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The hospital escape describes Venom Snake's flight from Dhekelia SBA Memorial Hospital while it was attacked by XOF in 1984. Venom's escape directly leads into the Phantom Pain Incident.


On March 16, 1975, the Militaires Sans Frontières was attacked by XOF and wiped out, with Big Boss being believed to have been deceased. In actuality, he survived, albeit in a critical condition. Although the doctors at Barranquilla Coast succeeded in saving Big Boss' life, they could not fully resuscitate him due to his falling into a coma as a result, with Miller witnessing this, and also inquiring about the medic, with their admitting hesitantly that he took shrapnel to the head. Big Boss ultimately fell into a nine-year coma and eventually awoke in February 1984. After waking up, he was greeted by Ocelot who had been watching over him. Ocelot informed him of Zero's plan to have the medic from the crashed chopper act as a body double for him, as well as updated him on other other developments which had come to light during his coma.

Big Boss made a fast recovery and one of his first actions after getting back on his feet was to go for a smoke. When Ocelot found him outside the ward, which was a non smoking one, he informed him that the XOF had found out about him waking up, adding that "the man on fire" had chosen that time to wake up as well.

These events meant that they would need to speed up their plan and wake up Big Boss's double right away. Big Boss showed apprehension about having somebody else assume his identity against their will. Nevertheless, he ended up being talked around to the idea by Ocelot, realizing that it was necessary to ensure his own survival, and that it was what the medic would have wanted. With that said, they agreed to wake him up right away and act as his bodyguard under the guise of Ishmael, to ensure that he escaped the hospital alive and returned to full health.


On February 26, 1984, Venom Snake woke up from his coma. A nurse, Alexandra Pikrammenos, was making her rounds when Venom Snake's movements caught her attention. She approached him and asked if he could hear her. When she realized that he did, she ran to get the doctor, Evangelos Constantinou.

On February 29, Pikrammenos returned with Constantinou, who, after conducting some basic motor tests to see if he's functional, told Venom Snake that he had been in a nine year coma. This, however, caused Venom Snake to go into shock, forcing the doctor and nurse to sedate him. On March 4, he regained enough consciousness to follow Constantinou explaining that nine years prior, Venom Snake had suffered various injuries which included 108 fragments of shrapnel and human matter such as bone and teeth, with a huge chunk being situated on his cerebral cortex. Constantinou also implied that Venom Snake's left arm was lost in the accident, with Venom Snake going into shock again after verifying that he had indeed lost his arm, forcing the nurse and doctor to sedate him again.

On March 9, Constantinou verified that the hospital had been infiltrated by people planning to kill Venom Snake, and that he needed to be put through plastic surgery to hide his identity. On March 11, the doctor showed Venom Snake his reflection, and explained that he had healed up "pretty well", before admitting that the bandages were actually intended to mask his identity. The doctor also gave Snake the identity of Ahab to keep his identity hidden.

While he was explaining this, a female assassin managed to stealthily place a garrote on Pikrammenos and kill her, before proceeding to kill Constantinou. After the deed was done, she then called in to an unknown employer and relayed that she had not killed Venom Snake yet, as the patient lying in the bed next to him, Ishmael, had seen her face. She then stated that her employer can "consider it done" before moving at Snake with a knife as he is struggling to get to the discarded handgun the doctor originally had. She then picked up the handgun and readied it at Snake, but was then jumped by the other patient, Ishmael, who grabbed hold of her from behind and placed her in a chokehold. She eventually freed herself, knocking over a tray of medical supplies and tossing him near a wall.

The patient then tried to throw several objects that fell from the tray at her, eventually throwing a flask of rubbing alcohol at her, which shattered against her forearm while countering. She then threw her knife at the patient, hitting his left shoulder, and then proceeded towards Venom Snake and strangled him. However, before she could finish the job, she was suddenly set on fire, forcing her to let go and flee to a window, but then she crawled over to Snake, just as Ishmael removed the knife from his shoulder and threw it back at her, and then threw another bottle of rubbing alcohol at her, intensifying the flames, and forcing her to jump out of the window.

