TMA Sesquicentennial Article -- January 2003
By Marilyn Baker
Often in history it helps to return to the original scripts, especially when conspiracy imbroglios overshadow the circumstances at hand.
Compelling examples are the reports of the physicians whose first imperatives on Nov. 22 and 24, 1963, were to save the lives of three patients arriving at Parkland Memorial Hospital's emergency room in Dallas.
Just hours after ministering to the assassinated President John F. Kennedy and the gravely wounded Gov. John B. Connally of Texas, physicians dictated their reports. Soon, they also recorded their efforts to save Lee Harvey Oswald, the man Dallas police had charged with the crimes. At the request of the Texas State Journal of Medicine , what is believed to be the first publicly released dictation was forwarded to Austin, and after reviewing the reports, the advisors and editors determined that they should be published almost verbatim. A misspoken word or two was corrected when the tempo would allow, but the reports stand as graphic pictures, frozen in time, of two November days in 1963. Those fresh reports also provide a peek at state-of-the-art emergency medical treatment in the early 1960s.
Adjacent to The University of Texas Southwestern Medical School at Dallas, Parkland Memorial Hospital was the primary trauma center for Dallas, treating an average of 272 patients daily in 1963, and had a reputation for skilled handling of gunshot wounds. Some UT Southwestern faculty, though still young, had served in World War II and in Korea. Most physicians looking after the president, the governor, and Lee Harvey Oswald were in their 20s, 30s, and 40s. Thus, the first doctor to see the president in the emergency room was Charles J. Carrico, MD, 28, a surgical resident who had graduated two years earlier from UT Southwestern. Alerted, other doctors sped to Trauma Room 1 to assist, including Malcolm O. Perry, MD, and Charles R. Baxter, MD, assistant professors of surgery; Ronald Jones, MD, chief resident in surgery; Marion T. "Pepper" Jenkins, MD, professor and chair of the department of anesthesiology; A.H. Giesecke Jr., MD, assistant professor of anesthesiology and a Parkland staff anesthesiologist; Jackie H. Hunt, MD, staff anesthesiologist; Gene Akin, MD, anesthesiology resident; Robert N. McClelland, MD, assistant professor of surgery; Paul Peters, MD, a urological surgeon and assistant professor of surgery; William Kemp Clark, MD, associate professor and chair of the division of neurosurgery; Fouad A. Bashour, MD, associate professor of medicine in cardiology; and Don T. Curtis, DDS, an oral surgeon.
Governor Connally was seen originally in the emergency room by Dr. Carrico and by Richard Dulany, MD, a surgical resident. From Trauma Room 2, the governor was transferred to a main operating room. Looking after him were Robert R. Shaw, MD, professor of thoracic surgery and chief of thoracic surgery; James H. "Red" Duke, MD, surgery resident; George Thomas Shires, MD, professor and chair of the department of surgery; Charles F. Gregory, MD, professor and chair of orthopedic surgery; James Boland, MD, thoracic surgery resident; William Osborne, MD, and John Parker, MD, orthopedic surgery residents; Ralph Don Patman, MD, surgery resident; and Drs. McClelland, Baxter and Giesecke, who had assisted with the president.
On Nov. 24, some of the same physicians -- Drs. Shires, Perry, McClelland, Jones, Jenkins, Osborne, and Akin -- would try to save Mr. Oswald's life after he had been shot by Jack Ruby, a Dallas nightclub operator. Helping with his care were Gerry Gustafson, MD, Dale Coln, MD, and Charles Crenshaw, MD, surgical residents; William Risk, MD, urology resident; and Harlan Pollock, MD, and Curtis Spier, MD, anesthesiology residents. Dr. Bashour also assisted, providing an internal pacemaker.
In a recent conversation, Dr. Giesecke, who had assisted with the president's resuscitation and then managed the anesthesia for the governor, vividly recalled the circumstances on Nov. 22. He was in the cafeteria having lunch and talking over a research paper with Dr. Jenkins, his department chair, and Dr. Jones. An urgent call came over the hospital's public address system, "Dr. Shires to the emergency room. STAT !"
"Hold on, I thought!" he wrote in his book on the first 50 years of anesthesiology at Southwestern. "Dr. Shires was chair of surgery, nobody would ever call him ' stat' to the emergency room. Stat calls were for the interns and residents, not for the chair of surgery. I gulped one last bite before we learned from Ron Jones, a surgery resident, that the president of the United States had been shot. The time was 12:30."
