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Nathan Foote is overcome with emotion while nurses cheer him on as he departs from M Health Fairview University of Minnesota Medical Center In Minneapolis on May 3, 2021.
Nathan Foote is overcome with emotion while nurses cheer him on as he departs from M Health Fairview University of Minnesota Medical Center In Minneapolis on May 3, 2021. (Bonnie Jo Mount/Washington Post )

The lungs arrived in a chartered jet, hooked up to a machine to keep them warm and pumped with blood on their way to a transplant recipient.

Two surgical fellows delivered the fragile organs to Stephen Huddleston, a transplant surgeon at the University of Minnesota Medical Center, who won't even begin removing a patient's old lungs until the new ones are safely in his hands.

Nathan Foote was motionless on the operating table, already under anesthesia, his chest cut open in a clamshell incision. His lungs were so scarred from COVID-19 that doctors back home in Sioux Falls, S.D., told him he was going to die. The amateur rapper had posted a farewell video on his Facebook page, worried that he would die forgotten and alone in his hospital room. His wife brought their children to say their goodbyes.

That was December.

But Foote, then 42, got lucky. On Jan. 17, he was accepted as a candidate for a double lung transplant at the University of Minnesota Medical Center, one of about 200 COVID-19 survivors nationwide to receive new lungs since the coronavirus pandemic began.

Foote's life had been a story of tragedy and redemption. A member of the Rosebud Sioux tribe, he grew up on reservations and in tribal housing in South Dakota. He was sent to an Indian boarding school, where he was bullied and learned to fight back. At 16, he went to prison, ultimately serving two stints for a total 15 years on assault and drug convictions. He had found love with wife Angie, a hospital administrator, and in the past nine years left his drug habit and gang behind, embracing family life, music and his job installing tinted windows for an auto detailing shop. He'd kept working through the pandemic, largely dismissing COVID's threat, until he got sick in late October 2020.

Now he was getting another chance — albeit a long shot — at a new life, a crucible that would test his marriage and family and force him to confront his troubled past even as he hoped for a future.

Angie took three of their sons to the Mall of America to pass the time during the eight-hour surgery. She was in Foot Locker buying them shoes when the nurse called to say surgery had begun. Around 3 p.m., they were at Chick-fil-A when the nurse called back to say it was going well. And they were eating pizza that evening when Huddleston called to say the surgery was a success. It was a tough fit, Huddleston said, but he was able to "stuff" the lungs inside Nathan's chest cavity, which had shrunk during his long illness.

Angie saw Nathan a few hours later, covered in tubes and wires, but with color in his face for the first time in five months. He wouldn't be able to talk for a few days, but he used a text-to-voice app on his phone to communicate.

"I'm still alive," he wrote.

But for how long?

___

About three weeks after the transplant, Nathan's scar was healing, and he got dressed for the first time — in sweats and a Mickey Mouse T-shirt — preparing for a walk up the hospital corridor.

He had spent 12 weeks on the transplant waiting list, so long that Huddleston began to fear he would die before a match could be found. It was a lonely stretch. Angie was the only family member allowed to visit, so he got by on phone calls, including from his older brother Junior, who would call and talk for hours on end while on the road for his job as a truck driver.

About 80% of Nathan's lungs had been scarred after a two-month battle with COVID, doctors said, and by December, he was on such a high level of oxygen that home equipment could not sustain him. His lungs were becoming so brittle that eventually they would give out, doctors said.

On Jan. 5, before he was accepted as a transplant candidate, Nathan had gone live on Facebook from his dim hospital room, gasping for air as he tried to get the words out with an oxygen cannula in his nose.

"It's true, I don't have long to live," he said. "There's no way I'm going home ... COVID f---ed my lungs up so bad that I can't live without a machine. ... So now I sit and wait, I wait for death to come."

It was ironic, he said, because he had finally figured out how to stay out of prison and gotten his life together. "Crazy, huh?"

Angie brought their five children — now ages 8 to 18 — in one-by-one to say goodbye. Nathan asked the older boys step up around the house; he played Go Fish with the youngest, Kyous, who couldn't understand why everyone was crying. Then came the oldest, Naven, 18, who is transgender. The two had clashed for months over Nathan's refusal to use male pronouns for Naven.

"Could you just accept me as your son?" Naven asked.

"Does it mean that much to you?" Nathan said. Then, "I love you, son."

Naven burst into tears, and went to hug his father.

