ hospital bills and the first weeks of his recovery through a federal reimbursement program. The social worker also offers to help Perla find insurance through the Affordable Care Act. The solution is temporary. Jesus and Perla still face a pile of medical bills down the road. But it’s enough to move Jesus to active status on the national transplant waiting list, among 1,000 other active candidates. Perla shows her happiness around Jesus, but inside, she tries to control her excitement. More challenges lie ahead. Jesus must match with a donor who is compatible with his blood type, tissue type and chest size. The organs have to be in good condition — and preferably nearby, since lungs can be preserved on ice only for six to eight hours. The wait could last days, weeks or months. The longer Jesus lingers, the higher his chances are for complications that could delay or derail the process. During Jesus’ walk the following week, he asks to peer out one of the hospital’s large windows, his first glimpse outside in more than two months. With Perla close to him, he stares at the sun-drenched trees and the city beyond. “It’s so big out there,” he mumbles. “Soon, you’ll be able to go outside,” Perla says. “If you continue how you’re going, you’ll be there.” Chapter 2: The match Warning: This chapter includes graphic photos from a surgery ‘What’s meant for me will be there for me’ Jesus Ceja Ceja weeps uncontrollably as Houston Methodist Hospital music therapist Elizabeth Laguaite croons a Spanish-language song about miracles. It’s nearing noon on Nov. 4, and Jesus’ lung transplant — the only operation that can save his life from a destructive COVID infection — appears imminent. After waiting three weeks for a donor with a healthy, compatible set of lungs, the hospital’s transplant team believes it found one. Sitting up in bed, Jesus dabs his eyes with a blanket and mouths the words of the song, “Way Maker” by Priscilla Bueno, while Laguaite strums her guitar, singing in soprano. It reminds Jesus of his father, Jose Ceja, a rancher and harmonica player who died of COVID in Mexico months earlier. Way maker, Miracle worker, Promise keeper, Light in the darkness Miles away from the hospital, members of Methodist’s transplant team prepare to remove the donor lungs, which must survive one final examination before being transported to the hospital and stitched into Jesus’ chest. In his room, Jesus does not think about the transplant ending his life early, or the lifelong cocktail of medications he will be forced to take after the surgery. He just wants to leave the hospital and be with his family, even if that means he can no longer support them as a migrant worker who frequently traveled from their home in Cotija de la Paz to the United States for well-paying, physically taxing jobs. His wife, Perla Munguia Ceja, sits at his bedside, stroking his forearm. A muted Telemundo reports the “coldest day so far this year,” a cloudy 55 degrees. They are emotional, but faith and patience calm their nerves. “What’s meant for me will be there for me,” Jesus tells Perla, not for the first time. Six floors below them, in a quiet surgical lounge, Dr. Erik Eddie Suarez, the hospital’s 47-year-old surgical program director of heart and lung transplantation, tries to relax before Jesus’ surgery, slowly eating a yogurt and thumbing through the news on his phone. The five-plus-hour procedure won’t be easy: The blood vessels that feed the lungs carry all of the body’s blood, and the slightest tear or misplaced incision can lead to catastrophic bleeding. Suarez likens a typical transplant to separating noodles in a bowl of spaghetti without tearing them. Critically ill COVID patients such as Jesus look different — like someone poured concrete into that bowl and let it set. The virus can cause such severe scarring that the lungs, blood vessels and arteries fuse together inside the chest cavity — increasing the chances of severe bleeding. It will be Suarez’s job to carefully separate the blood vessels and arteries to cut the diseased organ from the body. It’s 1:15 p.m. when Suarez receives a text from a member of the retrieval team: “We need to talk.” There’s a problem with the lungs. ‘I can’t do this’ Three weeks earlier Jesus’ daily physical therapy sessions are becoming too easy for him. Last month, in September, walking 50 feet down one hallway was a huge accomplishment. Now, in mid-October, he walks multiple laps around the ICU while connected to his life-support machine, pulling along the posse of medical workers who support him. After meeting the requirements to earn a spot on the national organ waiting list, he works to build strength for his next hurdle: matching with a