by James Frey
The call was white male, late twenties or early thirties, massive trauma, massive head wounds, massive blood loss, and then the unusual part, which was the first of so many unusual occurrences with Ben and his case, hundreds of shards of glass imbedded in his body. I’m a geek about my job, and after doing it for many years—I was forty-one when the case began—I still get excited when a case comes in that sounds different or challenging for some reason. At the time, I didn’t even think about the human element of it, that someone had just undergone some horrific event and was experiencing feelings and emotions that are far beyond anything within the realm of my experience. I just thought about the potential medical and technical challenges involved and how I would solve them. Ben changed that for me. Now much of what I think lies within the human realm of the surgical experience, what the patient is feeling, what the people who love the patient are feeling, and how I can help with those issues as well. I understand that all of our lives revolve around what we are feeling at any given moment. There is nothing more human than emotion.
I got up and I said goodbye to my fellow Yankee fans and I quickly made my way to the trauma suite. Everyone was getting ready, the nurses, the assistants, the residents, and I was the last to arrive. At that point, and again this was before my experience with Ben changed me, because my position as the head surgeon is one of authority, I tended not to speak to any of the people I worked with unless I needed something from them or needed to discuss a specific aspect of the impending surgery with them, both of which were rare. While I scrubbed in and prepared myself for whatever it was that was arriving, I was silent.
The moments while a team waits for a patient can be very tense. You stand at the ready. While you have a general idea of condition, you do not often know what the specific medical issues are, and you have no idea if you will be there for ten minutes or ten hours, though there is rarely anything in between. Different surgeons handle it differently. I think of myself as a batter in a baseball game, actually in the seventh game of the World Series, with the bases loaded, a three-and-two count, down by three runs, in the bottom of the ninth inning. I have one swing to either succeed or fail and the result entirely depends on what I do and how I perform. Unlike in baseball, though, I cannot hit a single, a double, or a triple. I either hit a home run or I strike out, and the patient either lives or dies.
As I mentioned, I was intrigued and excited by the call, and had no idea what a patient who had shards of glass imbedded in his body would look like or what I would need to do to make that patient survive. When paramedics enter the hospital with a critical case, they are greeted by ER doctors and members of the surgical team, and there is a transfer of information related to the patient: the circumstances of the trauma, issues, if any, during transfer, a preliminary diagnosis, if one is possible. Once the transfer is made, the patient is brought into the trauma bay, where I, and the rest of the team, go to work. It is usually a fairly seamless process, and it is one that is repeated with great regularity.
Not so with Ben. The EMTS were covered with blood, as was the stretcher. They started to describe the scene, and one of them kept repeating something I myself said many times later, which was that there was no way the patient should be alive, and that he had no idea what was going on with him. The doctors and nurses, who were incredibly seasoned and experienced, and had seen all manner of horror and gore after years in a public New York City emergency room and trauma unit, were shocked almost into paralysis, and one of the nurses vomited. Each looked to the others for direction, which is not entirely surprising. In life we often look to others for simple, but difficult answers, despite the fact that we have those answers ourselves. They needed to get him into surgery, and they needed to do it as soon as possible.
One of them took the initiative and urged the others to act, and they started moving towards me and my team. We can always hear them as they bring the patient into the trauma bay, hear the wheels of the gurney, the various squeaking sounds it makes, hear the nurses talking to each other, sometimes the patients scream, cry out, or moan. As they get closer, I tend to become calmer, more focused, and more aware, and time slows down in a way that makes those few brief moments seem incredibly long and peaceful. I sometimes wish I could live forever in that state, and believe that those who find enlightenment, people like Ben, though he discovered so much more than that, live their entire lives that way.