Nathan had qualified for a transplant because he was young and otherwise healthy, Huddleston said, and strong enough to survive the risky and expensive procedure, which cost an average of about $1.3 million in 2020, according to Milliman Inc., an actuarial and consulting firm.

COVID patients comprise a growing number of lung transplants nationally. Of the 2,980 lung transplants performed between August 2020 and October 2021, 7.4% were COVID-related, according to the United Network for Organ Sharing, the nonprofit organization that manages the nation's organ transplant system. That number could grow beyond acute cases to COVID survivors whose organs may deteriorate over time, according to David Klassen, the network's chief medical officer.

The M Health Fairview University of Minnesota Medical Center in Minneapolis is one of the oldest and most well-established lung transplant programs in the county, experts say, but Nathan's path was fraught with uncertainty. Even with new lungs, it was unclear how long he might live. About 10% to 15% of the program's lung recipients die within the first year, and half don't make it five years, the hospital said, survival data similar to the national rate.

As part of his recovery, Nathan's team had been pushing him to exercise because patients need to be mobile and able to eat and drink on their own before they can be released. He was on high levels of steroids to prevent his body from rejecting his new lungs, and the drugs increased his irritability, occasionally turning him into the "Hulk," as Angie put it.

Nurse practitioner Jennifer Rieger came by one morning as Nathan was sitting up trying to eat breakfast. She asked why he wasn't exercising more. Angie was sitting on the bed next to him, her face puffy after being up all night with a migraine.

"I don't know man, I don't work here," Nathan snapped. He was tired and frustrated, feeling like he should be getting better faster.

Angie tried to explain that the physical therapist hadn't come yet.

"I'm talking here!" Nathan barked.

"You're also being rude," Angie shot back.

"Did she ask you the question? Did she say, 'Angie, how's he doing? How has he been?'" Nathan said. "No!"

The room got quiet.

"Should we start over?" Rieger asked.

"No, nobody listens to me," he said, slamming his silverware. "I'm f---ing done, man."

After a beat, he turned to Angie and said softly, "I'm sorry, but you've got to let me finish my stuff before you butt in," he said.

Rieger jumped in to diffuse the tension. "It's easy to let frustrations boil over, but just know that we're all here for you. OK? You guys are so great," she said.

Angie got up and left the room in tears.

A few hours later, Nathan was on the move, out for a walk flanked by Angie, who carried his chest tube drainage apparatus, and his physical therapist, Risa Valentini, wheeling an oxygen canister.

After a few dozen yards, he collapsed in a chair at far end of the hallway in a family waiting area that overlooks the Mississippi River. Valentini and Angie hovered above him.

"I need to rest for a little while," he said. "I feel like I'm 400 pounds."

"But your oxygen levels are good, 98%," Valentini said.

"My lungs feel like I need more air, even though I don't," Nathan said.

"Maybe it's anxiety?" Angie said.

"Your mind and body just need to relearn how to work together," Valentini said. She asked if she could turn the oxygen off so Nathan could try walking without it.

"I'm down with it," Nathan said.

She turned off the oxygen, and he moved slowly along the tiled hallway, through the crowded nurses station and back to Unit 6B.

___

A week later, "Discharge 5/3" was written on the whiteboard in Nathan's hospital room. On the bed was a bag of more than two dozen medications, including the three immunosuppressant drugs Nathan will be taking for the rest of his life. He will have to change his lifestyle now that he is immune-compromised, the transplant team warned. They gave him a long list of things he now must avoid: undercooked eggs or meat, strong sunlight, alcohol, heavy cleaning chemicals.

They were handed one last thing just before leaving: a thick envelope with a sepia-toned pamphlet titled "An Expression of Gratitude." It contained instructions on how to contact a local nonprofit organization to connect with the donor's family to thank them for the lungs - if they chose to.

Finally, as Nathan departed the hospital floor where he had spent nearly four months, the nurses lined the corridor to clap. He wept. He was wheeled out into the chilly spring day, where he took the first deep breaths of outside air into his new lungs. Angie was waiting for him in her red Chevrolet Trailblazer. Sun peeped out of the pallid gray sky — just for him, Angie said, as she helped him into the car.

"This is it!" he said.

At the small apartment where Angie had been staying about two blocks from the hospital, she had stocked the kitchen with Nathan's favorite snacks — Doritos, Little Debbie Oatmeal Crème snack cakes. She'd bought a used TV and pushed the twin beds in the bedroom together. It would be the first time they'd sleep in the same bed in more than six months, she said.