Sending Drs. Giesecke and Hunt to the operating room for equipment, Dr. Jenkins, who had founded the anesthesiology department at Parkland, rushed downstairs to the emergency room. When he arrived, the president was being rolled in the door, and looking after him was Dr. Carrico who, Dr. Giesecke recalled, had just completed a rotation on the anesthesia service where he had performed more than 50 intubations. The young resident knew right away that the president needed an endotracheal intubation.
Dr. Giesecke picked up an electrocardiographic monitor and an anesthesia machine and joined Dr. Jenkins and the others at the president's side. "We didn't keep them in the emergency room then," he explained. Likewise, in the early 1960s -- before space medicine had yielded electronic marvels for medical and surgical care -- connecting an electrocardiogram was not a simple process. Dr. Giesecke had to attach the needle electrodes and shove them into the president's body. He remembered having a "weird" numbing sensation. There was no response. When the light came on the screen of the oscilloscope, there was no electrical activity, only a flat line. Soon, there was only a blank screen.
Dr. Hunt meanwhile tapped him on the shoulder and told him that Dr. Duke needed him across the hall in Trauma Room 2, that the governor had a chest wound. Until then, he had not known that anyone else had been wounded. When he arrived and saw that the governor was conscious but having great difficulty breathing, he asked that he be taken upstairs to the operating room where he could put him to sleep. There, he began managing his anesthesia during a five-hour marathon of operations on his chest, wrist, and thigh. Finally, in case his patient needed him, Dr. Giesecke spent the night in the hospital.
"Dr. Jenkins and Dr. Shires came in the next morning and called us together," he remembered, "and said we needed to write reports. This was going to be a historic event." The physicians each took Dictaphones, and recorded their observations and actions. The individual reports the physicians dictated were published -- with minor editing and verification with authors -- in the Texas State Journal of Medicine article, "Three Patients at Parkland," in January 1964.
"Do you have any idea how many times that article has been quoted?" Dr. Giesecke asked in 2002. "Literally thousands."
Reports on the president came from Drs. Carrico, Perry, Baxter, McClelland, Clark, Jenkins, and Bashour. The successive reports of the physicians paint a wrenching portrait of the president's condition: his lack of responsiveness on initial examination; the eyes deviated and pupils dilated; the locations of the wounds; the missing portions of the right temporal and occipital bones; the considerable quantity of blood on the patient, the carriage, and the floor; and the brain tissue on the carriage and floor.
Brief excerpts of their dictation offer glimpses of what the physicians faced and how they managed the crisis.
Dr. Carrico: . . . when the patient entered the emergency room on an ambulance carriage, he had slow agonal respiratory efforts and occasional cardiac beats detectable by auscultation. Two external wounds were noted. One was a small wound of the anterior neck in the lower one third. The other wound had caused avulsion of the occipitoparietal calvarium, and shredded brain tissue was present with profuse oozing. No pulse or blood pressure was present. Pupils were bilaterally dilated and fixed. A cuffed endotracheal tube was inserted through the laryngoscope. A ragged wound of the trachea was seen immediately below the larynx. The tube was advanced past the laceration and the cuff inflated. Respiration was instituted using a respirator assistor on automatic cycling. Concurrently, an intravenous infusion of lactated Ringer's solution was begun via catheter placed in the right leg. Blood was drawn for typing and crossmatching. Type O Rh-negative blood was obtained immediately. In view of the tracheal injury and diminished breath sounds in the right chest, tracheostomy was performed by Dr. Malcolm O. Perry and bilateral chest tubes were inserted. A second intravenous infusion was begun in the left arm. In addition, Dr. M.T. Jenkins began respiration with the anesthesia machine, cardiac monitor and stimulator attached. Solu-Cortef (300 mg.) was given intravenously. Despite those measures, blood pressure never returned. Only brief electrocardiographic evidence of cardiac activity was obtained.
