Identity and consciousness
He had been kept alive with tubes for nearly 17 years. What was his name, and was he at all aware what was happening?
It was his 34th birthday and the icing from the cake was his first taste of food in almost 17 years. He didn’t react when the dollop of chocolate settled onto his tongue. Maybe his taste buds had stopped working. Or maybe he had just forgotten what real food was like.
What else had he missed all these years he’d been confined to a hospital bed? How long had it been since he heard a dog bark or a baby cry? Since he squinted from the sun in his eyes or felt rain on his cheeks? Since he was held by someone he loved?
He’d been kept alive with breathing and feeding tubes, and until a month before his birthday party in January 2016, he’d been known only as “Sixty-Six Garage.” That was the name on his hospital bracelet, the name on the door to his room, the name on the sign above his bed, the name the state of California used to pay the nursing home for his care.
It’s the name he probably would have been buried with if Ed Kirkpatrick, director of the Villa Coronado Skilled Nursing Facility, hadn’t let me into Room 20 — Garage’s room. I’d already spent nearly a year at the Villa, reporting on people on life support. I’d documented what life
was like for people kept alive this way — more than 4,000 in California alone — and the life-and-death choices their families were forced to make. Now Kirkpatrick was trusting me to tell Garage’s story.
“He’s a human being. And 16 years is too long to go without knowing who this was,” Kirkpatrick later said of his decision. “We need to CSI the hell out of it.”
Kirkpatrick shared what little he knew of Garage’s story. In 1999, he had been in a crash in the California desert, somewhere near the U.S.Mexico border. When first responders found him, he had only a Mexican phone card and a few pesos in his pocket, so they assumed he was an immigrant who’d entered illegally. He was airlifted to a hospital in San Diego, and when there was no hope he’d recover, he was transferred to the Villa.
The name “Sixty-Six Garage” came from a place near the accident, where Garage’s vehicle was towed, Kirkpatrick told me. That, like so much of the lore surrounding Garage, would turn out not to be true.
Kirkpatrick said Garage was in a vegetative state, which meant he wasn’t aware of his surroundings or even himself. So each time I saw him, I looked at him as though he wasn’t a person — like he was someone with no thoughts or feelings. Until one day, early in 2015, he smiled at me.
Despite all the research I had read and despite knowing that a smile can be a reflex, I was convinced in that moment that Kirkpatrick was wrong — Garage was still in there.
For the next two years I would track down the people, documents and scientific evidence I needed to understand how an ordinary Mexican teenager lost his humanity after crossing the border, kept alive by a system that didn’t care enough to learn his name.
Finding Garage’s name turned out to be the easy part.
The tough part was navigating the blurred lines that separate consciousness from unconsciousness — and figuring out whether that smile was really a smile.
The hallway to Room 20 is a dividing line of sorts. On one side are people who are old and frail but can breathe and eat on their own. On the other are people kept alive by tubes and machines, who are either unconscious or have no way of indicating otherwise. Room 20 is on this side of the hallway.
An old guy the staff calls Papa is in the first bed. He had a stroke years ago. Unlike his two roommates, he appears aware of his surroundings, able to grunt when he is in pain, or wants his TV on, or when the plastic collar around his neck, which keeps the blue oxygen hose attached to the hole in his windpipe, is too tight.
Next to Papa is a 22-year-old bicyclist who was hit by a car going 55 mph on a dark California highway and then run over by a second car. He stares mindlessly at the ceiling, as though he is frozen in place, caught in a limbo that defines this unit.
Closest to the patio doors is SixtySix Garage. He is attached to two tubes, one connected to a hole in his throat, the other to a hole in his stomach, the only way he has been fed since 1999.
Room 20 is on a unit designated “subacute” by the state of California, but pejoratively known as a “vent farm” by some doctors. More than 4,000 people are on life support in about 125 facilities across the state. The number includes only those covered by Medi-Cal, the state’s insurance program for the poor and disabled.
The nursing home guesses Garage was born sometime in 1960, but to me it’s obvious that he is a young man — in his 30s. Under the flimsy sheets, his torso makes only a small outline, like that of a teenage boy.
Garage has thick dark hair that is usually shaved about half an inch from his scalp. His face is round, his eyelashes long and straight. His face is supple and his skin hadn’t taken on the translucent sheen like the others down the hall. His full lips are often coated with the pasty white film that accumulates on a perpetually dry mouth.
I visited Garage regularly and learned the routine of his life.
He appeared to move in and out of consciousness, sometimes smiling like a small child, other times staring at the ceiling and striking his right leg on the corner of the bed for hours. There were days when he looked catatonic, and days when he’d stare wide-eyed as though he was seeing everything around him — the feeding machine, the TV that hung on the wall across from him, and me — for the first time.
Each day he was changed and turned. Liquid food and medicines were pumped into his stomach — he was on seven medications, including an antidepressant.