"I was thinking about that too," Nathan says with a smile.

___

"Legs hurt, can't sleep, eyes burn, count sheep," Nathan rapped to a hook emanating from his cellphone. It was July and he was back in Sioux Falls in the home studio of friend and hip-hop artist Gabriel Night Shield.

In June, Nathan's doctors said he could start coming home to Sioux Falls for weekend visits, and he and Angie had left Minneapolis in such haste he forgot to pack socks and underwear. They returned to their modest one-story home in Sioux Falls, a block from the Sanford USD Medical Center complex — where Angie works as a patient access supervisor — to a cardboard sign that said "Welcome back Dad," cranky teenagers and a Great Dane who at first didn't recognize him.

The kids had worn their grandmother's patience thin during their parents' absence. Nathan Jr., 17, spent a lot of time at his girlfriend's house. Naven, an aspiring paleontologist, expanded his basement menagerie and hung a pink, white and blue transgender pride flag above the dining table. His tarantula collection had grown from one to three, along with hissing cockroaches for food. "Why did she do that?" Nathan asked Angie. "I mean, 'he'?"

Nathan's relationship with Naven had long been fraught, as with creative-minded Lyric, 13, who also chafes against his father's brusque personality. Nathan's rough childhood and time in prison made him a tough guy, quick to roar. Angie constantly has to remind him that what worked while he was locked up doesn't work on the outside.

Saying goodbye to kids had broken him, Nathan said, and he hoped for a closer relationship.

"My worst fear is I'm no longer a memory, we lost touch. Maybe I caused too much pain and they don't give a f---," he wrote in one verse.

Nathan was sitting in Night Shield's home studio, dark but for a blue light, Avengers posters on the wall — working on another transplant-related song. The two men have known each other for years through the hip-hop scene, appearing at shows and in music videos together, turning out anthems of "lit" nights in the "Six-O-Savage," a play on South Dakota's 605 area code. Nathan, who goes by the stage name Crimespree, a nod to his past, has amassed a loyal following, and has music available on Spotify and iTunes.

"I ain't never written like this before," Nathan said. "Never had this type of style and flow. Even the beat's different. Before, my style was much more aggressive, more street, thug music. This one I'm going to get more personal with it. Now I have something to say ... people are going to be like, 'Man, this guy has really changed.'"

"You should do like just an EP of five or six songs talking about your last year or whatever, and you could do a celebratory song at the end of it," Night Shield said. "Like, 'I'm still here.'"

Nathan began to rap.

"I'm still breathin' / they said I wouldn't make it. I ain't ready to go, I ain't ready. They said I was supposed to die / how would you take it?"

Eventually he would title the song "I Ain't Ready" and sample the sound of his own ragged breath.

Then Night Shield cued up the latest song by their favorite group, Bone Thugs-N-Harmony, a collaboration with rapper Merkules called "Homicide." The Cleveland-born hip-hop group, which has a large Native American following, was Nathan's first inspiration when he learned to rap in prison from a lifer who saw him writing a letter and taught him how to rhyme.

"Song of the year," Night Shield said.

"I haven't listened to it," Nathan said. "In the hospital I didn't feel like listening to music."

All Nathan wanted to do was to be strong enough to be rap onstage again. He'd recorded a track for one of Night Shield's new songs, but they had to edit it because Nathan wasn't able to sustain his breath.

"I'm on a mission to be remembered ... remember that!!!" he wrote on Facebook. A friend commented, "Shoot bud I will remember you for your health triumph. Not music. The music is just an extra perk."

The next day, on July Fourth, the Footes piled into the Trailblazer and drove 45 minutes to the Royal River Casino for the annual fireworks display — a family tradition. Nathan had hurried them out the door because he wanted to get a parking space, joking, "I'm not strong enough to bully anyone this year."

Dozens of families gathered in the casino's parking lot several hours before the official display began. At first, things were the same as they had always been — the casual grousing as they set up the tent, the tinkling notes from the ice cream truck, the whistle of bottle rockets. Around them, people lit sparklers and colored smoke bombs. Occasionally the dry grass would catch fire, and people would race to douse the flames with their water bottles.

They had bought more fireworks than ever before, three bags — plus an enormous box of Miracle Fireworks' "Ultimate Hero," five-inch canisters that exploded with a thundering boom. They had been 16-year-old Mason's choice at the fireworks stand, and Angie had tried to veto them, but Nathan overruled her. "Let him have it if he wants," Nathan said.