donor. The process is a logistical feat that hinges on mathematical calculations and surgical intuition. All adult lung transplant candidates who make the list are assigned a Lung Allocation Score — a grade between 0 and 100 that determines their rank based on the urgency of the operation and the chances of post-surgery success. The higher the score, the higher the position on the list. Jesus’ score of 90.3 puts him in the top 1 percent of roughly 1,000 active candidates nationally, giving him priority for the next available donor who meets his compatibility requirements, which include matching blood and tissue type. The match generates automatically. After a donor is declared brain dead, the regional organ procurement organization inputs their medical information into the national database, where an algorithm compares that information with the candidate’s requirements. If Jesus registers a match, Methodist’s transplant team will be instantly notified and have a chance to further examine the donor lungs. And Jesus needs a match quickly, due to his reliance on ECMO, an aggressive life-support machine that oxygenates the blood in the body. He learns about this complication the hard way on Oct. 14, when he registers a fever and a deep weariness chains him to his bed, as if all the strength he rebuilt during physical therapy had evaporated. He can’t walk and loses his days in sleep. Through lab tests, doctors confirm another blood infection — this one worse than the one he suffered in early September. He becomes too sick for a transplant, and he is inactivated from the waitlist he worked so hard to reach. Doubt stalks a demoralized Jesus and Perla, who wonder: How much longer will this fight continue? He’s been hospitalized on life support for two months now, not including the 11 days he spent on a ventilator in a Baytown ICU. He was lucky to find a bed at Houston Methodist Hospital in late July, when the delta variant launched a punishing surge of infections that peaked on Sept. 8 with 25,200 new daily cases across Texas. The blood infection has taken hold at the tail end of that wave, as life outside the hospital settles into normalcy. For Perla, it spoils the illusion that Jesus battled through the worst. Her prayers are not enough to hold back her tears, which escape every evening during the hourlong drive from the hospital to Jesus’ trailer in Baytown. Jesus turns to his mother, Evangelina, who is now helping Perla support him. “I can’t do this,” Jesus tells her. “I’m so tired.” The message disturbs a matriarch still grieving for her husband, as the virus that took her spouse now appears to be claiming her youngest child. Jesus’ siblings worry, too. His oldest brother, Gabriel, has not seen him in person since Jesus first entered the Baytown ICU. But on Oct. 16, Gabriel takes time off from his job at a natural gas plant, where the brothers worked together until Jesus’ COVID diagnosis, to visit Jesus. Gabriel sits by Jesus’ bed in silence, watching him slumber under layers of blankets, warily eyeing his brother’s whitish-yellow face. After a few minutes, his eyes flutter open. If Gabriel had seen his brother days earlier, Jesus would have cracked a smile and asked how work was going. Maybe Jesus would have repeated the same thing he always told “Gabo” during their calls: I’m going to fight, every day, always. But on this day, Jesus can barely speak. “Don’t worry,” Gabriel whispers. “Just go back to sleep.” Gabriel’s usually optimistic personality wilts. When he drives back to his Baytown home, he feels he may have seen his little brother for the last time. A match There is no exact science that determines how long a person can be connected to ECMO, but COVID is testing the limits at hospitals nationwide. In early 2020, surgical and critical care specialists at Methodist considered removing COVID patients from the machine after two to three weeks if they did not improve. Before the pandemic, most people either recovered or died within that time frame, so doctors thought it was futile to keep someone plugged in longer. A small number of transplant candidates needed the machine to make it to surgery, but with such little research available on the new virus, lung transplants were considered too risky for COVID patients. Then, late in that spring, early evidence from COVID hot spots such as New York, Paris and Italy forced hospitals to reconsider the possibilities. Some critically ill patients began recovering after extended ECMO courses, as the machine gave the lungs an opportunity to heal and rehabilitate. For people such as Jesus, with irreversible damage, transplants emerged as a viable option in June 2020 and provided yet another reason to prolong