"Time to Go"

Venom Snake noticed that his left arm was missing and a basic hook like prosthetic arm was in its place. He was later approached by Ishmael, who claimed to have watched Venom Snake during his nine year coma, and that the world wanted him dead. After a rumble, Ishmael gave Venom Snake a digoxin injection to help him walk. They then proceeded to leave at 02:03am.

Ishmael then proceeded to make sure the coast was clear before having himself and Venom Snake leave the room, making sure a chopper was out of sight from a nearby window. Due to the digoxin taking too long to take effect for Venom Snake, Ishmael and the former were forced to change plans and head for the elevator. They arrived at the elevator, only to discover a mysterious gas-mask wearing child at the area. In addition, the elevator suddenly burst into flames with the Man on Fire walking from the flames towards the two. However, the man disappeared after the fire sprinklers went off. Unable to use the elevator, Ishmael and Venom Snake went back the way they came. By this time, Venom Snake managed to regain the ability to walk.

The two were forced to hide from a helicopter, with Ishmael also forcing Venom Snake down when the latter came close to being discovered. He then noticed that Venom Snake's arm was broken from the earlier encounter with the Man on Fire, offering to help by relocating the arm. They then saw another helicopter dropping off some soldiers via fast rope, as well as a discarded smoke grenade. Ishmael had Venom Snake duck into a nearby patient holding room, with Venom Snake following another patient before being grabbed by Ishmael and made to hide underneath one of the beds. They witnessed a XOF soldier proceeded to murder two patients, inside the room, execution style.

Upon leaving the room, Venom Snake and Ishmael witnessed a nurse and another patient requesting help from a chopper, only to be gunned down. The duo then proceeded to avoid the searchlights. One patient ended up being killed by one of the soldiers. Eventually, Ishmael and Venom Snake proceeded to duck into a stairwell alongside a patient, with the former proceeding to barricade the door with a row of lockers. However, they then discovered that the soldiers are trying to use a welding torch to break through. Ishmael and Venom Snake were then forced to descend down the stairs. The patient went upstairs right into the path of some soldiers and was gunned down. Although Ishmael intended to go down the stairs fully, he was forced to turn back due to the XOF soldiers, directing Venom Snake back upstairs.

They then went into a hallway filled with a large amount of patients and nurses, who are then promptly caught in a massacre on both sides of the hall, with Venom Snake nearly being killed, with Ishmael saving Venom Snake by grabbing him and throwing him into another room. Ishmael and Venom Snake then proceeded to hide between two different sides of the room behind various curtains, while several soldiers proceeded to try and hunt them down. The XOF soldiers managed to kill some patients, while Venom Snake and Ishmael trying to evade the patrols entirely. Ishmael followed the soldiers, overhearing that they are to continuing the search. With soldiers nearby, Ishmael and Venom Snake pretended to be among the recently deceased nurses and patients in the adjoining hallway.

As the soldiers commenced their searches, shooting rounds into the corpses to ensure they were dead. Ishmael accidentally leaked an IV bag, which eventually got a guard to notice, giving away Venom Snake's attempt to hide. However, the gas masked child proceeded to apparate and disapparate, distracting the soldier. The Man on Fire reappeared again. The soldiers then attempted to fend him off, only for the Man on Fire to withstand several of their attacks, even setting one of the soldiers alight and forcing him to jump through a window. Eventually, the Man on Fire sent a hail of bullets in their direction, causing Venom Snake's leg to dislocate. A chopper then arrived and attempted to destroy the Man on Fire, with little success (with the missiles only being able to destroy the Man on Fire's uniform at most). The Man on Fire then proceeded to fire a blast at the chopper, severely damaging it and causing it to crash land.

The Man on Fire then pursued Ishmael and Venom Snake, the latter limping from his earlier injury. Ishmael then attempted to use a handgun he had stolen from one of the soldiers on the Man on Fire, only for him to absorb the bullets. Ishmael proceeded to shoot out a sprinkler, causing it to drench the Man on Fire and force him to retreat. Venom Snake then proceeded to relocate his leg, fixing it. With no other options left, Ishmael decided to take the stairs down. Ishmael then proceeded into a hallway, also shooting a patrolling soldier, before finding a discarded handgun. He discarded the magazine and adjusted the gun before refilling it. He then gave the handgun to Venom Snake. Venom Snake then proceeded to fire the gun at a fire extinguisher to halt the blaze, and then alongside Ishmael proceeded to shoot two soldiers nearby.

