Short
Order Medicine: Chapter Nine: Bennie
Chris Cain Bennie Washington had the misfortune to be born to a Native American family steeped in century old feuding with the Bowmans, another large family in the small valley an hour northeast of our town where surviving tribes of native Americans struggle with the realities of modern times. Though many of these people strive to preserve the higher values of an ancient people, some are just angry and dysfunctional. It doesn’t take being any particular race or subculture to suffer the toll of life in the late twentieth century. Poverty of mind and wallet, drugs, alcohol, fatherless families, and bad governing has brutalized some of every social or racial group in our country. We may feel the impact more in an impoverished county, in a bankrupt state, where jobs are few and welfare enslaves those without work or motivation. In any case Roundale, a tiny valley in some of the most beautiful land in the world, has its problems. It is populated by the descendants of the original Native American people of the land. It is also inhabited by ‘new-agers’ and hard workers who fled the violence and congestion of the large cities south of our county. During the mid seventies, this cultural and racial mix produced new job opportunities for those left out in the cold by sawmill closures and general economic collapse. For the most part, the blend was to everyone’s advantage. Some, however, couldn’t make it. Because of too much whiskey or archetypal parental abuse, there are always reasons or defenses for bad behavior. So much parlor talk can never change the reality that a few individuals are self-destructive and take others down with them on the way out. It is the family way... The Washingtons and the Bowmans hated each other since before anyone could remember. If there once was a reason, a transgression of person or property perhaps, the reason was no longer necessary to fuel the present day conflict. Hatred has a life of its own and is passed down through generations as the children become angry people at the end of the belt or boot of the father or uncle or in this case, the brother. Bennie’s brother Buck was one such angry young man. Violence came easily and naturally when freed from skimpy moorings by alcohol. Drinking was part of everyday life and if the initial symptoms of the alcohol numbed forebrain were laughter and blind screaming wildness, the later symptoms, as the day wore on, were irritability and volatility. Like a bad headache that makes someone want to squeeze their head in a vise until something hard and sharp pops out, Buck could also get relief by inflicting pain on others. Anyone. Including family. Bennie was not like Buck or his other brothers or sisters, or uncles or father. Bennie had what could only be termed a sweet disposition. He did what he could do to avoid the family legacy of violence and did not drink in excess. He loved his family only because they were family, not because of any particular gifts of nourishment ever received. But it was in his nature to roll with the punches and to see the positive side of anything. His eyes were wide and gentle, his smile disarming. He had done well in school but a high school diploma was not enough to buoy him out of the Roundale valley into a world of greater opportunities and a wider choice of social contact. One drunken Friday night, in 1978, after too many days of drinking and complaining, Buck smacked Bennie in the head, knocking him to the ground in the driveway. Whatever the feud of the moment, whatever meanness fueled by a recent shoot-out with the Bowmans - none of this mattered to Bennie and no longer mattered to Buck. There was only the rage of the moment that drove Buck into the pickup where he started the engine and backed up, running over Bennie’s body. Bennie was not knocked out by this assault, but couldn’t scream very well because his face was now in at least two pieces. Buck’s mother heard him yelling at Bennie and at the moon, and came outside to see what had happened. Appropriately horrified, she called the ambulance, a small volunteer organization, and held her injured son as she quietly wept. She had known something terrible would happen again someday. A year or so before, Bennie’s sister, in a jealous rage, had pushed their other sister into the path of an oncoming vehicle. She died instantly. Otherwise, the violence and wildness and drunkenness were pretty much a male thing. The women either suffered in silence or ate themselves in to a life of morbid obesity and early diabetes. I was running our emergency department on the evening of the event. The call came over radio that the Roundale ambulance was inbound to our facility with a nineteen-year-old male who had been run over by a truck. We were told that his face was severely damaged, and then the radio signal broke up due to distance and terrain. The road to Roundale snakes along the Eel River through a canyon bordered by thousand feet high very steep mountains. There are only a few spots along the way where radio signals get through. We often find ourselves waiting for over a half hour until the ambulance comes close enough to the main highway for the signal to reach the repeater and then on to us. And so, we waited for our victim with the facial injuries. This could be bad or not so bad depending on the physics of the event. Skulls are somewhat like eggshells, very hard to break in