In OR 4 where James Brady lay prepped and ready for brain surgery, the story was quite different: A life was hanging on the edge. Dr. Kobrine looked at the CT scans a final time to consider his options and decided on a coronal opening. This is an ear-to-ear incision over the top of the head. Kobrine thought it would afford the best possible exposure. The operation began less than an hour after Brady was shot.
There was concern about Brady's left eye. The swelling was so pronounced that it was putting pressure on the eye. Dr. Mansour Armaly, an ophthalmologist, made a small incision to drain the clot on the eye.
As he peeled away the scalp, Kobrine could see the bullet hole through the skull. It was less than a centimeter in diameter. (To this day, Kobrine is uncertain whether the bullet--later identified as a "devastator"--exploded on impact. It probably didn't, nor did any of the others.) Kobrine saw that the bullet had gone through the sinuses and realized that this would greatly complicate Brady's recovery if he survived. The injury there created a direct air passageway to the brain that could lead to infections.
A saw was used to cut the skull and expose the brain.
Kobrine initially focused his attention on an opening made by the bullet in the dura, the outermost membrane covering the brain. He widened it to work down deeper into the left frontal lobe, from which he cleaned out the bone and bullet fragments and removed dead tissue.
One of the several doctors shuttling between the operating rooms and the second-floor offices where hospital and White House officials waited popped his head into OR 4. "The networks report that Brady is dead," he said.
"No one has told Mr. Brady or me that," Kobrine replied without looking up.
Neurosurgery is called the queen of surgery because such precision is required. Wearing a microscopic lens and illuminating the small surgical field with a high-intensity light attached to his forehead, Kobrine moved quickly. Brady's intracranial pressure remained very high.
Kobrine now moved to the right side, where he made a large opening through the dura to suction out a small hematoma near the surface.
Suddenly something entirely unpredictable happened--something that in great part is the reason Brady lives today.
Deep within the right side of Brady's brain, a large blood clot--the same clot that was so worrisome when Kobrine saw it on the CT scan--spontaneously burst. It could have been a catastrophe. Instead it was a godsend.
Its force was so great that it gushed up and through Brady's brain tissue, literally creating a fountain of blood when it broke through the outer surface of the right frontal lobe. If someone could have selected a place for that clot to burst its way out of Brady's brain, it would have been in the right frontal lobe. This is one of the less important areas of the brain, especially for someone who is right-handed. The bursting of the clot opened up a world of possibility unthinkable only moments before. It decompressed the potentially fatal pressure buildup within Brady's brain. His high blood pressure returned to normal.
The opening made by the bursting also provided Kobrine with an access route down into the brain. From this he was able to retract the right hemisphere and control the bleeding from two major damaged vessels with silver clips and electrified forceps. One of the vessels was the anterior cerebral artery, which had been severed by the bullet. He then slipped his finger into the opening and felt the main fragment of the flattened bullet near Brady's right ear. He extracted it with forceps.
There was still much to be done, and Brady remained in critical condition. But something close to a miracle had taken place.
The president's x-ray indicated that Dr. Aaron had been looking too low for the bullet. Now he put a catheter into the bullet track and began to follow the path. Minutes passed. He thought of closing the chest and leaving the bullet inside but decided to stay with it a while longer.
Finally, his fingers felt something hard. Sounds of relief filled the room as Aaron removed the bullet by carefully squeezing it out through the lung tissue.
Now he knew why it had been so hard to find: It was flattened to the size and shape of a dime. It was thin at the edges, thicker in the middle. Rifling marks were still evident on the edges. As before, a Secret Service agent extended a cup for the bullet.
The bleeding from the wound had finally stopped, and Aaron left a drainage site where he removed the bullet, irrigated the wound area, and began to sew over it, having made certain no major section of the pulmonary artery was damaged. Two tubes were left in the President's chest, one at the top for air retrieval, one at the bottom for drainage. Now, more than three hours after the President entered surgery, the doctors began to close his chest.
There was some debate as to where the President should spend the night--the intensive-care unit or the recovery room. Aaron wanted him in the recovery room. It was near the operating suite and, in the case of complications, provided quick access to the OR.
Shortly after 6:30 in the evening, the President, still breathing through the endotracheal tube, was wheeled across the hall into a corner of the recovery room.