Run Interference

Upon arriving at the heavily guard lobby, Ishmael, decided to cause a distraction by throwing away his silencer as well as shooting at the guards. Ishmael then left the premises to search for an escape vehicle. The gas masked child appeared once more, using his psychokinesis to block the door with a destroyed chopper, blocking Venom Snake's escape. When The Man on Fire appeared as well, he absorbed the soldiers' bullets and deflected them back before turning his attention to Venom Snake.

Eventually, a tank managed to destroy the rubble, forcing Venom Snake to dodge, with soldiers following in behind it, firing on the Man on Fire, when suddenly the helicopter's blades became active due to the gas masked child psychokinesis, and dismembered the soldiers. The tank then drove in and fired at the Man on Fire, who survived the blast before being run over by the tank. Venom Snake then proceeded to leave, while the Man on Fire destroyed the tank and knocked Venom Snake back. Venom Snake then attempted to defend himself against the Man on Fire, when he was saved when an ambulance ran over the Man on Fire, with Ishmael, who was driving the vehicle, telling Snake to get in.

They then escaped the hospital, evading various fire trucks and other emergency vehicles, as well as various meteoric objects that were presumably remains of the hospital thrown by the Man on Fire, although Ishmael was knocked out after gunfire from a helicopter shattered the ambulance's windshield, also causing his head to collapse on the steering wheel and thus cause the ambulance to beep its horn, forcing Venom Snake to take over the wheel. They then had to evade the helicopter via a tunnel, although a roadblock forced them to crash and leave the vehicle upturned.

Return of Ocelot

The vehicle eventually ended up in the suburbs of Xylotymvou near the area of the base hospital. At 02:32, Ishmael regained consciousness inside the vehicle. He was dragged out by Ocelot. Ocelot then told him to follow him and hurry, while also calling him Big Boss. Ishmael then left, although not before getting one last look at the vehicle and Snake's trapped body. Venom Snake then awoke at 03:07 only to find Ishmael gone. He crawled out of the windshield. However, he then finds himself face to face with the child, who then summons a giant whale made out of fire, which proceeded to consume the chopper nearby. The flames then form to reveal the child and the Man on Fire present atop of a demonic flaming unicorn. Snake is rescued by Ocelot atop a horse, Ocelot told Snake that he's his ally.

Ocelot then supplied Snake with a shotgun, telling him to slow down the pursuing fiery entity. During the pursuit, Ocelot expressed irritation at the Man on Fire's persistence before stopping himself and then cryptically asking if he's "back from the dead". They ultimately managed to evade them, a lightning strike resulted in the bridge collapsing and Ocelot, Snake, and Ocelot's horse falling into the water. Both survived along with the horse.

As Ocelot helped them along, however, the child and the Man on Fire watched in the distance before disappearing. Ocelot then introduced himself before stating he remembered him while identifying Venom Snake as Big Boss. He then explained that a certain individual had sent him with two objectives: Rescue Venom Snake, and then save the man who hired him to do the job: Kazuhira Miller. After relaying what had happened nine years before, Ocelot told Venom Snake that Miller was being held in Afghanistan.

Ocelot brought Snake up to speed on the Soviet-Afghan War, explaining that Miller had been captured by forces of the Soviet 40th Army, while training the Mujahideen there. Miller was to be transferred to a Soviet garrison for interrogation, with Ocelot estimating that he had two weeks at best under torture. They then arrived at a whaling ship that would transport them to Port Qasim.

On 05:59 at Western Ormideia, near the ruins of the bridge, Ocelot reconvened with Big Boss and told him to use the motorcycle, assuring him that it's all tuned up and ready to go and that he'd handle the rest. He then gave Big Boss a passport with a faked identity, also suggesting that he change his face as well. He explained that Venom Snake would take his place, and would believe he was Big Boss as well, with Big Boss summing it up as being his own phantom. Finally, Ocelot assured him that Snake could handle it before telling him to leave. However, before Big Boss did so, he had to smoke a cigar, with Ocelot lighting it. Big Boss promised that he and Ocelot would meet again. Ocelot then left on D-Horse, with Big Boss leaving shortly after.