some orientations, fragile in others. Depending on the weight of the vehicle, the firmness of the underlying ground, the speed of the vehicle and the size of the tire, the injury could be of any magnitude. We waited. This was a time when the hospital emergency department was small and less formally structured than what would come later. The local family practice doctors, I being one at the time, volunteered to respond to emergencies during the day, running up from our offices that were within a hundred yards of the hospital. We were paid eighteen dollars an hour to stay in the hospital at night. It wasn’t very busy, but we saw the full range of emergencies from heart attacks to gunshot wounds. One physician, one nurse, and the telephone were the resource base. The local ambulance at that time was run by a colorful character nearing the end of his career, willing to drive at any speed under any conditions to get patients out of his rig, into competent hands. He wore ‘coke bottle’ glasses but no one was sure if he really could see much of anything. Rumor had it that he intended to ‘go out’ in a flash on a code 3 run at top speed into oblivion. Just before a non-lethal forced retirement (the ambulance company was bought), no one would ride with him anymore. The ride was exciting, but not worth repeating. Prior to his final run, I was to ride in the back more than once. I didn’t have any choice. The Roundale ambulance arrived with Bennie’s head looking like it had been dipped in ketchup and cotton balls. Loose pieces of gauze were stuck here and there, most of them falling off. Everything was soaked in blood and betadine (brown iodine containing disinfectant). As I began to take the gauze off, I told Bennie to nod or grunt in response to questions, if he could not answer. Soon enough, I saw why he would not be able to answer verbally. Though I had been out of training for nearly five years, and had some exposure to trauma in training, I had never seen anything like this. It was the closest thing to a living anatomy lesson on facial structure that I could imagine. Bennie’s face was unrecognizable. The entire right half of his face was broken off and hanging to the side by strands off tissue. A two-inch gap between the center of his nose and the adjoining right cheek sinus was evident. I could see the details of bony structures with exposed sinus cavities, trabecular (spongelike bone mass in between the solid bone surfaces) bone of the facial skull bones, and through the broken hard palate to the tongue. The right side of the jaw was in several pieces and likewise displaced to the right, towards the ear. The lips and cheek remnants were like hamburger, all definition of origin obscured by bleeding, clots, mangled skin, and muscle. Further up, the forehead was also separated just above and to the right of the nose. The eye socket moved with the frontal (forehead) bone and the right eye was hanging out of the displaced socket, tethered by the optic nerve. He was conscious and knew what had happened and where he was. His breathing was noisy as air was moving past a good deal of loose tissue and blood, but he was getting enough air at the moment. His brain was relatively uninjured as only the face was battered. The rest of the skull had done its job to protect the brain. The only fractures above his chest were in front of and below the cranial (brain) cavity, i.e., the face and jaw. He did sustain fractures of his collarbone and shoulder blade but this was the least of his problems. His neck was not broken. He wasn't spared the pain of such an injury by drugs or unconsciousness. He was completely present for the first hour of his trauma. The rest of his body had tire marks on the chest and abdomen, a distended abdomen, and absent bowel sounds (the absence of gurgling suggesting major internal injury). My inner voice moaned, "Oh, my God." At any sizable facility, I would simply call everyone in. X-ray, lab, the ENT (ear, nose, and throat) specialists, ophthalmologist, anesthesiologist, general surgeon, etc., and get out of their way. This guy needed a doctor, and it was clear to me I was not the one. But, my job is to do what I can do, stabilize and transport as safely as possible to the physicians equipped to attempt some kind of repair. I was grateful, at that moment, that I was not a facial surgeon. Even if I knew where to start, the job would be tedious beyond comprehension. I enjoy the challenge of repairing some complex lacerations, but this was something else entirely. I needed to get him down the road, alive. His greatest risk would be interference with adequate breathing. If his upper airway became obstructed with facial parts or blood, I would have no good way of placing an endotracheal tube (through the mouth, into the upper windpipe) through the wreckage. This was not a point in my career when I was creating surgical airways (cutting open the neck over the ‘Adam’s apple’ and putting a tube into the windpipe at that point, below any obstruction from above – a cricothyroidotomy). We placed two intravenous lines to give him fluid and medicines if needed, and called the ENT doctor in the town twenty miles south. He agreed to stand by and I got in the ambulance with the patient. I called one of my partners and asked him to come to the emergency room if there was any business. He couldn’t refuse. Those were also times when we were a very small group of