ECMO. Now, nearly all of the 17 COVID patients who received lung transplants before Jesus at Houston Methodist Hospital did so after long ECMO courses. And they all risked facing the kind of severe infection that fractured Jesus’ will to live. But Jesus does not quit easily. Sitting on his bedside tray is a small paper booklet made by his 7-year-old daughter, Victoria, containing family photos, reminding him of the love awaiting him outside the hospital. After a week of steady antibiotics, the bacteria clears from his blood, and he is reactivated on the waitlist. Multiple donors match with Jesus over the next several days, but something is always off: size, bloodwork or tissue. The transplant team consistently declines the offers, none of which is serious enough to notify Jesus and Perla. Until the night of Nov. 3, when a donor with a seemingly perfect set of lungs matches with Jesus. Suarez, the surgeon on duty at the time, accepts the organs, despite one concern: a dark shadow on the X-ray image at the bottom of the right lung. Suarez thinks it might be a quick fix. A compressed lung, maybe. Dr. Dewei Ren, the transplant surgeon on the retrieval team, will need to investigate further. Dry run Transplant coordinators Edel Rodriguez Zubiaur and Manuel Rodriguez jump into action at the hospital, hastily typing consent forms, documenting the donor’s information and ordering nurses to discontinue certain medications for Jesus before surgery the next day. Perla arrives at the hospital around 8 p.m. to fill out paperwork with Jesus. The coordinators explain how the recovery process will work but leave out the donor’s identity, which is heavily guarded information during lung transplants. Jesus can learn the person’s identity only after the surgery, through a careful process facilitated by the hospital and the donor’s organ procurement organization, if Jesus and the donor’s family want to know. Paperwork complete, Perla drives home for a good night’s rest. When she returns the next morning, Laguaite’s music slows time for the couple, as they lean into each other, finding strength in held hands and the little contact Jesus can offer. Downstairs, Zubiaur uses his phone like an appendage, delivering constant updates from the retrieval team to Suarez, the top decision maker. “The team just arrived at the hospital.” “The donor is in the OR.” “Ren is preparing to make his incision.” At the donor hospital, Ren touches the bottom of the right lung where the shadow appears on the X-ray and feels a hard, rubbery texture, like a tire, where he should feel a light and spongy surface. Pneumonia. The transplant coordinator on the retrieval team informs a disappointed Suarez and Zubiaur. With a patient as sick as Jesus, Suarez has no choice but to reject the lungs. Last-minute problems halt the transplant process in roughly 15 percent of matches. When candidates are notified of a match, but ultimately never receive the lungs, it’s known as a “dry run.” It’s a relatively routine part of Suarez’s job, yet he can’t help but feel deflated for Jesus, who may not have time for another opportunity. He delivers the news to the couple in Spanish: With these lungs, he explains, Jesus would likely die. He urges them not to give up hope. Jesus and Perla’s eyes meet without a hint of sadness. They trust the doctor. If they made it this far, they can wait for the right set of lungs. Adrenaline So they wait. For 15 days. Then finally, the call comes. It’s 1 a.m. Nov. 19 when Perla’s phone flashes in the dark night, ringing with news from Jesus: He matched with another donor. Propelled by adrenaline, Perla can’t fall back asleep and instead packs for a long day in the hospital. They pass the hours calmly, silently watching TV in Jesus’ room, not knowing about the chaos unfolding on the opposite end of the ICU, where a man lay dying, his oxygen levels dropping fast. Suarez and another transplant surgeon, Dr. Ray Chihara, rush to connect the patient to ECMO. In unison, the surgeons quickly navigate guide wires, then ECMO tubes, into each of the man’s femoral veins in the upper thigh. A phone rings on a counter 5 feet away. “Is that me?” Suarez asks the room buzzing with hurried nurses and ECMO operators. “No, that’s my phone,” Chihara replies. Suarez is awaiting a call from the retrieval team with information about the lungs Jesus matched with hours earlier. After 15 minutes, the patient is connected, and Suarez leaves the room, ripping off his gown and bloody gloves, to take a call from the retrieval surgeon, Dr. Philip Chou. “No pneumonia?” Suarez asks. “Nice and soft?” “The lungs are good,” Chou says. “OK, we’ll get going then,” Suarez says, upbeat. Twenty-one hours after the 