The CT scan of James Brady's brain was more discouraging than the original x-rays and clinical findings. Dr. David Davis, chair of radiology at GW and a neuroradiologist, looked at the scans—three-dimensional sectional views of the interior of the brain—and said he did not think Brady would survive. Besides the widespread bone and metal fragmentation, there was continued brain swelling, and the CT scan had picked up a very large clot developing in the right frontal region. That clot was as dangerous as any of the other injuries and was contributing to the swelling and intracranial pressure. The scan also showed that the bullet had traversed the brain's ventricular system—the walls of which make spinal fluid—further decreasing his chances of survival.
There was some talk of not operating at all, but Kobrine and the rest of the physicians in the CT room realized that they had no choice. To save time, Kobrine aborted the CT scans when he had enough information to prepare himself for the operation. He knew that it was crucial to begin quickly. He spoke briefly with Brady's wife, Sarah, but could offer little encouragement.
As Kobrine rushed Brady to OR 4—one of the neurological operating rooms—he figured Brady's chances of survival were less than one in ten. As they neared the OR suite, Kobrine was annoyed to see someone being wheeled in ahead of his critically injured patient.
"Who's that?" Kobrine asked.
"The President," he was told.
The president's stretcher had been wheeled from the ER straight down the hall to the 13-room operating suite. He was accompanied by IV poles carrying blood and fluids and by Secret Service agents, physicians, nurses, and technicians. At his side was Mrs. Reagan, holding his hand.
Sol Edelstein, the ER director, walked in front of the stretcher to stop it from moving too fast. He was afraid the IV lines could be yanked out of the President's arm. Another doctor held the President's foot because the stretcher had no sides. They took a shortcut through the recovery room. The patients there, still groggy from anesthesia, lifted their heads to see what the commotion was about.
David Gens was in his street clothes. He was to assist on a peritoneal lavage or "belly tap" and didn't want to take the time to run to the men's locker area to change into his sterile greens. He went into a small closet near the OR, closed the door, and changed in darkness. Dr. Ruge, wearing a warm wool suit, removed it, wound it up in a ball, and put it on a windowsill when he changed into his greens. Ruge continued to reassure the President that things were going well, that he was in good hands.
There were medical gawkers. One, a GW staff member, remained on the telephone in the posting area just outside the OR and talked and talked, refusing to hang up. Mike Barch, the Medical Center administrator, threatened him with arrest if he didn't leave. He left. Another gawker, a gynecologist, stayed on in the operating room. He just wanted to help, he kept saying. He was shown the door.
A Secret Service agent removed his shoes. He thought it was necessary before entering the OR. "You could tell the Secret Service men," one doctor said. "They all had some part of their OR greens on wrong."
The President was taken to OR 2, the cardiac-surgery room with an amphitheater. Brady went into OR 4 with Kobrine, and McCarthy into OR 5 with Tsangaris and chief surgical resident Colombani. The three patients arrived at the operating suite at virtually the same time.
The ORs are lined with green ceramic tiles that often give off a hollow sound. OR 2 was filled with too many people for that.
Stephen Pett, a thoracic surgeon who was in the operating room to assist Aaron if necessary, was asked by a Secret Service agent to identify anyone he didn't know. Pett glanced around, then focused on one face.
"I don't know that guy," he said, pointing to a tall man.
"That's the President's doctor," he was told.
As the President was lifted off the stretcher and onto the operating table, he looked around and, in a move his doctors interpreted as an attempt to break the tension, said: "Please tell me you're all Republicans."
Dr. Joseph Giordano, a liberal Democrat who was there to do the belly tap, said, "Today we're all Republicans, Mr. President."
Dr. George Morales, an authority on anesthesiology, continued to attend to the President.
"How are you going to put me to sleep? I can hardly breathe now," the President said.
Everything would be fine, Morales assured him.
Assisted by Dr. Manfred Lichtmann, chief of anesthesiology at Walter Reed Army Hospital until he joined the GW faculty, Morales faced the risky problem of putting to sleep a 70-year-old man who was injured seriously and had just eaten, a factor that could provoke vomiting.
Valium was administered, followed by a synthetic narcotic and then Pentothal. As the President was drifting under, Lichtmann performed what is called the Sellick maneuver: With his fingers, he pressed the cricoid cartilage—a ring-shaped cartilage on the upper trachea—against the esophagus, exerting enough pressure to block the esophagus and prevent any backward flow of food and stomach acid if the President vomited. The major risk occurs if food and acid come up and go into the trachea and are drawn into the lung.
