More doctors were arriving.
Dr. Drew Scheele, a general-surgery intern who had been a helicopter pilot in Vietnam, where he'd seen many gunshot wounds, including his own, looked at it with Price. They both realized they were looking at the entry wound of a bullet. Two other new arrivals, Gens and Bennett, also thought it was an entry wound.
Price turned to Jerry Parr, the Secret Service agent. "It looks like he's been shot," Price said.
Dr. Ruge gave Ronald Reagan this news. The President nodded. Ruge added reassuringly: "Everything is okay."
Wendy Koenig asked the President if he'd had a tetanus shot recently. He couldn't remember. She gave him one.
They gently rolled the President from side to side, looking for an exit wound. There was none, so the bullet had to be in him. Then Price and O'Neill thought they noticed distended neck veins, a disturbing sign because it could be caused by cardiac tamponade, the filling of the pericardial sac surrounding the heart. This could mean the bullet had struck the heart. On the other hand, heart sounds were normal. It was too early for certainties.
The physicians treating the President during these first few critical minutes were all very young. Most were around 30 and had been doctors for only the three or four years of their residency training. Bill O'Neill had been a doctor for only eight months.
They wondered what was going on in his mind when they poked at him, listened to him, and tried to speak reassuringly to him. He knew none of them. They realized the President was worried, perhaps frightened, although he was masking it well. They admired his coolness.
The young physicians had moments when, for a flashing second or two, they were awed by what they were doing. And more than once the thought skittered across the mind: My God, this is the President--I'd better not screw up. For some, it caused a temporary reluctance to treat him.
But most of them had completed a three-month rotation at the shock-trauma unit in Baltimore, the premier trauma unit in the country. They also had gained experience with trauma at GW. Moreover, the trauma team--formed at GW just three years earlier--had, under the direction of Dr. Joseph Giordano, drilled and drilled until they knew the treatment protocol instinctively.
Now the protocol was doing what it was designed to do. In times of serious injury, confusion, exhaustion, or all of these, the protocol becomes the thinking process--it tells the team what to do and how to do it. It is based on logic and is designed for speed. Critical to its success is aggressive overtreatment, searching everywhere so that not only the most obvious injuries are treated but also the smaller, more insidious ones that can quietly kill the patient.
Following protocol, David Gens examined the President's abdomen. He found no tightness, no sign of abdominal injury.
The President's left chest was thumped with hands and fingers. Where it should have sounded hollow, there was a dull, flat resonance. His left pleural cavity--the space between his left lung and the chest wall--was filling with blood.
Dr. George Morales, an anesthesiologist, placed an oxygen mask over the President's nose and mouth and kept reassuring him that everything was under control. The President repeated that he was having difficulty breathing. Someone had placed a sheet over the President's lower body after Dr. Gregory Hornig, an intern, had inserted a Foley catheter into his bladder to monitor urinary function.
Twelve minutes had passed since President Reagan's arrival at GW.
Press secretary James Brady, 40, grievously wounded, was wheeled into trauma bay 5B, next to the President, separated only by a curtain. His arrival was followed by that of Secret Service agent Timothy McCarthy, 31, the least seriously wounded victim of the Hilton shooting. He was put in ER 3, just a few feet from the trauma bay. Doctors and nurses split off to attend Brady and McCarthy.
The crowd in the ER kept growing. The noise increased; the air grew hot. Brad Bennett, a member of the trauma team, tried to remove everyone without a specific function. When he wasn't doing that he was squeezing the red-cell blood packs to force the vital, oxygen-carrying cells into the President as fast as possible.
Farther away, Doctors Dennis O'Leary and Sol Edelstein and administrator Mike Barch were attempting to control the crowd. Excitement, tension, and fear gripped many in the ER, but panic was never a factor.
Senior faculty physicians continued to arrive, some still perplexed about why they had been summoned. One asked aloud: "Why the hell was I paged?'' A curtain of people in front of him parted slightly and he saw the face of the President. He said no more.
The attending physicians asked Dr. Ruge, who was observing, about the President's health.
Adhesive tape and sulfa drugs.
Any medical conditions?
An old prostatectomy 15 years ago. Nothing else.
The President's blood pressure continued to rise.
A chest tube was readied to remove the blood flooding his left lung. Wesley Price put a shot of Xylocaine into the President's side, between two ribs, to dull the pain of the incision and tube insertion. As he prepared to cut, he heard the voice of Dr. Joseph Giordano, a faculty surgeon and head of the trauma team.
"You'd better let me do this one," Giordano said. Price realized it was appropriate that the senior physician take over.
Giordano cut an opening through the skin and muscle wall. He stuck his finger into the opening to make certain he was into the pleura, put a clamp on the tube, and popped it into the hole. The President winced at the pain. The other end of the tube was connected to a suction device called a Pleur-evac. Wendy Koenig had to fill the Pleur-evac partially with sterile water to begin the suction process. In the excitement, she poured a bottle of water into her shoe. The next time she hit the target.
Blood gushed out of the President's chest tube--1,300 cc's of it, perhaps a fourth of his total supply. No one was alarmed; chest tubes normally pull out a lot of blood when they are first inserted into a wounded chest.
But the blood continued to come, and one man was keeping an especially wary eye on it.
Dr. Benjamin Aaron had been in his office in the Burns Building doing paperwork when he was paged to the ER. He had been up until 2 AM the night before, repairing a complication from an open-heart operation, and earlier that day he'd done a coronary bypass operation.
A 48-year-old chest and heart surgeon, and a Navy surgeon for 22 years before he came to GW in 1979, Aaron was calm and understated, a man not only accustomed to the tight tolerances and demanding pressures of cardiac surgery but one who thrived on them. After he arrived at the ER, he saw that an arterial line had been hooked to the President's left wrist, and doctors were getting readouts of his blood pressure and pulse on a monitor. His blood pressure was now above 100. His pulse was steady. Aaron saw that the EKG monitor reading indicated a strong, normal heartbeat.
Usually, when a chest tube is inserted and the lung reexpands, the injured vessels close off and the bleeding stops. In about 90 percent of cases involving this type of chest wound, surgery is not performed.
But in Ronald Reagan's case the bleeding didn't stop. That was the first thing that disturbed Ben Aaron. The second was the color of the blood. It was not the bright red of freshly oxygenated blood. It had a darker cast to it, suggesting venous blood. Aaron knew that venous blood coming out of the chest meant some part of the pulmonary artery--through which venous blood is pumped from the heart to the lungs--was injured.
He tried to drive from his mind the thought that he was treating the President of the United States, tried to concentrate on the simple thought that he was attending a 70-year-old man with a gunshot wound. He said little. He listened to the President's lungs. He watched the ruby-colored blood flowing out of the President's chest.
In 5B there was little hope for James Brady. The hole through his skull, just above his left eye, leaked cerebral tissue. His eyes were so swollen that they could no longer be examined to see if his pupils were fixed and dilated, and the only hopeful sign was that on arrival they still reacted to light. His left eye had swollen to the size of an egg. He was unconscious, but his body sometimes thrashed.
The bullet had traversed the two hemispheres of his brain, and nearly 90 percent of such wounds are fatal. His brain had begun to swell. When swelling is uncontrolled, the brain "herniates" down--the only direction it can go in the confines of the skull--and compresses the brain stem, which regulates heartbeat and other vital functions of the body. When this happens, the patient dies.