1 a.m. phone call, at 10:05 p.m., Perla cradles Jesus’ face and whispers her final “I love you” before the staff whisks him into an elevator for surgery. The transplant Jesus lies anesthetized with his arms pointing toward the ceiling, wrapped and bent at the elbows, as Suarez makes his first incision. The surgeon slides his scalpel from armpit to armpit, tracing the line he drew with a black marker, curving underneath each of Jesus’ pectorals and between his ribs. He trades his scalpel for an electric pen, which he uses to cut and cauterize the thicker layers of fat, muscle and bone that conceal Jesus’ organs. The pungent smell of burning flesh overwhelms the room, as Jesus’ chest creeps open like the hood of a car. Light beams down onto the exposed chest cavity from overhead lamps and the surgeons’ black-rimmed glasses. The surgeons use forceps to tease and dissect bits of soft tissue. At 11:59 p.m., Jesus’ lungs come into view, red and scarred, pulsating with the rhythm of his beating heart. A phone rings. Chou is calling. Frank Martinez, the transplant coordinator in the operating room, holds the phone up to Suarez’s ear, so the surgeon can keep his gloved hands sterile. “Everything OK?” Suarez asks, concerned. “We just got the lungs,” Chou says. “We’re on our way back.” Chou says he ran into a delay in the operating room. Suarez realizes he and Chihara will need to pause the surgery to give them time, once they finish the delicate work of separating Jesus’ pulmonary arteries and veins that flow to and from the heart. Slowly, with delicate cutting and prodding, they identify these critical highways of blood. The severity of Jesus’ inflammation and scarring has made it difficult to pull them apart. The surgeons move calmly to avoid any misstep around a main artery, which would kill Jesus in seconds. He is already bloody — very bloody — but Suarez has seen worse. So far, he and Chihara can control it with steady drainage. “I feel the airway right there,” says Chihara, identifying a key connection they need to sever. With the arteries and vessels separated, the surgeons save the major cuts for later. They leave Jesus’ open body in the OR with perfusionists and anesthesiologists and fall back to the now dark surgical lounge to rest their eyes for 20 minutes. The digital clock on the operating room wall says 1:58 a.m. when Suarez and Chihara cut away Jesus’ diseased left lung and place it in a plastic tray, gnarled and dead, as red as the blood draining from Jesus’ body. The song “comethru” by Jeremy Zucker plays as Suarez operates in Jesus’ half-empty chest, cauterizing blood vessels to prevent further bleeding. At 2:05 a.m., Chou finally arrives, rolling a blue ice chest along the outer edges of the operating room. Suarez steps away from Jesus and pulls the donor lungs from an ice-filled plastic bag. Without blood flow, the lungs appear white with portions of pale pink. Suarez probes the loose tunnels that will supply Jesus’ body with oxygen, then places the lungs on Jesus’ stomach and separates them. He replaces the left lung first, meticulously suturing the passageways together, like the airtight pipelines Jesus insulated at Gulf Coast refineries. With the left lung attached, the blood flow changes the color of the deflated organ to a deep pink and purple. Suarez pinches a loose flap of tissue and asks the anesthesiologist to inflate it through a ventilator. As it grows and tightens with air, the pink overwhelms the purple. Suarez squeezes the lung, pushing air into every corner, until the inflated organ fills the empty space on the left side of Jesus’ chest, dwarfing the dead lung on his right. Suarez releases a long exhale, then turns to Chihara. “OK,” he says. “Switch sides.” Exhausted from the long, restless day, Perla sleeps in Jesus’ F-150 parked in a chilly medical center parking garage. Her phone wakes her again. She looks at the screen: It’s 5:26 a.m., and the hospital is calling. She immediately picks up. Suarez greets her and explains in Spanish: Jesus is recovering in the OR after a successful surgery. He’ll be in pain when he awakes, the doctor says, and he may need to go back to the operating room. But it’s all part of the process. Perla begins to cry. “When can I see him?” she asks. “In about an hour.” Perla walks back to the hospital, exhausted, alone and happy. Soon, they can leave this place, hopefully in time to spend Christmas together as a family. Chapter 3: Recovery ‘A new man’ Jesus Ceja Ceja pulls up his T-shirt and gazes at the black scar that curves across his chest like a “W.” Stitches seal four holes on his stomach, where drainage tubes penetrated his body, and a fifth hole on his neck from his life-support