The Sellick maneuver was brought off beautifully, and, with remarkably little Pentothal, the President went under. A tube was introduced into his trachea to permit him to breathe during surgery.
Giordano, Gens, and Price began the belly tap. Giordano made a small incision just below the navel and inserted a catheter through it into the abdominal cavity, sealed off from the chest by the diaphragm. They poured in a liter of sterile saline solution and then shifted the President's position to wash the fluid around and out. When the cavity emptied they examined it, and it was clear. The procedure had taken 30 minutes, and they were now 99 percent certain that he had no abdominal injury. To be 100 percent certain, they sent the fluid to the laboratory for analysis.
As Gens was closing the abdominal incision, a thought struck him. He looked up at the faces surrounding the President on the operating table and asked: "Does anyone know what's going on out there?"
There was silence. Then Gens was asked what he meant.
"A lot of people were shot," Gens said. "Is there a conspiracy?"
No one knew. No one had had time to give it much thought.
For the exploratory operation, Dr. Aaron would be assisted by Dr. Kathleen Cheyney, a thoracic fellow at GW and Aaron's regular surgical assistant. Dr. David Adelberg, an intern, would also assist. Lula Gore and Thomas Rhodes would be scrub nurses, and Deborah Medenhail and Priscilla Segal were circulating nurses.
Aaron insisted that the President be treated like anyone else. He feared what doctors call the "VIP syndrome," in which famous people are accorded deferential treatment and usually are much the worse for it.
They turned the President on his right side at about a 45-degree angle and made a six-inch incision along the front and left side of his chest.
Aaron "opened," and Cheyney retracted the incision as Aaron cut. The President's chest muscles were parted and his ribs were spread with a large chrome rib separator. When Aaron got inside the chest he found a 500-cc clot of blood in the left lower lobe. Now the full amount of blood lost by the President was nearly 3,000 cc's, about half of his total supply.
The entry point of the bullet was a jagged slit, but as the bullet had moved into the lung tissue it had made a round hole, about the diameter of a dime.
Aaron saw that the blood flowing out of the wound was still dark. He was convinced that part of the pulmonary artery down in the lower lobe had been struck.
He kept exploring. He opened an area near the heart and looked at it. The pericardium had not been hit. The aorta also was untouched. Aaron now began following the bullet track. The bullet had apparently headed on a downward course until it hit the top of the seventh rib and was deflected toward the upper middle of the chest.
He held the President's lung in his hands, feeling in the soft, spongy material for the hard fragment of bullet he was determined to find and remove. He was as impressed by the texture of the lung as he had been by the muscle tone of the President's chest. Both resembled those of a much younger man.
"It made sense to take the bullet out of the President," Aaron later said. "What I wanted was a nice, clean operation. I didn't want to back out and leave the bullet in there."
But he couldn't find it.
He kept fingering the lung—squeezing, probing—but the bullet wouldn't turn up.
Then the fear hit him. Maybe it had gotten into the pulmonary vein. If that had happened, it could have gone into the heart and now be moving out into the arterial tree. That, Aaron knew, could be very serious.
He asked Ruge: How important is it that I get the bullet out?
What's important is that the President survive, Ruge answered.
Aaron kept looking. Several minutes passed. Tension in the OR mounted.
Lichtmann, often the anesthesiologist when Aaron performed heart surgery, had seen him in tight spots before. He knew the signs—the knit brow, the tight expression—and he often tried to break the tension. He tried it now.
"You enjoying yourself, Ben?"
Aaron glanced up and smiled for a split second.
Lichtmann and Morales kept monitoring the President's vital signs. His arterial pressure was good. But the EKG picked up a minor electrical-conduction abnormality in the President's heart. It was a preexisting condition, they were told.
Aaron called for another x-ray—a side view—to get a better fix on the bullet's location. The film was rushed down to the lab for developing.
In OR 5, everything was moving routinely. Paul Colombani was performing most of the surgery on Tim McCarthy. The bullet had traversed McCarthy's right lung, diaphragm, and right lobe of the liver.
They found the bullet behind the liver, and when Colombani plucked it out he thought it looked strange. It appeared to have a hollow point, shiny on the inside and copper-colored on the outside. It was hardly deformed at all.
He gave the bullet to a Secret Service agent who was holding out a cup. Another agent took extensive notes. The news was rushed to OR 2 that the weapon used in the shootings was a .22 caliber, not a .38.
McCarthy's vital signs remained stable. They were sure he would survive.