doctors, highly interdependent on one another. We would never think of refusing a request or favor. I was frightened. Maybe more anxious than scared, but very tense. I felt that we had to beat the clock, poor Bennie’s hourglass, for him to have a prayer. If he stopped breathing, I had no plan. There would be no way to assist breathing with a mask designed for a standard face, not a scrambled face. I would probably attempt to stick an airway into his throat, but I did not want to have to try. I felt a trainwreck headed towards Bennie and me at a very high speed. I sat pretzled up next to Bennie in a very cramped old ambulance at floor level, watching his face intently, periodically asking him if he was getting enough air. He grunted affirmatively and I held his head to minimize movement as we flew down the highway at nearly one hundred miles an hour, ‘coke bottle’ glasses at the wheel. The twenty-mile trip over a small mountain was over in thirteen minutes, though I feared parts of both Bennie and me were still on the road. He was wheeled in to surgery right from the ambulance, at eleven at night. Two ENT surgeons were present and I was free to return to the more mundane medicine of backaches and fingers cut on broken glass while doing dishes. A classic. As unfortunate as Bennie’s injury was, he was lucky to have landed in the able hands of the ENT surgeons who chose our neck of the woods to have their practice. They were and are as competent as anyone in their field, anywhere. They operated for twelve hours. Twelve hours! Piece by piece, layer by layer, bone, muscle, and soft tissue were brought together as best as possible. The jaw was stabilized with appliances called arch bars that wire the lower and upper teeth together for stability. The eye was salvaged as best as possible, though it didn’t work. Tubes were place for drainage, breathing, and to maintain nasal passages. His abdomen was also opened and a liver laceration was repaired. No matter how good his facial repair, he would not have survived the night without control of internal bleeding from his liver wound. In the days that followed surgery, Bennie was out of his head in a violent delirium thought to be consistent with brain concussion. Even though there was no actual bleeding or gross destruction of brain tissue, nerve cells respond poorly to being run over by a car. Concussion is the result. Irrational, uncooperative, and self-destructive behavior complicated his care. By the tenth hospital day, in spite of nursing attempts at restraint (tying hands to the bed rails with roll gauze), Bennie managed to disassemble his arch bars and had to be taken back to surgery to replace this hardware. Over the next two weeks, he again dismantled this dental hardware and had to be returned to the operating room, once more, for replacement of bands and wires. At this time, he also had to have his abdomen re-opened for drainage of an abscess that had formed under his right diaphragm, on top of his liver. He had been having fevers prior to this re-operation and subsequently got much better with clearing of his mental status. Also because of persistent infection in the eye socket which did not respond to antibiotics, the eye was removed when it burst open in a final declaration of uselessness. After one and a half months, Bennie was discharged. He had arch bars holding his jaw together, a plastic right eye, a strap splint for fractures of the clavicle (collarbone) and the scapula (shoulder blade), and a tube sticking in just below the right twelfth rib for irrigation of his resolving abscess under the diaphragm. The hole in his neck from a tracheotomy (breathing tube placed under his ‘Adam’s Apple’), had closed on its own by then. Just over one year later, Bennie was again at the wrong
place at the wrong time and intercepted a bullet with his left jaw.
The bullet exited
his body through the right side of the neck. By the time he arrived in
the emergency department, he had a pulse but no measurable blood pressure.
Within a few minutes, he stopped breathing. While a tube was inserted
into his windpipe so that a respirator could breathe for him, large intravenous
tubes were inserted into his arms. He needed several liters of fluid
to bring his blood volume and pressure up to life sustainable levels.
The two general surgeons in our town at that time performed six hours
of surgery on a very small area of his body. He was found to have a shattered
left jawbone, perforated esophagus (often a lethal injury because of
uncontrollable infection), carotid artery disruption (one of the big
arteries carrying blood to the face and head), and a torn internal jugular
vein (the big vein which carries blood from the head back to the heart).
The surgeons repaired everything, wired his jaw (again!), and inserted
another tracheostomy tube. For long term care of a major head and neck
injury, the breathing tube must be moved from a through-the-mouth placement
to a through-the-neck location to avoid damage to the vocal cords and
upper trachea. His recovery was complicated by development of a condition
called ‘shock lung.’ This produces a lack of oxygen because
of fluid accumulation in the lung from the massive assault to his anatomy
and physiology. This condition passed without doing further damage and
by the ninth hospital day, his stitches were taken out, his tracheostomy
was discontinued, and surgical drains were removed. He was making it!