Dr. Jenkins: . . . Dr. Carrico had begun resuscitative efforts by introducing an orotracheal tube, connecting it for controlled ventilation to a Bennett intermittent positive pressure breathing apparatus. Drs. Baxter, Perry, and McClelland arrived at the same time and began a tracheostomy and started the insertion of a right chest tube, since there was also obvious tracheal and chest damage. Drs. Peters and Clark arrived simultaneously and immediately thereafter assisted respectively with the insertion of the right chest tube and with manual closed chest cardiac compression to assure circulation. [It is] evidence of clear thinking of the resuscitative team that the patient also received 300 mg of hydrocortisone intravenously for the first few minutes. For better control of ventilation, he then exchanged the Bennett apparatus for an anesthesia machine and continued artificial ventilation. Dr. Gene Akin . . . and Dr. Giesecke connected a cardioscope to determine cardiac activity. During the progress of these activities, the emergency room cart was elevated at the feet in order to provide a Trendelenburg position, a venous cutdown was performed on the right saphenous vein, and additional fluids were begun in a vein in the left forearm while blood was ordered from the blood bank. All of these activities were completed by approximately 12:50, at which time external cardiac massage was still being carried out effectively by Dr. Clark as judged by a palpable peripheral pulse. Despite these measures there was only brief electrocardiographic evidence of cardiac activity.
These described resuscitative activities were indicated as of first importance, and after they were carried out, attention was turned to other evidences of injury. . . . With the institution of adequate cardiac compression, there was great flow of blood from the cranial cavity, indicating that there was much vascular damage as well as brain tissue damage. [Dr. Jenkins, in the journal report, had mentioned he saw "the right cerebellum protruding from the wound," and he later corrected this, stating that it was cerebrum.]
Dr. Perry: A small wound was noted in the midline of the neck in the lower third anteriorly. It was exuding blood slowly. A large wound of the right posterior cranium was noted, exposing severely lacerated brain. Brain tissue was noted in the blood at the head of the carriage. . . . While additional venesections were done to administer fluids and blood, a tracheostomy was effected. A right lateral injury to the trachea was noted. The cuffed tracheostomy tube was put in place as the endotracheal tube was withdrawn and respirations continued. Closed chest cardiac massage was instituted after placement of sealed-drainage chest tubes, but without benefit. When electrocardiogram evaluation revealed that no detectable electrical activity existed in the heart, resuscitative attempts were abandoned.
Dr. Baxter: The president had a wound in the midline of the neck. On first observation of the other wounds, portions of the right temporal and occipital bones were missing and some of the brain was lying on the table. The rest of the brain was extensively macerated and contused. The pupils were fixed and deviated laterally and were dilated. No pulse was detectable and ineffectual respirations were being assisted. . . . Meanwhile a pint of O negative blood had been administered without response. When all of these measures were complete, no heartbeat could be detected. Closed chest massage was performed until a cardioscope could be attached. Brief cardiac activity was obtained followed by no activity. Due to the extensive and irreparable brain damage which existed and since there were no signs of life, no further attempts were made at resuscitation.
Dr. Clark: [Dr. Clark cited the sequence of procedures up to the time he arrived and the sequence of arrival of the other physicians, and added that considerable quantities of blood were present in the president's oral pharynx.] . . . the president had bled profusely from the back of the head. There was a large (3 by 3 cm.) amount of cerebral tissue on the cart. There was a smaller amount of cerebellar tissue present also. The tracheostomy was completed and the endotracheal tube was withdrawn. Suction was used to remove blood in the oral pharynx. A nasogastric tube was passed into the stomach. Because of the likelihood of mediastinal injury, anterior chest tubes were placed in both pleural spaces. These were connected to sealed underwater drainage.
Neurological examination revealed the President's pupils to be widely dilated and fixed to light. His eyes were divergent, being deviated outward; a skew deviation from the horizontal was present. No deep tendon reflexes or spontaneous movements were found. When Dr. Clark noted that there was no carotid pulse, he began closed chest massage. A pulse was obtained at the carotid and femoral levels. Dr. Perry then took over the cardiac massage so that Dr. Clark could evaluate the head wound. There was a large wound beginning in the right occiput extending into the parietal region. Much of the right posterior skull at brief examination appeared gone. The previously described extruding brain was present. Profuse bleeding had occurred and 1500 c. of blood was estimated to be on the drapes and floor of the emergency operating room. Both cerebral and cerebellar tissue were extruding form the wound. By this time an electrocardiograph was hooked up. There was brief electrical activity of the heart, which soon stopped.
Dr. McClelland: [When he arrived, the president was being attended by Drs. Perry, Baxter, Carrico, and Jones, and he assisted with the tracheostomy for distress and tracheal injury.] The president was at that time comatose from a massive gunshot wound of the head with a fragment wound of the trachea. . . . Dr. Jones and Dr. Paul Peters . . . inserted bilateral anterior chest tubes for pneumothoraces secondary to the tracheomediastinal injury. Dr. Jones and assistants had started three cutdowns, giving blood and fluids immediately. [The cause of death, Dr. McClelland's report in the journal stated, was the massive head and brain injury from a gunshot wound of the right side of the head. In his original chart, he mistakenly had said the left side.]
