The swelling had already caused an increase in Brady's intracranial pressure--which in turn shot his blood pressure up to 240/160, a very high reading. It was his body's way of compensating, of trying to force blood into the brain to oxygenate the tissues. But he had used up all his reserves.
Everything that could be done in those first few minutes was done. Major credit for this should go to Dr. Judith A. Johnson, an anesthesiology resident who switched to Brady from treating the President, when she realized that there were enough people to attend to him.
She put an endotracheal tube into Brady's windpipe, a delicate procedure when a patient has a serious head wound. To prepare him she had given him Pentothal and a curare-type drug to paralyze him so he would not fight the tube he needed for breathing. His head was elevated 45 degrees to relieve intracranial pressure.
Working with Dr. Jeff Jacobson, a neurosurgery resident, Dr. Johnson gave Brady a large dose of mannitol and steroids to decrease the intracranial pressure.
All this was done within Brady's first eight to ten minutes in the ER.
Dr. Arthur Kobrine, a neurosurgeon on the GW faculty, was paged to the trauma bay, where he saw Dr. Ruge, a friend from their days together at Northwestern Medical School. Ruge once taught at Northwestern, and Kobrine did part of his residency there. Ruge asked Kobrine if he would examine Brady. Kobrine was blunt with Dr. Ruge after the examination.
"Dan," he said, "I don't think he's going to make it, but I think we ought to operate."
Ruge told him to do whatever he thought he had to do.
It was crucial that Kobrine move quickly. Within 20 minutes of Brady's arrival at the hospital, he was wheeled into the CT scan room. There, thanks to a computerized x-ray technique called tomography, doctors would see the extent of his injuries and would know if surgery held out any hope for what seemed to be a doomed patient. Despite the medication he was receiving, Brady's brain was continuing to swell.
In ER 3, Secret Service agent Tim McCarthy was in stable condition. The only outward sign of injury was a small, bloodless hole in his right chest. A peritoneal lavage was performed--a procedure in which sterile fluid is put into the abdominal cavity and washed out to determine if any blood is present. There was. Exploratory surgery would be necessary.
McCarthy asked about the President. Dr. Stephen Pett, a thoracic surgeon, and Doctors Jack Fisher and Norman Odyniec were among those attending him.
It was several days later that McCarthy talked about his ordeal. As he lay on the sidewalk at the Hilton, he said, he could feel no wound, no blood, although he thought he'd been hit twice. Then a paramedic rushed up to him and asked if he'd been hit. I think so, McCarthy said. The paramedic couldn't find a wound, and told McCarthy he didn't think he'd been hit. Well, then, you'd better shoot me, McCarthy thought to himself--I don't want the world to think I just fell down out here.
Perhaps 18 minutes had passed since the President's arrival at the hospital.
Ben Aaron kept watching the ruby-colored blood flow out of the President. Not a flood, but more than a trickle.
The President's blood pressure was now nearly normal. His color was better, but he couldn't breathe without difficulty. If the President kept losing blood, the doctors would not be ableto keep giving him fluids indefinitely. When blood is replaced by fluids, the patient's hemoglobin diminishes; even though the blood pressure is normal, the tissues are deprived of oxygen, and the kidney, heart, and lungs lose function. If whole blood is administered for too long, the patient's blood loses its ability to clot. That possibility was approaching.
A portable x-ray machine was wheeled into the trauma bay, and within two minutes a chest film was taken and developed. Dr. David Rockoff, the head of chest radiology, was there to read it.
It showed that with the blood draining out through the chest tube, the lung had reexpanded. Rockoff also noticed an irregularly shaped, hazy area where blood remained in the left chest cavity. Then he saw a small, slender metal fragment shaped almost like a comma in the shadow of the heart. It was the bullet. Ben Aaron looked at the film. According to their viewing angle, the bullet could have hit the heart, the aorta, or the pulmonary artery. But the dark color of the blood coming from the President's chest still suggested that its source was the pulmonary artery, not the aorta, which produces bright-red blood.
Rockoff needed to know the caliber of the bullet. If it was a .22, they were seeing all of it. If it was a larger caliber, another fragment might have hit a rib and been deflected into the abdominal cavity.
He turned to a Secret Service agent standing next to him and asked: "What caliber bullet was it?"
The agent said he didn't know but would find out. What followed was one of the most inexplicable incidents in the President's shooting.
Rockoff listened as the agent turned to a superior and said, "They've got to know the caliber."
The superior said, "Then call the FBI. They've got the gun."
The Secret Service agent went to a phone and called the FBI. This is what was then overheard in the GW emergency room:
"What do you mean you 'can't' tell me?" the Secret Service agent said. "The doctors here have to know."
He turned to his superior and shouted: "They won't tell me."
"You tell them they've got to tell you! It's the President."
His voice rising, the Secret Service agent told the FBI: "We've got to know, and we've got to know now!"
There was a moment's silence before the agent turned to Rockoff and said: "It's a .38."
Rockoff relayed the news to colleagues. "We need a belly film to look for the rest of the bullet," he said.
This occurred 20 to 25 minutes after the President was admitted. The physicians treating the President worked under the assumption that he had been shot with a .38, and they would continue to assume that until, about an hour later, a .22-caliber bullet was removed from Tim McCarthy.
An abdominal x-ray--the "belly film"--of the President was taken immediately. One would have been taken anyway, but if the doctors had had correct information about the caliber of the bullet, it would have been done later. If time had been a more critical factor, the misinformation about the bullet could have been costly.
The abdominal film was negative. The doctors then assumed--because they could find no evidence of a bullet anywhere else--that it had probably hit something and shattered, and only a fragment had entered the President.
Dr. Neofytos (Newt) Tsangaris, acting chairman of surgery, was on the phone. "We're probably going to need three ORs," he said. Only two operating rooms were available now; another would be ready in a few minutes.
Nancy Reagan was ushered through the crowd in the ER and into the trauma bay. She held her husband's hand and leaned over to kiss his forehead. "Honey, I forgot to duck," he said.
After a brief visit, she returned to the small room at the entrance to the ER to join Edwin Meese, James Baker, and Lyn Nofziger, members of the President's staff.
Gens and Bennett tried to insert a large-bore line into the President's jugular vein to push in more fluids. This required the President to lie completely flat. It was very hard for him to breathe. He said he could take lying flat for only a few seconds. They failed to put the line in the first time and abandoned the attempt.
Ben Aaron was still watching the blood flowing out of the President. "When you see blood coming out of the chest that fast, and that persistently, without letup," Aaron would say later, "then you have to make some decisions."
It was now obvious that surgery was the safest course. Was a large blood vessel in the wound ready to burst? Would the blood flow suddenly increase? Those were the questions on Aaron's mind. He didn't want to be wheeling a 70-year-old patient who was in shock into the operating room for chest surgery.
Aaron now told the President that he wanted to go in and find the source of the bleeding and stop it. The President said go ahead. Aaron then spoke with Mrs. Reagan and explained options. She said go ahead.
The President had been in the hospital for about 30 minutes.