He went home a few days later, a very lucky young man. The bullet entered his back over the lower lumbar spine and traveled diagonally through to the left hip area. His left leg was partially paralyzed and there was no sensation of the rectal area or the penis. There was no muscle tone in these areas. At first it seemed that he only had a neurologic injury but he soon developed shock from internal bleeding. He was taken to the operating room where his abdomen was opened and explored. It was found that he had a huge bleed into the body space in back of the intestines. After exhausting efforts to control bleeding from the front failed, he was turned over and the left sciatic space, just above and to the side of the hip joint on the buttock, was opened and dissected towards the large supply arteries coming from above. A medium sized artery that supplies the pelvic organs was found to be the culprit and was repaired. After nearly two dozen units of transfused blood and plasma, his blood pressure stabilized and he returned to the intensive care unit. Though the bullet did not actually sever the spinal nerves, the shock wave produced as the bullet moved through caused damage that was initially the same as complete destruction. We never know how much neurologic recovery will occur after an injury such as this. The range varies from complete to none. Bennie left the hospital two months later with a leg brace, a program for home wound care of still unhealed pelvic wounds, and with competence in self-catheterization for bladder care. He had no bladder or penile function. He could barely walk. He was, however, happy to be alive and looking forward to being home with his mother who was more than happy to take care of him. He was done being shot and run over. About fifteen years later, he was seen in the office of the orthopedic surgeon who had cared for him during that last extensive hospitalization. The office visit was for an unrelated problem, but served to reveal what had transpired over so many years since this tragic disabling trauma. Bennie walked with a small stabilizing brace on his leg, almost no limp, had no bowel or bladder problems, and had sired two children! His one eye twinkled as he smiled in triumph over the morbid fates of life in Roundale. Though my only direct contact with Bennie was that first night in the ambulance as I held his bloodied head and wondered about the next second or two, some form of connection precipitated out of that mess. I am certain that he has no knowledge of my role in his life that first night. My hands held his head and my mind managed his immediate fate. My spirit danced with his for a moment and in the place where we are all one - I recognize him as a fellow sufferer. I’d know his twinkle anywhere. In 1995, there was a Native American murder in Roundale and subsequent shutout with sheriff’s deputies. One of the deputies, Bob, took a bullet in the head and died. He was no ordinary police officer. A Navy Seal for twenty years, distinguished and decorated, he retired from the military to become a police officer and was within two years of a second retirement. Not only superbly competent, he was considered a man among men, a gentleman and warrior. He had a kind heart and a sharp eye. He would do anything for his team, and often did. Never with an ax to grind, his decisions were carefully considered and then skillfully executed. Without any need to puff with power, laughter and lightness came easily. He took his own time to help teach my wife and me pistol competence at the local range. His stories about sea snakes and snipers made the hair raise up my back. In two years, he would retire from forty years of service from the front lines, with two pensions and a passion for abalone diving. He was still a young man. Those of us in the emergency department knew him because all of the police officers bring arrested subjects in for ‘medical clearance’, or wound repair. As grim as this part of the job is, most of the officers are good company and share dark humor and the latest off color jokes from the ‘station.’ Bob usually had some of the best. He treated his prisoners with respect and our staff with affection. The funeral procession was so large it had to be moved
to a different town. The gutters ran wet with tears. Thousands of officers,
friends,
and family attended. I had to work that day so my quiet weeping came
after my nurse Cindy returned with the little memorial pamphlet and poem
for a human hero. Roundale’s ancient blood feud had spilled into
white man’s world and the wound festered for a long time. One of
the Native Americans named Three Wolves was accused of the killing. He
hid out in the mountains for months only turning himself in when a world
famous defense attorney volunteered his services. Most thought that he
was guilty but the jury found him innocent. Apparently, the argument
that Bob had been mortally wounded by ‘friendly fire’ in
the chaos of the moonless midnight shootout was supported by the absence
of autopsy ballistics. His body was cremated less than twenty fours hours
after the shootout! Could this be true? Evidence destroyed, we will never
know. Most of us who cared about Bob just want to scream. When will we
get it? We are all in this mess together. No one really makes it unless
we all make it. The problem is, those that don’t know this make
the good battle seem hopeless. Except for small circles of friends and
loved ones... All Rights Reserved © 2004 Jon Sterngold |