Kyous, the youngest, set off a rocket that exploded into tiny Army men with parachutes, and his dad laughed watching him run across the field trying to catch the figures as they floated down from the sky.

"He's so skinny now, it's crazy," Mason said, watching.

"Who, Dad?" Naven asked.

"Remember when he was getting so big?" Mason said.

Angie's agitation grew as smoke continued to sour the air.

"I'm concerned about your dad being out there without a mask on," Angie said. "His lungs don't need to take any more smoke."

"Why do you care?" said Lyric.

"Lyric, I don't need your smart remarks," Angie said. She got up to go to confer with Nathan, and soon he slipped his mask back up his face.

Later, back in her camp chair, Angie began to cry. In the field before her, Nathan helped Kyous set off a rocket that exploded into a pink smiley face, tiny points of light stretching across on the sundown sky.

"Before transplant was a possibility, this is the thing I thought about having to do myself," she said. "If I was sitting here without Nathan right now it wouldn't be the same. And a small part of me wonders how many of these I have left with him."

___

For months, Nathan had been contemplating his own death. What he wasn't expecting was to lose his brother.

In early September, Nathan's older sister Rachel called with devastating news: Junior was seriously ill with COVID-19 and not expected to survive. Nathan logged on to the Facebook Messenger group just in time to see his siblings crying and saying goodbye, Junior's megawatt smile obscured by the ventilator. After a while, Nathan couldn't take it and logged off. "It could have been me," he said.

How could he be gone? Bavily Foote Jr., 50, the jokester, storyteller, originator of funny nicknames. He'd been one of Nathan's main supporters during his long hospital stays and had often called to check in from his rig on the road. Junior had underlying health issues that put him at greater risk of COVID, but he had not gotten vaccinated.

On Sept. 3, the day Junior died, only 29% of residents of Tripp County, S.D., where he lived, were fully vaccinated.

Nathan came home to Sioux Falls for good in July. He bought a Great Dane puppy — another purchase Angie first opposed, then OK'd — that Lyric named "Boom," whose care and feeding helped to unite the family. He tracked down a copy of his GED from his prison days and enrolled in community college with the goal of becoming a chemical dependency counselor. His first essay assignment for English was a description of his goals. His was "to stay alive for a year."

He'd been living with a cough that's common among lung transplant recipients and adjusting to his new immunocompromised life. He is now the designated driver for his hip-hop crew, but he has also resumed eating runny eggs. Angie has to remind him to take his medications sometimes.

"I got everybody telling me how to live," he lamented. Yet his mortality is never far away from his mind.

"They're telling me most people don't make it," he said. "I don't want to be 'most people.'"

The how-to pamphlet on contacting the donor family remained unopened, because, Nathan said, he wants to "accomplish something first."

A few weeks later, Nathan was shaking hands in the receiving line at Junior's funeral at a community center in his hometown of Winner, S.D. There was gospel music, a vanilla-frosted cake that said "Keep on Truckin' Jr., You'll be Missed," and a star quilt that an aunt had sewn in Junior's honor hanging from the wall. A white feathered dream catcher twirled from the ceiling with a photo of a smiling Junior in its center. Nathan and the pallbearers pulled on a memorial T-shirts with Junior's likeness, the kind Nathan once feared his children would wear at his funeral.

Nathan was too choked up to do a eulogy, devastated by his brother's decision not to get vaccinated.

"Here I am standing in front of you, and you don't learn from my situation?" he said. "If you want to be ignorant, that's your choice."

Later, the family gathered in a small cemetery dotted with white crosses on a wind-whipped hill at the Rosebud Reservation, home to the Sicangu Sioux, one of the seven tribes of the Lakota nation. Nathan and another brother dug the grave for Junior's ashes the night before, with Angie stepping in to take a turn at the shovel when Nathan ran out of breath. Mourners took turns throwing handfuls of earth on top of the grave.

Afterward, the couple drove back to the community center to help clean up. They drove by Junior's trailer, the city pool and the doughnut shop where they went for a monthly treat as kids. The family struggled after his mom and dad split up. Nathan sometimes stole chips from the grocery store to stave off hunger. He slept on the floor wrapped in a blanket from head to toe to keep off the roaches.

His mother, Melda Struck, taught him how to fight to defend himself at an early age, then sent him to an Indian boarding school.