The doors opened and he was brought into the trauma bay, and for the first time in my fifteen-year career I heard an audible gasp come from every single person in attendance. It was a surreal, unbelievable sight, like something out of a Hollywood horror movie, something that shouldn’t have been possible and isn’t possible, but was right in front of my eyes. There was blood everywhere. There were huge, deep lacerations everywhere. When I heard glass shards, I expected small pieces of glass, maybe an inch long at their longest. What he had in his body were not shards, but actual pieces, some as tall as ten inches, some as wide as twelve inches, and we were only seeing what was visible above the level of his skin. The back of his skull had been crushed, and there were pieces of it that appeared to be missing. We could not see his face at all because it was entirely covered in blood. Everything was entirely covered in blood.
The first stage of treatment in any trauma situation is the stabilization of the patient. Death from blood loss was the obvious first concern. If a patient has lost more than 40 percent of their body’s blood volume, they are likely to be in decompensated hypovolemic shock, which usually results in multi-organ failure. While we checked his blood pressure, which was at 40 over 20, the lowest I’d ever recorded in a living patient, and checked his pulse, which was 30, again an absurdly low number, we gave him injections of epinephrine and atropine to jumpstart his heart and get his blood pressure and pulse up.
Simultaneously, we tried to get heart-rate monitors and BP monitors on him, but it was incredibly difficult because we were weaving the wires around glass shards that had very sharp edges. We inserted a central venous line and transfused him with type O negative uncrossmatched red blood cells. Though we wanted, at some point, to take the glass out of him, we needed him to be stable first, and we needed to figure out which pieces to remove first, and in what order the rest of them would come out.
He shut down three times in my care, went into full cardiac arrest. We defibrillated him, which was difficult because of the glass, and on one occasion I absolutely know the defibrillation worked, but on the other two his heart appeared to start functioning again on its own, which was both surprising and confusing. We kept putting blood into him and he kept bleeding and we kept putting it in. I don’t know the actual amount, but it became something of a game, a game where a man’s life appeared to be at stake, and in which I and the other people in the room were working with incredible urgency and resolve, making sure we were transfusing more blood in than he was losing, a game that we knew would result in death if we did not succeed. What we could see of his skin was white, and I don’t mean the Caucasian white, I mean truly white, alabaster white, like he was carved from marble. And no matter how much blood we put in, his skin didn’t change, and his body showed no indication that it was actually maintaining the blood.
While we were stabilizing him, I also needed to cover and protect his head. He had sustained a comminuted skull fracture, which means it had broken into a large number of small pieces, through which I could clearly see his brain. I assumed there was intracranial bleeding, most likely subdural, epidural, or intraparenchymal, and even if I could keep him alive, he would suffer from massive brain damage. We applied compression dressings using sterile surgical bandages, gauze, and surgical tape and moved his head as little as possible. We found pieces of his skull that were the size of nickels and bagged them in case we might be able to use them later.
Two extremely long and stressful hours after he arrived at the hospital, his heart rate and blood pressure were stable, or at least stable enough for us to attempt to start rem
oving the pieces of glass from his body. I took a step back and took a deep breath and looked at what was ahead of me. There were three IV lines transfusing blood into his body. We were applying pressure everywhere we could, but blood was still coming out of him at a rather alarming rate. We had been able to clean him up and cut away his clothing, and his skin was still deathly white. There was glass protruding from his legs, his arms, his abdomen and chest, there were smaller pieces in his face, and there were a number of large pieces that had been deeply imbedded into his back when he hit the ground.
I tried to identify pieces of glass that had nicked, punctured, cut, or potentially severed major veins and arteries: the jugular veins, carotid arteries, and subclavian arteries and veins in the neck, and the femoral arteries and veins in the legs. I wondered what I couldn’t see, possibly damage to the aorta, the inferior vena cava, or the pulmonary vasculature, which are deeper in the chest and torso and were beneath my field of vision. While the conventional wisdom of a non-medical professional might say it would be best to remove the pieces of glass from those veins and arteries, there was the very real possibility that they were tamponading further bleeding and had sealed areas that had been damaged or destroyed. Getting through this part of Ben’s treatment would be part luck and part strategy and, if successful, part miracle.
