Free Extreme Medicine by M.D. Kevin Fong

the presentation that Pomahač saw, Dallas looked as though he had been massively injured. A huge featureless graft had been pulled into place where his face had once been. Pomahač remembers thinking to himself that the man in the slides was so completely disfigured that he no longer looked human.
    After they got off the stage, Janis and Pomahač got to chatting. Having heard of Pomahač’s pioneering work in the field of partial facial transplants, Janis suggested that perhaps Pomahač’s team at the Brigham could help Dallas. But Pomahač was pessimistic; he was unsure how much of the structure of the face remained intact underneath the graft. To be reconstructed, Dallas would need a full face transplant and for this the underlying blood vessels would have to be intact. Judging by the details of the medical report and the photographs of Dallas that Pomahač had seen, he doubted that this could be the case.
    Still, he decided to investigate further. Pomahač brought Dallas to Boston and began to assess him. Many aspects of his injury were at least as bad as he had feared. He was blind and had lost one eye. The structure of the nose had been entirely destroyed; he had no lips, and where there should have been a mouth, there was only a slit. Dallas was reduced to drinking through a straw, and when he ate, he had trouble keeping food in his mouth. He could just about speak, but the words were sometimes muffled and difficult to comprehend.
    But as Pomahač came to know Dallas better, he couldn’t help but be won over by the force of his personality. Here was a patient who remained positive despite the accident and open about the disfigurement he had suffered. He was also realistic in his expectations and clear about his motivations. The injury had left Dallas blind and so, one might assume, less conscious of his facial features. But the opposite was true. In conversations with Pomahač, Dallas explained the profound discomfort he felt in sensing the reactions of others to his appearance—the silence that fell in a previously busy restaurant when he sat down to eat and the hush that filled rooms in his presence. He was acutely conscious of all of this. But most of all, he worried about how his young daughter would cope with questions and comments from friends as she grew older.
    While this didn’t alter Pomahač’s technical decisions, it certainly shifted his emphasis. He wanted desperately to help this man, a feeling that went beyond the ordinary duty of care.
    Pomahač had been preparing for the possibility of performing a full face transplant for more than two years, assembling a crack team from various medical disciplines. He knew that the surgery itself was just the centerpiece; a host of clinicians and other health-care professionals would be necessary to make Pomahač’s ambition a reality. For this plunge into the unknown, he would have to make sure that his team was meticulously prepared. This responsibility he gave to his friend and colleague Tom Edrich, an anesthetist.
    By this stage, the team was on call twenty-four hours a day, waiting for the phone to ring summoning them to action. Meanwhile, there was plenty to think about. Where should the intravenous lines be sited? What degree of immunosuppression would protect the graft from rejection without running unacceptable risks? For Edrich there was the question of how to prevent the patient’s airway from closing and suffocating him after the anesthetic had taken effect. Normally he would insert a tube through the mouth and thread it into the windpipe. But with burn patients, mouths were often too badly distorted to allow this to happen.
    Meanwhile, the question of whether or not Dallas could be a candidate for facial transplantation depended upon the state of the blood supply that remained. Pomahač’s team set about conducting an extensive mapping of his vascular anatomy, injecting liquid opaque to