Dr. Bashour: At 12:50 p.m., Dr. Bashour was called from the first floor of the hospital and told that President Kennedy had been shot. He and Donald W. Seldin, MD, professor and chair of the department of internal medicine at UT Southwestern, went to the emergency room where they found that the president had no pulsations, no heartbeats, and no blood pressure. The oscilloscope showed a complete standstill.
For 25 fervent minutes the doctors at Parkland tried to resuscitate the president to no avail. At 1 p.m., Dr. Clark declared him dead.
Remaining, however, was the final diagnosis -- the autopsy. This, too, required medical attention, normally the responsibility of Earl Rose, MD, the medical examiner in Dallas. When it appeared that he was to be overruled in the president's case, he asked Vernie A. Stembridge, MD, professor and chair of pathology at UT Southwestern, to help persuade the Secret Service that the autopsy, by law, should be performed in Texas. When they were unsuccessful, Dr. Stembridge urged Dr. Rose to accompany the body and the Kennedy entourage to Washington. Feeling strongly that the autopsy should be performed in accordance with Texas law, however, Dr. Rose believed he should not go. Members of the Secret Service meanwhile wheeled the president's body from Trauma Room 1, very nearly running over the medical examiner. The president's body, wrapped in a blanket, was placed in a casket and flown to the nation's capital, where pathologists at the Naval Medical Center at Bethesda, Md., as chosen by Mrs. Kennedy, performed the autopsy.
Later that day, Dr. Rose performed the autopsy on the body of Officer J.D. Tippit, also reportedly shot by Lee Harvey Oswald; two days later, that of Mr. Oswald; and four years later, the body of Mr. Ruby, who died of lung cancer while awaiting a new trial for his crime.
In the 1990s, as Ashbel Smith professor and chair emeritus of pathology, Dr. Stembridge continued to believe that the ensuing secrecy, stirred by the hasty removal of the president's body, helped foment the vast conspiracy theories that have continued to thrive. In 1992, he persuaded Dr. Rose to talk with Dennis Breo, who was writing an update for the Journal of the American Medical Association aimed at assuring an accurate record. As a member of the 1977 House Select Committee on Assassinations, Dr. Rose had supported its conclusions that wounds to the president's neck and head came from behind and above and that there was no room for doubt on the finding. He, too, continued to believe, as he told Mr. Breo, that if the autopsy had been performed in Dallas, it "would have been free of any perceptions of outside influences to compromise the results. After all, if Oswald had lived, his trial would have been held in Texas and a Texas autopsy would have assured a tight chain of custody on all the evidence. In Dallas, we had access to the president's clothing and to the medical team who had treated him, and these are very important considerations." He added, "If we have learned anything . . . It is that silence and concealment breed theories of conspiracy . . ."
Mr. Breo and JAMA Editor George D. Lundberg, MD, also a pathologist, interviewed James Joseph Humes, MD, and "J" Thornton Boswell, MD, who conducted the autopsy at the Naval Medical Center, joined later by Army Lt. Col. Pierre M. Finck, a ballistics expert at the Armed Forces Institute of Pathology. Their report stated that President Kennedy "was killed by a devastating gunshot wound to the head fired from above and behind by a high-velocity rifle. The second bullet that struck him in the back of the neck was also fired from above and behind. That's it. Everything else is adventitious."
Dr. Humes, who was in charge, agreed with Dr. Rose that the body was illegally removed from Dallas under Texas law and that there would have been less confusion if the autopsy had been performed in Dallas. He told Dr. Lundberg and Mr. Breo, however, that at the time, "Lyndon Johnson did not know what was going on in Dallas on this day, and for all he knew a cabal could have been in the works. He wanted to get back to . . . Washington, D.C. He would not leave without Jackie Kennedy, and she would not leave without her husband's body." He also felt that the autopsy was probably "the least secret" in history and that the cause of death was "blatantly obvious."
Also speaking to Mr. Breo in 1992 were the physicians primarily trying to resuscitate the president, Drs. Carrico, Jenkins, Perry, and Baxter. Dr. Carrico, who became chair of the department of surgery at UT Southwestern, commented, "We were trying to save a life, not worrying about entry and exit wounds."