machine. “I feel like Frankenstein,” he tells his wife, Perla Munguia Ceja, and his mother, Evangelina Ceja Aguilar, in a fourth-floor room in Houston Methodist Hospital’s Dunn Tower. “I don’t even want to know how they opened me up.” It’s 7 p.m. on Dec. 7, four months to the day since he entered the Houston hospital with a COVID infection that destroyed his lungs and three weeks since his double-lung transplant. The 29-year-old has already changed out of his hospital gown into a comfortable shirt and black-and-gray checkered sweats. A nurse removed the final IV from his arm — his last remaining link to a machine. And the staff that became his family in the ICU filed into the room to say their emotional goodbyes. It’s time to go home. Jesus can finally breathe on his own with enough strength to continue outpatient physical rehabilitation. Perla packs the 22 medications that Jesus must take every day for the next year before weaning down to 10. Immunosuppressants will become a permanent fixture in his life to stave off rejection, a common threat for transplant recipients whose immune systems attack the new lungs as if they were a virus. The same drugs also will make Jesus more susceptible to severe illness, so the transplant team urges him to be careful, especially as the pandemic persists. The state is reporting about 3,500 new cases per day, a far cry from the 25,000 recorded during the peak of the delta surge in early September. But another wave is possible: Just the day before, Harris County Judge Lina Hidalgo announced the first local confirmed case of the omicron variant, a COVID mutation with unprecedented contagiousness. Jesus now must avoid simple pleasures such as smoke from a barbecue grill, alcohol, unpasteurized cheese and carbonated beverages, like soda and Topo Chico, all of which can cause lung infection or irritation. Underpinning his new lifestyle is a looming reality: Only about 60 percent of lung transplant recipients survive after five years, and just 33 percent survive after 10 years. As he prepares to leave, the staff presents him with a departing gift: a framed poem, “Another Chance” by Helen Steiner Rice, about creating a new beginning. He reads the Spanish translation and buries his face in Perla’s arms, crying. After questioning for months whether he’d make it this far, he confronts a new challenge: As someone who built his life around the type of physical labor he is now restricted from, how will he forge his new identity? A seasonal worker who frequently traveled from his home in Cotija de la Paz, Michoacán, to the United States, Jesus took pride in his specialty as a pipe insulator at petrochemical plants. He easily found work with industrial contractors and often served as a team leader, directing groups of older and more experienced men. The job gave him a purpose, but it also forced him to be around gasses and chemicals that would damage his new lungs. He has experience working construction and fixing cars, but that requires strength that might take him years to rebuild. Perla, who also grew up on a ranch in Cotija, does not have time to work. She will be consumed with caring for Jesus, their 7-year-old daughter, Victoria, and 3-year-old son, Erick. For now, they rely on federal food benefits, money from family, modest donations and the hospital’s financial assistance program. Jesus rolls out of the hospital in a wheelchair into the brisk 65-degree air that makes him retreat back inside for warmth. Evangelina rubs his shoulders as he stares out the window at the bustling sidewalk and long line of cars, waiting for Perla to drive up in his F-150. Baytown awaits. Mirrors It was always hard for Jesus to leave the comfort of his family’s ranch in Cotija for Baytown, but living in the industrialized hub allowed him to commute to his temporary worksites in the Gulf Coast region. He rented a small trailer, nearly as wide as his wingspan, to serve as a home base when he found temporary lodging closer to his jobs. Even when he lived with roommates, he felt lonely without Perla and the kids. But he had to press on. The work carved their only reliable path to the United States. The couple wanted to build something of their own, separate from their ranches that brought their families so much serenity and so little income. Many people in Cotija work seasonally in the United States to support their lives in Mexico. But Perla, a U.S. citizen, and Jesus, a lawful permanent resident, wanted a place to raise their growing family with steady work, security and a good education for the kids. They thought the COVID infection wiped out that future. Now, settling down in their desired destination, they begin to weave a different version. Jesus