I had a vascular surgeon and his fellow join me and offer their opinions. I felt they might have something to offer that would help me, and help Ben, in some way. None of us had any idea where to start, or what to do, or what path to take, or what we might have in store for us when we started to actually remove the pieces. So I just started. I had three residents with me, and I had two of the residents prepared with suture in case sutures were needed, and I had the other prepared with a bipolar bovie, which is an electro-cauterization instrument. We had two surgical nurses with suction and another with an aspiration wand that delivered an anticoagulant. There were other nurses monitoring his vitals and continuing to transfuse him.
Once we started, we moved very quickly, because every movement, especially removing the largest pieces, resulted in blood loss, sometimes fairly significant blood loss. If we hadn’t moved quickly, Ben would surely have died. There were a number of scares, and a number of times when his vitals dropped dramatically, and a number of times when we couldn’t stop the bleeding in what I considered a timely manner. But Ben wouldn’t die, and now, at this point, after everything, I believe that what we did that day probably didn’t matter very much. Ben was not going to die.
Nine hours after we started, we tied the last suture. He had a total of 745 stitches, both internal and external, and an additional 115 external staples. We had used 40 units of blood, which is approximately double the amount any human has in their body at any given time. We also gave him multiple units of platelets and fresh frozen plasma. And for him, the day was far from over. There was a team of cranio-facial surgeons and neurosurgeons standing by to deal with his skull and brain injuries. As I stepped back from the table, I saw one of his hands twitching, which I took to be a good sign, and I stepped over and took hold of it, hoping that somewhere, on some level, he might find it comforting. To my great shock, his grip was very strong, very firm, and I immediately felt something similar, but deeper and more profound, to what I feel in those moments just before surgery, an intense calm and sense of peace and contentment. It was unreal, and obviously unexpected, and it ultimately changed my life in so many ways. I didn’t want to let go. I didn’t want that moment to end and I didn’t want that feeling to ever leave me. But all things leave us, all people, all feelings, no matter how we want them to stay, no matter how tight we hold on to them. We lose everything in life at some point. I lost that moment the instant I let go of his hand.
After he was hemodynamically stable, he needed a CT scan of his head to determine the extent of intracranial injury. Moving a patient as critical as he was can be very difficult, very complicated, and very slow, so I knew I had some time to take a break, and I needed one. I went to our break room and took a shower and tried to take a nap but couldn’t fall asleep. I was extremely awake, felt electric. I imagine I felt the way people feel when they take cocaine or ecstasy, though I have never used either of those or any illegal drugs. I got dressed and found Ben back in the OR, where the surgeons were now working on his brain, and I gowned up so I could watch the procedures. They had basically completed what was already a craniotomy, and evacuated both epidural and subdural hematomas. I watched the surgeons do some skull reconstruction using titanium plating, though they appeared to leave much of his skull as it was in case of cerebral edema, swelling of the brain, which can lead to brain herniation downward and death. Four hours after they started, Ben was taken to the post-anesthesia care unit.
He was later moved to the surgical ICU, and even though he was stable, he remained on life support: supplementary ventilation, intravenous therapy with fluids, drugs, and nutrition, and urinary catheterization. He was kept sedated using propofol so that we could monitor brain swelling and function. The ICU took over his day-to-day care, though I would continue to treat him, as would the cranio-facial surgeons and neurosurgeons. When I left the hospital, I felt very good, given the extreme nature of the situation and the trauma, about the care we had provided and Ben’s prospects for some type of recovery. It was very early in a case like this, and normally it takes quite a while for us to really know how and if a patient is or is not going to recover. I assumed that I would come back the next day and everything would be more or less the same. I should have known better.