Ocelot then returned to the whaling ship transport and reconvened with Venom Snake, with it setting off. While on the way there, Ocelot brought over a new prosthetic for him.

Behind the scenes

"Facts do not exist, there are only interpretations."
―Friedrich Nietzsche, opening quote for "Truth - The Man Who Sold the World"

Time frame for hospital, as seen via the calendars.

The hospital incident was first shown in the Spike VGA 2012 teaser for Metal Gear Solid V: The Phantom Pain, then simply titled The Phantom Pain and indicated to be a separate game development from the Metal Gear series by the company Moby Dick Studio. Throughout the trailer, scenes from the hospital escape are shown, alongside narrations popping up that asks where they are, why they can't move their body, if they're dreaming, and speculating they may have gone to Hell before demanding they open their eyes (it is heavily implied that the narration was the player character's inner thoughts). Its connection to the Metal Gear series and specifically to Metal Gear Solid V (which at the time had initially been assumed to be limited to Ground Zeroes) was later revealed at GDC 2013, which also included a brief playable demo of the hospital escape, covering the start of the playable section up to the first encounter with the Man on Fire.

The hospital incident is the basis for the "Prologue: Awakening" chapter as well as "Episode 46: Truth: The Man Who Sold the World" of Metal Gear Solid V: The Phantom Pain, the latter of which reveals the plot twist that Venom Snake is not the original Big Boss, as the player had been led to believe. In "Truth", the player can understand some of the Greek language used in the hospital; the player's customized face is shown in a mirror instead of Big Boss's; the previously obscured MSF group photo now shows the medic; and the episode ends with the ambulance crash, followed by Ocelot's meeting with the real Big Boss.

"Awakening" marks Ocelot's return to the franchise for the first time since Metal Gear Solid 4: Guns of the Patriots. "Truth" also marks the first time Ocelot and Big Boss have shared the screen together since Metal Gear Solid 3: Snake Eater.

According to Hideo Kojima's notes in the Piggyback Collector's Edition Guide's art gallery, the hospital escape in Cyprus was meant to show how Metal Gear Solid establishes cinematic drama within an action game, comparing it to the style found in linear games. He also elaborated that the prologue serves to remind the player of the gaming experience in previous Metal Gear Solid episodes, and quickly have it evolve into something new, comparing Snake's crawling, crouching, and eventual standing to the theory of Man's evolution. Fittingly, this coincides with Sahelanthropus's theme of evolving from the usual hunched-over stance of most Metal Gears to standing upwards, like the species it's named after. Additional concept art included in The Art of Metal Gear Solid V also revealed that Venom Snake originally was going to initially have the arm somewhat intact, albeit significantly stripped to the bone and stained red, and the nurse was originally going to have severe deformities on the left side of her face, having significant burnmarks.

The medical calendar frequently changes each time the player wakes up. It also changes when the player selects their avatar upon close inspection, foreshadowing the twist that's revealed in Truth: The Man Who Sold The World.[1]

The Hospital Escape was indirectly alluded to in Metal Gear Survive when recruiting Miranda, as she explained that she returned to the hospital after communications went off unexpectedly and, just before being sent to Dite alongside a doctor, saw that the hospital was on fire. In addition, Virgil AT-9 mentioned that the ambulance Miranda was in and a crashed chopper that the Captain and Reeve briefly witnessed arrived at the same time, and the chopper had formerly belonged to XOF.

Though mostly all of Ishmael's lines from both the Prologue and Mission 46 are subtitled, there is one particular line of dialogue that isn't, and can play during the first encounter with XOF, if Venom Snake decides to go towards the XOF soldiers instead of following Ishmael, prompting him to ask: "Do you have a deathwish?"

In the ending for Chapter 1, the player is given the option of either firing on Skull Face or not. If they do so, each time he is shot will have Venom Snake transforming into his appearance from the prologue chapter, implying that Venom Snake's actions during that time were done out of revenge towards Skull Face for the latter's attack on the Hospital in an attempt to kill him.


Notes and references