Some days, he was placed on a gurney for a shower. A hydraulic lift was used to lower him into a special wheelchair so he could be moved into the hallway or activities room. He seemed to hate leaving his bed. He’d kick at the nursing assistants, and when he was finally settled into his chair, the corners of his lips would turn down and he’d have tears in his eyes.
One day I wheeled him outside, into the courtyard. But the traffic noise, the breeze, the openness of the sky — it all seemed to frighten him. He wouldn’t stop crying, so I took him back to his room.
Most of the time, he lay in bed with the TV on. His pillow was often stained with blood because the friction between the fabric and his scalp created lumps that bled.
Sometimes Garage opened and closed his mouth as though he wanted to speak, but the only sound that came out was a gurgle — the sound of mucus collecting in his chest. The gurgling grew louder when he appeared upset — especially when he was about to be suctioned.
Suctioning was essential to Garage’s survival because he couldn’t clear the mucus from his throat like a healthy person. If he wasn’t suctioned every few hours, the mucus might clog the hole in his throat and cut off his oxygen supply.
I watched the procedure dozens of times. A nurse or nursing assistant would insert a narrow plastic tube into the hole in his throat and remove the mucus with a small vacuum. Garage’s cheeks would inflate and his face turned red, like a balloon atop his tiny, rigid body.
Kirkpatrick said the process is “like waterboarding,” a form of torture where water is poured into a person’s breathing passages to create the sensation of drowning.
“It’s the same physical concept and you’re doing it seven, eight, nine times a day to a person,” Kirkpatrick said.
I learned that counting on my fingers in Spanish seemed to comfort Garage as the tube went down his throat.
“Uno, dos, tres, cuatro, cinco” was the only Spanish I knew. I’d repeat it until his arms relaxed, the red faded from his face and the gurgling softened, as though he were a child who had been hushed.
Garage’s expressions and movements often mimicked those of an infant. He’d reach for the baby toys I brought him and try to copy me when I showed him how to press the buttons or tap out sounds on the hard plastic. His hand would flail and his fingers would reach for the buttons, but he didn’t have the aim or strength to push hard enough to trigger the toy into action.
One evening, I held up a plastic baby mirror and tapped it with my index finger until it made a “click, click” sound.
Garage reached out with his left hand and tried to copy my movements. After about the third try, his finger hit hard enough to make a sound. He smiled and made eye contact with me, as though he knew — we both knew — that he’d done something remarkable.
Between 2015 and 2017, I spent hundreds of hours sitting on a folding chair, observing and taking notes, trying to document the life that was playing itself out in that small corner of Room 20. When I wasn’t there, I was often traveling to California’s Imperial Valley, not far from the U.S.-Mexico border, to figure out how Garage had ended up in this place.
The Imperial Valley supplies many of the vegetables the rest of the country eats, and about half of the workers who pick those vegetables are in the country illegally. This is where Garage was headed when the crash happened, according to the 16-page accident report I eventually found.
The California Highway Patrol had destroyed the report years ago, but I tracked down an unredacted copy at the Imperial County Public Works Department, which reviews accidents within its jurisdiction. The report became my road map. I found witnesses, first responders and a man who survived the crash to piece together what happened on a clear blue day at an intersection in the middle of farm country.
The sun was just coming up that Thursday, June 10, 1999, when Garage and at least three other men climbed into the back of a 1988 Chevy pickup and hid under a pile of suitcases. The driver steered the truck down Bowker Road, a two-lane road that begins at the border.
Here in the valley, the topography can trick you into believing you’re somewhere in the Midwest: lonely farmhouses planted in the middle of vast fields, winds that pick up at sunset and smell almost electric. But the white-and-green Border Patrol vehicles parked every few miles along the road are a reminder this is not Middle America.
In 1999, the Imperial Valley was one of the busiest corridors in the country for Border Patrol apprehensions. In those days, only a single fence or nothing at all marked some parts of the border between San Diego and Tijuana. So many migrants were streaming across that warning signs were posted on nearby freeways showing silhouettes of a man and woman running with a child.
Bowker Road passes by farmers’ fields, an occasional smattering of houses, a gas station and an elementary school. Nine miles north of the border, Bowker intersects with Evan Hewes Highway, a smooth, flat fourlane road.
There’s a stop sign on Bowker. But that morning, the pickup’s driver ignored it and sped into the path of a 1978 Toyota Celica.
The two men in the Toyota — Abel Ramirez, 33, and Gregorio Flores Mendez, 31 — were carpooling to work on a nearby farm.
Mendez, in the passenger’s seat, saw the truck. It “was going fast, like 50 miles per hour,” he said through an interpreter.
He also saw the lights of a Border Patrol vehicle coming up fast behind the truck.
“They were chasing them,” Mendez said.
Ramirez hit the brake, but it was too late. The Toyota slammed into
‘I opened up the blinds and all I saw was a pickup truck on its side and a bunch of people running. And then I heard the helicopters. And they were like around this area trying to find the people.’ — BRENDA VILLEGAS, describing the accident that injured the man known as “Sixty-Six Garage”