When I arrived, there were no urgent cases, so I went to the ICU to check on Ben and see if there were any new developments. I picked up his chart, and I noticed immediately that his name had been changed from Ben Jones to John Doe, and that his date of birth had been changed to unknown. I placed the chart back into the wall file and went towards the ICU offices, where I saw the ICU attending standing with two uniformed police officers and another man who appeared also to be a police officer but was wearing a suit. The attending introduced me to the men and told them that I had treated the John Doe when he had first arrived and had performed the first surgery on him. I asked them why he was being considered a John Doe, and they proceeded to tell me that his name was fake, his driver’s license was fake, his fingerprints did not show up in any city, county, state, or federal databases, and that they could find no records of a man named Ben Jones born on the date listed on his driver’s license in any of the city, state, federal, or law enforcement databases at their disposal. Needless to say, I was surprised. I told the officers that I didn’t know anything beyond what was on his chart and what I’d experienced with him in surgery, and I had no idea who he was or where he was from. I also suggested they speak to the men who had been gathering in the waiting room, who had said that they worked with the patient on a construction site. They said they had spoken to those men, and that all of them knew him as Ben Jones, and they had examined all of the paperwork the site manager had on file, and that all of it contained the same information that appeared on the fabricated driver’s license. Again, I told them I knew nothing. They asked if anybody else had asked about the patient, or if there had been any other inquiries about him. I said not that I knew of, but that I had been either performing or observing surgery with him for almost twenty-four hours and normally didn’t have that type of contact with individuals looking for information on patients. They said thank you, and they left.
I went back to Ben’s room with the ICU attending and we started talking about his case, his prognosis, and started exchanging ideas about treatment. He had ordered an electroencephalogram to test brain function and was hoping to get a quantitative electroencephalogram to fully map Ben’s brain and see what areas had been damaged and how badly. When he left, I had a moment alone with Ben and I reached for his hand, the same hand I had held before, but there was no reaction. It was limp and cold and felt like the hand of a corpse.
I continued to follow the
case over the course of the next week. There was a fairly significant amount of press related to the accident—it was a controversial building being put up by a high-profile developer—and it gave the newspapers and blogs a few days of salacious headlines. We had hoped the coverage would help with an identification, but no one came forward. I got harassed by a couple of reporters who waited outside the entrance of my apartment building and stuck tape recorders in my face, hoping to get me to say something they could write about, but I knew to keep quiet, and that despite the tape recorders, the reporters would write whatever they wanted and the newspapers would print whatever they felt like printing. My truth is in the life and death I witness at the hospital every day. Ultimately, life and death are the only form of perfect truth that exists in the world. Everything else is subjective, and subject to an individual’s perspective. I don’t look for truth in the media.
Aside from the mystery of his identity, Ben became a medical mystery. His lacerations healed in a remarkable, unheard-of amount of time; after a week we were able to remove all of the sutures, all of the staples, and his wounds were closed and starting to scar. He was weaned down on the respirator, and we continued to feed him intravenously. The electroencephalogram results were erratic and unexplainable. At times he appeared to have suffered brain death, where there is absolutely no activity of any kind registering on the EEG monitors. At other times he appeared to be in a persistent vegetative state, where cycles of sleep and some base awareness, but not cognition, were recognizable. Once or twice a day he went into a state of extreme brain activity, centered in two regions of his brain, the medial orbitofrontal cortex, which is one of our emotional centers, and the right middle temporal cortex, which is often associated with auditory verbal hallucinations. The activity was extreme to the point that it was almost immeasurable, and the neurologists working on his case had never seen anything like it, especially with someone who had experienced such severe brain trauma. The initial worries related to brain swelling, bleeding, and intracranial pressure disappeared, as his brain seemed to heal itself as quickly, and miraculously, as his body did. He would also, at times, twitch, shake, convulse, and make guttural noises, which should not have been possible with the levels of medication being used to keep him sedated. At the end of his first week with us, he had a second major craniofacial procedure, in which titanium plates were used to seal and close the remaining open areas of his skull. The surgery went well, and he was returned to the ICU. Two weeks later we learned his real name, or rather, we learned the name he was given at birth. He was still in a coma, though no longer medically induced. It was some time after that, probably a year or so, that I learned who he was, and that his name, or any name any person could have given him, was meaningless. He was, and that is what is important. He was and he will always be.