Aaron's day wasn't finished. Now he was called to examine another patient--one he'd operated on recently for a heart-valve replacement--who was bleeding. One look at the patient and Aaron realized he had to go back to the OR. He would spend 14 hours in surgery during a 24-hour period.
George Morales returned to his small office in the anesthesia area near the OR suite. He found it filled with communications equipment. On his door a makeshift sign read "Temporary White House."
After receiving a thorough medical briefing from Aaron and other doctors, Dennis O'Leary, dean for clinical affairs, left his hospital office to brief the nation at a press conference. He and Dr. Ruge were the candidates for the spokesman job, but Ruge declined, saying he thought there might appear to be a conflict of interest if he took on the role. He said that someone from the hospital ought to speak for the hospital.
Darkness had fallen when O'Leary crossed 23rd Street on his way to Ross Hall, where he was about to address the nation via TV and radio. As they walked, presidential aide Lyn Nofziger said: "Remember, you don't have to answer a question just because someone asks it."
As the world was hearing that the president had sailed through surgery, the specialists surrounding him in the recovery room were considerably more guarded in their optimism. The President's first postoperative x-ray showed white shadows that indicated pockets of airlessness in the lungs. It also showed considerable plugging of the small sacs and vessels from secretions. Toward the bottom of the film there was a shrunken, whitish area where blood had pooled. The x-ray also showed that the left lower lobe was collapsed. To some of the doctors the findings were worrisome; they could not understand why the lower lobe was collapsed. To others the collapse as well as most of the other complications were predictable and not alarming.
A finding that concerned all the doctors was the level of oxygen in the President's blood, a measure of his lungs' gas-exchange process. The lab analysis showed it wasn't working well. His blood's oxygen level was normal only when the respirator was giving him 80 percent oxygen compared with 20 percent in normal air. They began taking readings every few minutes by drawing blood out of the arterial line in his wrist.
The respirator was set to give the President something called PEEP, an acronym for positive end expiratory pressure. This allows the respirator to trap gas in the lung at the end of each breath to open up and prevent the collapse of lung airways.
The President was not yet conscious. He lay on the stretcher, with the endotracheal tube down his throat. He was hooked up to an EKG monitor, blood pressure and pulse monitors, and IV lines. His head was tilted up at 30 degrees, and he was surrounded by a small army of medical personnel, Secret Service agents, and some of his aides, Baker and Meese most prominently. The aides asked when the President would be able to make decisions but didn't receive a precise answer.
The President began to regain consciousness at about 7:30 PM, and he indicated that he couldn't catch his breath. It is a sensation many people on respirators experience, and it can be frightening. He was assured the respirator was doing his breathing for him.
Between 7:30 and 8 the President's wife, Nancy, and their son Ron visited briefly. They held the President's hand. Mrs. Reagan kissed him, and Ron leaned over and whispered into his ear. Although he was aware of their visit, the President remained groggy. Mrs. Reagan expressed the President's concern--and her own--that he felt he could not breathe. It was an advocate's role she was to play throughout his stay in the hospital. But they understood her concern and patiently tried to keep her abreast of developments.
Mrs. Reagan was now reassured that the President was breathing as he should with the respirator and, at the doctors' urging, she prepared to leave. Standing alone in the open doorway of the recovery room, she looked back intensely at her husband's bed for what seemed like minutes.
At about 8 PM the president experienced pain and was given morphine. He would be given it periodically for the next several hours. For security reasons, most of the President's drugs and meals were brought from the White House. Secret Service agents randomly selected other drugs from the hospital pharmacy.
Dr. Ruge remained in the recovery room that night and would stay at the hospital around the clock until the President was discharged. His role was important not so much for what he did but for what he didn't do. At no time did Ruge intrude, impose his judgment, or demand that outside consultants be brought in. He was in the spot to do that, and it might have afforded him some protection from second-guessing if he had. But he had confidence in the GW doctors, and they in turn trusted him. Nor did Ruge consider moving the President to Bethesda Naval Hospital, which was suggested by the Secret Service.
Ruge's attitude helped avoid the VIP syndrome. That evening two chief surgical residents, David Gens and Paul Colombani, were assigned to take continuing care of the President. Although some physicians at GW felt this was a mistake, that a large team of senior specialists should have been assigned, the more standard approach was taken. "Medicine by conference would have been the worst thing we could have done," one of his doctors said later. The President was, in the words of another of his doctors, "treated like any other 70-year-old man with a gunshot wound."
