The section of the ER set up for major trauma now clear, Kathy Paul walked toward the ER main entrance, which faced Pennsylvania Avenue. It had been less than three minutes since the first call on the white phone.
She watched as a black limousine pulled into the ER driveway, stopped, and out of the rear door stepped the President of the United States. She noticed he was dressed in a blue pinstriped suit, but her eyes riveted on his face, which was ashen. He looked frightened.
He walked through the three sets of double doors and said, "I feel like I can't catch my breath." He groaned, his knees buckled, and he began to fall backward. At that point Kathy Paul no longer was awed. The President now was a patient.
She grabbed his arm and, with a paramedic and two Secret Service agents, helped carry him the 40 to 50 feet to the trauma bay at the rear of the ER. They put him on a stretcher in 5A.
The trauma bay gleamed with the latest medical technology. Looming over the President's left side was a rectangular column that held the paraphernalia of trauma resuscitation, including bottled oxygen. Intravenous bottles filled with saline and lactose solutions hung at the ready. Shelves of gauze bandages, syringes, and sterile instrument packs surrounded him.
The President lay flat on the stretcher, bright lights in his eyes, his brows furrowed, his expression worried. There wasn't any obvious sign of injury, and hospital staffers had received no word in those first confusing minutes that the President might have been injured.
"I feel so bad," he said, laboring for air.
They began the trauma protocol.
Kathy Paul leaned over the President and started ripping and cutting off his clothes. All of them. The President kept repeating that he felt bad, that he didn't understand why he was finding it so hard to breathe. She thought he must be having a heart attack: His paleness, his breathing and chest discomfort all fit. She kept ripping. So did Wendy Koenig, who noticed a RR monogram on his shirt just before she tore it off.
Now standing at the bottom end of the President's stretcher was the tall figure of Dr. Daniel Ruge, his personal physician. Ruge had been at the Hilton. After making certain none of the injured on the sidewalk was the President, he had jumped into an official car that followed the presidential limousine to GW. A well-known neurosurgeon, he now put his hand on the President's foot to monitor his pulse, which was steady and strong. Ruge offered reassuring words to the President.
A crowd of Secret Service agents, DC policemen, and hospital personnel hovered in the ER. Radios squawked. The sounds of sirens still echoed outside. The noise in the ER mounted. At times it was nearly deafening.
Wendy Koenig put a blood-pressure cuff on the President's arm. She pumped it up and waited for the thumping sound of the pulse in her stethoscope.
Not a sound.
"I can't hear anything," she yelled.
"I can't get a systolic pressure."
The President is arresting, she thought, right here in front of me. She had to fight back tears. She remembered a nightmare she'd had a few months earlier, just after Ronald Reagan was elected president. He had been in the ER, ill and under her care. The memory of the nightmare was vivid. And now it was happening.
She pumped up the cuff again. Nothing.
She couldn't tell whether the President's blood pressure was too low or the noise level in the ER too high.
She pumped up the cuff one more time, and she palpated an artery with her fingers. She felt the first throb, somewhere between 50 and 60 systolic, a low pressure, suggesting shock. Normal would be 130.
Two minutes had elapsed since Ronald Reagan had walked in.
Cindy Hines, a medical technician, had automatically begun inserting intravenous (IV) lines into the arm of the man lying in front of her. In the excitement she'd never learned who he was. Not until she had put an IV line in his arm did she take the time to look up and see his face.
In trauma resuscitation there is nothing more precious than time; speed is the inviolable first principle. It is during the "golden hour"--the first 60 minutes--that most trauma patients are saved or lost. Most of those lost die from shock, caused when the body's blood volume becomes so depleted that there is not enough to go around. People in deep shock can be resuscitated. But if too much time is lost before shock is reversed, the major organs can't support the body, and the patient dies.
The President was ashen because his involuntary nervous system had taken over, redirecting his blood flow away from his skin and extremities and into his vital organs. There is little question that in those first few minutes the President was very close to shock if not in shock itself--as one of his physicians later said, the President was "on the brink."
No one knew what was wrong, because there was no obvious sign of injury. Jerry Parr, the Secret Service agent who had landed on the President in the limousine and then directed it to GW, an act which probably saved Ronald Reagan's life, thought he might have cracked one of the President's ribs. But in those first two or three minutes none of the nurses noticed any blood or other sign of injury. It was only when Kathy Paul saw blood on the President's hand and Cindy Hines noticed blood inside his mouth that they knew he wasn't arresting; he was hurt.
Urgent messages had already been dispatched by the paging operators throughout the hospital: "Trauma team to the emergency room." Many doctors also were paged individually.
A meeting of department chairmen and administrators on the top floor of the Burns Building, just across 23rd Street from the main hospital, was interrupted when Michael Batch, administrator of the Medical Center, answered his page. He came back in the room and announced that the meeting was over because the President of the United States was across the street in the emergency room.
Three physicians--surgical residents David Gens, Brad Bennett, and Paul Colombani--meeting for their regular Monday-afternoon discussion group in an on-call room, heard their pagers go off at the same time. Bennett answered. "You're wanted in the emergency room. Stat."
Stat, says a doctor, "means you get there before your clothes."
They came running.
Dr. Sol Edelstein, director of the emergency room, had just driven his wife home from the hospital, where she'd given birth to a son five days earlier. She had extracted a promise from him that he would take a week off. His pager went off minutes after they walked in the door.
Edelstein made the 20-minute drive from his home in Glen Echo Heights to the hospital in seven minutes.
"I can't breathe," the President repeated. The nurses took turns holding his hand and reassured him. He lay with his arms at his sides, his expression worried, but he was conscious and calm.
Three IV lines were now pushing fluids and packed red cells into him, boosting his rapidly depleting blood volume and blood-oxygen level.
Perhaps three minutes had elapsed since the President's arrival.
The first GW physicians to treat the president were Dr. Wesley Price, a senior resident who was not on the trauma team but who hurried down from an upstairs pathology office when he saw the motorcade heading into the hospital, and Dr. William O'Neill, an intern on the trauma team.
O'Neill thought his page was routine until he rounded the final corridor to the ER. From there he noticed a black limousine parked where the ambulances usually were, and he saw the presidential seal. "I hope it's not the President," he thought to himself.
Secret Service men made quick checks and allowed Price and O'Neill to go into the trauma bay. Both were stunned when they saw the President on the stretcher with lines going into his arms.
"Can anybody tell me what happened?" Price asked. No one seemed to know.
O'Neill, who had worked in the emergency room as an undergraduate, had seen a lot of trauma. "You develop an immediate gut feeling as to who is really sick and who isn't," he said later. When he saw the President he felt he was looking at someone potentially in jeopardy.
The President's palpable blood pressure was up to 78 systolic--still abnormally low but an improvement. The fluids were doing their job. The President's pulse was 88 and steady, an encouraging sign.
"Mr. President, where do you hurt?" O'Neill asked.
"My chest hurts, and I'm having trouble breathing."
"Do you know what happened?"
"Are you hurting anywhere else?"
"No, I don't think so."
The President was thinking clearly and able to move all four limbs. To ease his breathing, they propped his head up about 30 degrees.
Wesley Price, the son of a North Carolina preacher, put a stethoscope to the President's chest and listened for breath sounds. Listening to the right lung, he heard crackling noises. The breath sounds on the left side were diminished. Air was not moving in and out freely. As Price continued to listen to the left side he noticed a small, jagged slit, like a buttonhole, just below the President's armpit. There was a black spot around it, and blood was trickling out.