stands in the sparsely furnished living room of their new three-bedroom home that Perla found on the north side of Baytown, across from a mobile home park. A “bienvenido a casa” banner hangs on the wall beside a small TV on a dresser. All of his belongings are piled in boxes in the back room. “Well done,” says Jesus, impressed with the space. It’s more than enough for him, Perla and the kids, who are visiting family in Mexico but will return soon. Perla is picking them up next week. Jesus’ slow footsteps echo on the wood floors as he walks, quietly, into the bedroom and runs his hand over the blue plush blanket on their bed. A real bed. When he sits on the mattress, he faces the mirrors on the sliding closet doors, inspecting his beaten body. His 5-foot-7-inch frame weighs 137 pounds, down from his pre-COVID weight of 200 pounds. His black hair is thinner, his face marked by the straps of various breathing devices. What he sees matches how he feels. His newfound breath is weak and irregular, which is to be expected from a transplant patient off life support. He also struggles to comprehend that someone else’s organs live inside his body. Someone who had to die to give him life. It’s a strange feeling — one that’s difficult for him to describe. He doesn’t want to know anything about the donor or even the surgery. To him, those are unsettling facts that will only distract him from the recovery process. He wonders if he will ever feel like his old self, the man who never stopped moving. When Jesus was a boy, no older than 13, he and his seven siblings woke at dawn to chop the stalks of sugarcane covering their family’s ranch. Nestled in the mountains, the land was passed down from his father’s father, and the kids accepted the difficult work as a part of life. Jesus enjoyed carrying on his ancestors’ legacy, but as he grew up, he gravitated toward other interests. He learned how to fix cars, using Google as a guide, tinkering in his teenage years with his father’s Volkswagen Beetle. He had a knack for taking things apart and putting them back together. That ingenuity lent itself to architecture, which he briefly studied in Mexico until he met Perla and started a family. For the last four years, he bounced from 12-hour shifts on one side of the U.S.-Mexico border to parties and cherished family time on the other. In Cotija, he danced with Perla at festivals, carried the kids around their ranches and sang with his father and cousins outside a small market owned by his grandfather. As his changed face reflects back at him from the mirrors, his mournful thoughts of the past compete with the joy of being home. He walks to the kitchen to give himself an insulin shot and pricks his finger for his nightly blood sugar reading. Perla records the results in a book from the hospital. Later, Jesus takes a plastic cup filled with his daily pills, swallowing the first three one at a time, then knocking the rest back like a tequila shot. Reunion One week later Victoria beats her mother to the front door and runs straight to the bedroom, where her father lies in bed. “Papi!” she bursts as she jumps on the mattress and embraces Jesus for the first time since he left Cotija in early July. “I missed you.” Jesus kisses her cheek. A tear runs down his face. Victoria pulls back, and they study each other with nearly identical eyes. “I missed you, too,” he says. Erick, always shy, waits in the living room for a few minutes before wandering into the bedroom for his hug. Their arrival rejuvenates Jesus, who has been waking up at 3 a.m. with the sudden sensation of falling. He doesn’t remember his nightmares, but he thinks stress is triggering them. He worries about the amount of responsibility placed on Perla, who has shouldered the burden of paying the bills and finding a home. Now, she manages his strict daily recovery regimen, including clinic visits, physical therapy and breathing exercises. He feels like her third child. But those concerns melt as he sinks into a comfortable chair in the living room with the kids orbiting around him. Victoria shows him her new toys — a princess doll and a plastic horse, like the one she loves riding at Perla’s ranch. She fetches Jesus a cookie from the kitchen, then plops down on the arm of the chair, cradles his head and smacks a kiss on his forehead. She hands him a book, then a pillow. And by the way, she says, they have to watch “Sing 2” together. Erick, brimming with unchecked energy that reminds Jesus of himself as a child, crashes Hot Wheels on the floor and flails around with a flashlight, eventually holding the light up to the scar on his father’s neck. “What happened?” he asks, closely analyzing. “I got an injection,” Jesus replies, innocently. Erick grabs a nearby napkin and places it on the scar. “Leave it there,” the 3-year-old says. “So you’ll be better by tomorrow.” Jesus smiles and obeys. Perla giggles nearby. Jesus’ body does not let him enjoy the moment for long. After a few minutes, he yawns and drifts to the bedroom for a nap. Lingering fatigue is normal for people with newly transplanted lungs. Jesus will need about three months to regain enough energy to do normal tasks, such as driving and household chores. But later that night, he struggles more than usual for air. He checks his oxygen level, and the number worries him: 87 percent. He should be in the 90s. Something is wrong. ‘Why me?’ The next morning, Perla drives Jesus to his weekly appointment at Houston Methodist’s outpatient clinic in the Texas Medical Center, where he undergoes a series of tests that gauge his lung function. A COVID nasal swab is part of the process. The result comes back within a few hours: Positive. He and Perla don’t believe it. Dr. Howard Huang, medical director of the hospital’s lung transplant program, is notified immediately. He looks at Jesus’ X-rays and sees a haze covering his lungs, indicating inflammation consistent with his shortness of breath and cough. It’s unclear whether Jesus is battling COVID, another type of infection or lung rejection. Either way, Jesus must be readmitted with an aggressive treatment plan that includes monoclonal antibody therapy and remdesivir, an antiviral drug commonly used to treat the virus. In his weakened state, even a mild COVID infection could send him back to where he started, battling for his life in the ICU. “Why me?” is all Jesus can think as he dons another hospital gown in a smaller room than his old one, with less nursing attention and no visitors allowed. He is now fully vaccinated — a necessity for someone living with a suppressed immune system. He received two Pfizer doses while waiting for his transplant. Still, studies show immunocompromised people with one or two doses of the vaccine face a greater risk of breakthrough infections than people without immune dysfunction. And the ultra-contagious omicron variant is proving to sidestep immunity. That worries doctors, who note that Jesus’ symptoms are consistent with the virus, even though a string of negative COVID test results following the first positive test cloud his diagnosis. “How could this have happened?” Perla wonders. It couldn’t be the kids, she thinks, because Jesus told her about shortness of breath hours before they arrived. She and Evangelina, the only other people around him, are fully vaccinated and test negative. Jesus’ family braces for more bad news when, amid the confusion and worry, he responds to the COVID treatment. He bounces back within a few days and calls Perla from the hospital, bored and missing Victoria and Erick after their sole, too-short visit. The sight of a healthier Jesus makes Perla feel confident and in control for the first time in months after having gone through her own metamorphosis in the hospital. Her English is sharper from daily conversations with social workers, nurses and doctors. She stays organized, keeping track of Jesus’ progress with detailed notes in a daily planner. And the home she rented for the family fills her with pride. Their financial burden also has become less intimidating. Perla enrolled in an insurance plan with Community Health Choice, a local nonprofit insurer, and Houston Methodist has agreed to pay for the first year of premiums. She and Jesus can reapply for another year when that money runs out. Now, she focuses on bringing Jesus home in time for Christmas — their first in the United States. They had planned to host their largest gathering yet in the new house, with Jesus’ oldest brother, Gabriel, and his older sister, Yadira, joining them. It’s all Jesus wants. “I’m going to get better for you guys; I promise,” he declares during a video call with Gabriel. Christmas Eve Jesus’ side effects dissipate just in time for a Dec. 22 discharge. Christmas Eve in Baytown feels like their old life in Mexico. The smell of birria, which his late father always stewed to perfection, wafts from the kitchen throughout the busy house. A stump of Cotija cheese sits on the counter, waiting to be crumbled onto full plates. Norteño music plays on a Bluetooth speaker. Wrapped gifts rest under the Christmas tree in the living room, concealing more toy cars for Erick and Barbies for Victoria. A photo of Jose sits on a mantle in the corner, high above everything. Perla is already dressed up, wearing a pink polka-dotted blouse and black jeans, helping the kids get ready while Evangelina and Yadira prepare the food. Gabriel