Different doctors focused on different things during those first few hours in the recovery room. Dr. Samuel Spagnolo, pulmonary-medicine specialist, fixed on the rhythmic beeping and the steady line blipping across the screen of the EKG monitor. In all the hours Spagnolo watched, the President's heart didn't miss a single beat.
Sol Edelstein marveled at the powerful muscles in the President's chest, developed from outdoor work. Ruge said he'd seen the President toss around ranch posts as though they were bamboo sticks.
They now took another blood-gas reading, and the results were no more encouraging than the earlier ones. More x-rays were taken, and they showed the lower lobe still collapsed. There was concern that the President might have to stay on the respirator for up to three more days unless there was quick improvement. To keep him on 80 percent oxygen would invite other problems for his lungs.
The President was handed the back of a hospital progress sheet attached to a clipboard to write on. And write he did. Early notes continued to express his worry over his breathing, but their tone lightened at times.
"Am I alive?" he asked in one note after waking from a nap. Another said he'd like to shoot the whole scene over, beginning at the hotel.
Because his lungs were so congested, there was an attempt to perform a bronchoscopy. This involves slipping a fiber-optic tube down into the bronchi and clearing out clotted blood or other debris. The attempt failed because a bend in the endotracheal tube blocked the bronchoscope's passage.
Jack Zimmerman, director of the intensive-care unit and considered one of the best clinicians at the hospital, had come to the recovery room to assist. When the bronchoscopy failed, he had nurses Denise Sullivan and Kathy Edmonston take a small volume of saline solution and insert it into the endotracheal tube. It caused the President to cough, freeing mucous plugs and thinning out secretions, which were then suctioned out. In the midst of this the President wrote the note that echoed W.C. Fields: "All in all, I'd rather be in Philadelphia."
Most doctors and nurses took the note writing to be a reflection of the President's exuberance at being alive and as his way to break the tension.
The notes kept coming. One to Denise Sullivan, the head recovery-room nurse, read: "Does Nancy know about us?" The Secret Service took that note and all the others the President wrote.
Then came a different kind of note: "Was anyone else hurt?"
Sullivan, a quick woman with 15 years of nursing experience, froze for half a second and thought quickly. Two others were hurt, she told him, but not seriously. She had not heard of the fourth victim, Officer Thomas Delahanty, who had been successfully operated on at the Washington Hospital Center for a wound to his upper spine.
Then another note: "Did they get the guy?" Yes, Denny Sullivan told him, they did.
Ruge then conferred with the medical staff. There was agreement that if the President asked again, he was not to be told of the seriousness of the injuries to the others, particularly Jim Brady. Considering the President's condition, an emotional jolt was too much of a risk.
A new blood-gas reading was taken, and it showed improvement. The news was greeted with relief.
Tim McCarthy had been taken directly from the OR to the intensive-care unit for postoperative observation. He was doing well; his vital signs were strong and stable.
Toward 8:30 PM the six-hour operation on James Brady was ending. Dr. Kobrine had no certainty that Brady would ever be able to function again, but he was more encouraged now than he had been before surgery. Brady was wheeled into the recovery room at about 9, and Kobrine went to look for Sarah Brady.
Optimism took hold as the president's blood-gas level continued to improve. The oxygen from the ventilator was slowly reduced as his blood oxygen slowly increased--which meant his lungs were resuming function.
He remained alert and continued to write notes. "I don't think I've ever seen a person that age with that kind of injury do that well," Zimmerman said of the President's recovery-room performance.
As the hour neared midnight, it was becoming clear that if improvement continued, the President could be allowed to breathe without assistance before daybreak.
He apparently became unnerved momentarily when he overheard Ben Aaron describing to other doctors the condition of the heart patient he'd treated after he'd operated on the President.
"Is that happening to me?" the President wrote.
Marisa Mize, a recovery-room nurse who had come on at 11 PM for the night shift, reassured him that it wasn't. An attractive woman of 26, she sat next to the President for long periods of her shift--holding his hand, talking to him. At one point she rose to leave. The President seized her hand. His look told her not to go. She sat back down next to him.
At times she kidded him. "Don't worry," she said to him once, "your wife isn't holding dinner for you."
"I'm not that hungry, anyway," he wrote.