"I hated her," Nathan said. "She literally created a monster." These days things are better; they talk by phone and spend some holidays together. She showed up for Junior's funeral — late — and the two exchanged a measured greeting.

The institutional upbringing took a toll. Nathan kept getting into trouble and eventually beat a juvenile detention facility staffer so badly that he put her in the hospital. At age 16, he was sentenced as an adult to 10 years in prison.

Meeting Angie changed him, he says. ("She's a goddess / I already know this," he wrote in one lyric). Tattoos of her name bloomed on his hands. But his path to redemption was not linear. He spent his last five years in prison on drug charges after they already had begun their family. Angie was left behind to manage with three young children. In some ways, the experience living without her best friend prepared her for his long stint in the hospital, she said.

In the car leaving the cemetery, Nathan told Angie he felt numb.

"I don't know what's wrong with me right now," he told her. "I feel like I'm not grieving enough for him, and it's making me feel bad. Are people looking at me and saying 'Why isn't he crying, everyone else is crying, doesn't he care?' "

"You faced death, so you're still having your own grief to deal with, Nathan," Angie told him. "You're grieving the life you lost."

___

Nathan Foote drives for the first time in many months on July 18 in Sioux Falls.

Angie reaches out to support her husband during an exercise walk on July 18 in Sioux Falls. Exercise is an important part of Foote's transplant recovery.

Foote speaks on the phone while his youngest son, Kyous, plays video games on July 18 at their home in Sioux Falls.

Then in late September, Nathan had a setback. Scans showed that part of his new right lung had collapsed, and although doctors didn't believe his body was rejecting the organ, the complication meant he would have to return to an anti-rejection regimen of steroids and other medication to help his lung function improve. "How worried should we be?" Angie asked in an email to the transplant team. The answer came in a blunt phone call from Cindy Poehls, the physician assistant, who told Nathan he might have to go back on the transplant list if the treatment didn't work.

Three weeks later, Nathan walked into the pulmonary function lab in Minneapolis for the test that would determine his fate. He took a deep breath and blew into a machine that measures lung function. The results showed his lungs working at over 50%, an improvement, which meant he would not be going back on the transplant list — for now. "Yea!" the respiratory therapist said.

Out in the waiting room, Nathan handed the results to Angie.

"I went up!" he said.

"Thank God," she said. "It looks good."

Later, during his checkup, Poehls busily typed notes as she quizzed Nathan. Was he drinking 70 ounces of water a day? Exercising for an hour? And what about his mood?

Angie laughed.

"Oh my God, be honest," she said to Nathan.

"That's not the best," Nathan said.

"He's very irritable," Angie told Poehls.

Poehls told them that wasn't unusual.

Poehls told them finding a health psychologist should be a top priority and closed the checkup with an urgent warning. The number of COVID-19 cases among transplant recipients in their program had gone up significantly in recent days, she said, with an estimated 25 to 30% mortality rate. He should avoid crowded spaces, she said.

"If you do not need to go to Walmart, don't go into Walmart for a while," she said. "Be safe, do not do something if you feel there is even a remote risk to it."

What Nathan didn't tell his transplant team was that he had just been invited to be the opening act for Bone Thugs-N-Harmony when they perform to Sioux Falls in December, which would be a "bucket list" achievement for him.

For Angie, Nathan performing at a hip-hop show was just another in a long line of things — the extra fireworks, the new puppy — that she can't deny him because they don't know how much time he has left. Despite occasional squabbling, the couple's bond is strong, and the kids have been resilient, she said.

Nathan said he is trying to strike a balance between what he needs to do to keep himself safe and what he needs to do to embrace whatever time he has left. The pandemic's isolation and wasted days forced a reevaluation of life's priorities for many, mental health experts say. Nathan is going through it with a weakened immune system, a louder ticking clock — and on steroids.

"I'm trying to enjoy life now, I'm not trying to be depressed and down," Nathan said. "I'd been that way for months, sitting alone in the hospital."

So despite his doctor's warnings, and the fact that COVID cases are rising nationwide, Nathan will perform at the Bone Thugs-N-Harmony show, even if it is in a crowded amphitheater without vaccine or mask requirements. He thinks it will be OK because he'll wear a mask and be separated from the crown while onstage.

He's stronger now and will be stronger still in December, he says. He'll try out some of the new material. It will be lit, he said, a night no one will ever forget.

Annie Gowen reported from Minneapolis and South Dakota. The Washington Post's Alice Crites contributed to this report.


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