is in the back room with Yadira’s husband and Jesus, giving his brother a haircut, talking trash like they’ve done for years. “Man, you look terrible,” Gabriel says. “After I’m done you’ll look handsome.” “Don’t be an a--hole,” Jesus says, smiling. Gabriel gives Jesus his usual fade with the clippers. Jesus checks himself in a handheld mirror. “I look like a new man,” he says. The comment makes Gabriel sneak away to another room to cry. It’s like a dream for him to be cutting Jesus’ hair again. In the hospital, his little brother repeatedly asked him for a trim, and Gabriel thought he might not have the chance. Jesus also retreats into his room to change from his sweats into jeans and a blue button-up. He slides into a pair of boots, wobbly around his slim legs. Perla helps squeeze the straps into his pants and stands with him in front of the closet mirrors. She tugs at the front of his shirt, pulling the loose fabric. Each time Jesus looks in the mirror, at his scars and gaunt features, he reminds himself that he’s still breathing. The weakness lingers, but he feels more energetic than when he returned home, with a clearer path to recovery. Thoughts about the future simmer in his head. Maybe he can be a mechanic? Or possibly he and Perla can sell birria? He longs to provide for his family again. But he stops himself from thinking too far ahead, about the dormant question locked in the back of his mind: How much longer do I have? Instead, he tells himself to focus on the present, on the bits of progress in physical therapy, the satisfaction of a full breath, the intimate moments with his family, and the plate of green chicken enchiladas Evangelina brings him in the kitchen. Seated at the head of the dining room table, he is finally surrounded by the people who gave him a reason to live — the faces he thought he lost forever. In the kitchen 10 feet away, Evangelina and Yadira load more plates with enchiladas and birria. Gabriel slices up the Cotija cheese before taking a seat with his brother. Perla puts away the insulin shot Jesus just gave himself, then hovers around the table. Victoria darts past everyone, toward the Christmas presents. Jesus looks up from his food. “To enjoy all of this is a beautiful thing,” he says. About the series When the delta wave of COVID-19 hit Houston in the summer of 2021, hospitals were pushed to capacity as a surge of unvaccinated patients required intensive care. By early September, the state of Texas logged more than 25,000 new cases of COVID-19 per day. It was during this swell that Houston Chronicle photographer Godofredo Vásquez and reporter Julian Gill first met Jesus Ceja Ceja, a young, unvaccinated father of two fighting for his life in a 10th-floor hospital room at Houston Methodist. Over the next several months, Godofredo and Julian visited Jesus at least once a week, logging more than 100 hours’ worth of interviews and time spent photographing his journey. This project, Transplanted, follows Jesus’s journey - from his very first symptoms, to his battle to make the waiting list for a double lung transplant, and all the challenges he faced along the way. How to help Ceja family GoFundMe Credits Julian Gill is a medical writer at the Houston Chronicle, where he has worked since 2018. He previously worked at the Denton Record-Chronicle, where after graduating from the University of North Texas he covered police and county government. His work at the Record-Chronicle earned him a first-place award in the Freedom of Information category at the 2019 Texas Associated Press Managing Editors conference, for his article on the overtime practices used by Denton Police Department to monitor the city’s red-light cameras. Follow him on Twitter @JulianGi11 or email him at Julian.Gill@chron.com Godofredo A. Vásquez is a staff photographer for the Houston Chronicle. Vásquez was born in El Salvador but grew up in the Bay Area, where he attended San Francisco State University and graduated with a B.A. in Photojournalism. In 2021, he was recognized as Star Photojournalist of the Year by the Texas Associated Press Managing Editors, receiving top honors for his work photographing the inside of a COVID-19 intensive care unit. Follow him on Twitter @godovasquez or email him at Godofredo.Vasquez@chron.com. Editor: Maggie Gordon Copy Editors: Charlie Crixell & Natalie Webster Design, Development & Web Production: Alexandra Kanik, Ken Ellis, & Jordan Ray-Hart Visual Editing: Jasmine Goldband Social: Dana Burke, John-Henry Perera & Laura Duclos Newsletters: Tommy Hamzik

A young dad clings to his only hope after a destructive COVID infection. It comes with a heavy price.

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