In 2002, Dr. Giesecke, now the retired Jenkins professor of anesthesiology and former chair of the department of anesthesiology and pain management, recalled what his mentor and colleague, Dr. Jenkins, often had told him: The reason the physicians attending the president had not conducted a comprehensive examination was that all efforts were toward resuscitation. It was the only critical issue at the moment, and nothing else could be done until that was achieved. Further complicating matters was that after the pronouncement of death, the family wanted to conduct last rites. Thus the physicians stood back for the rituals, knowing meanwhile they had a highly trained pathologist in Dr. Rose across the hall and that he would perform a comprehensive examination.
"If that had been done," Dr. Giesecke asserted, "we would have a lot of answers where we now have questions." Although the physicians had little choice in 1963, nowadays, he added, a thorough examination is performed before the morgue does its examination. That is one of the "lessons" learned from the tragedy.
As Dr. Stembridge had commented, the medical examiner's dilemma that tragic day in Dallas had another important lasting outcome, spurring greater consciousness of the need for a strong, autonomous medical examiner system with clear jurisdiction of legal authority. In 1963, that still remained under the authority of the justice of the peace.
If one can picture the governor's wounds from the rifle shot on Nov. 22, Dr. Giesecke observed, one might visualize him in a seated position in the limousine, and follow a direct line from his right shoulder through his right wrist, which was resting in his lap, and then into his left thigh. The bullet that entered his body also is considered the same one that went through President Kennedy's neck.
After Governor Connally and his wife, Nellie, returned to the Governor's Mansion in Austin to recover, they met with the editor of the Texas State Journal of Medicine and with Pruett Watkins, MD, of Austin, chair of the journal advisory committee.
Recounting the scene in Dallas after he was struck by the bullet that pierced his chest, arm, and thigh, Governor Connally recalled raising himself in the back of the limousine but being unable to lift himself onto the stretcher. He was aided on to it, Mrs. Connally said, and then taken to Trauma Room 2 at Parkland, across the hall from where the president was being attended.
Dr. Giesecke recalled that when he reached Trauma Room 2, "Red Duke was there, a senior surgical resident. As a resident, he rotated to various special services, chest and cardiac at the time. He had a Vaseline gauze on the chest. A sucking area was preventing him from breathing, and Dr. Duke was trying to close it so he could get a breath. It wasn't working." The governor was still conscious, thus Dr. Giesecke advised moving him to the operating room where he could put him to sleep and control the breathing, and where the chest wound could be repaired.
On the way to the operating room, Dr. Giesecke had been briefed by Dr. Hunt, who already had examined the governor. His color was ashen, his pulse of normal rate and volume, but he was dyspneic and tachypneic, grunting as he exhaled. She remembered giving Mrs. Connally a cuff link while a tube was being placed in the governor's chest. "In 10 minutes, we were up in operating," he said.
Besides the occlusive dressing over the chest wound, Dr. Giesecke reported, Dr. Duke already had inserted a chest tube on the right, had placed a Foley catheter with recovery of 150 ml of urine, and was doing a cutdown in his right ankle. Meanwhile, the governor's chest and right axilla were being shaved in preparation for a right thoracotomy.
The reports of four physicians treating the governor were published, those of Drs. Shaw, Gregory, Shires, and Giesecke.
Dr. Giesecke: Because of his poor color, respiratory distress, and probable large blood loss, we decided to omit thiopental and to use cyclopropane and oxygen. Accordingly, we asked for quiet and for the governor to be covered with a clean cotton blanket. At 1 p.m., 20 minutes after his (Governor Connally) arrival in the emergency room, Dr. Giesecke started slowly with 800 cc cyclopropane per minute plus 2 liters of oxygen per minute. The governor's color had improved but his respirations were still rapid at 40 with grunting exhalations. He lost conscious without excitement at 1:07 p.m. and was given 80 mg succinylcholine chloride very slowly intravenously to prevent hard fasciculations and passive regurgitation. Laryngoscopy was atraumatic and easy and no abnormalities were noted. The pharynx and trachea were sprayed with 4 per cent cocaine and intubated with 34 Fr. endotracheal tube with a Knight-Grimm-Sanders cuff which was inflated to provide a good fit.
Dr. Hunt connected the leads to the electrocardiograph monitor, reported a very transient bradychardia during the intubation. The pulse rapidly returned to 100 and the electrocardiogram looked normal. A blood pressure cuff and stethoscope were applied to the left arm and blood pressure was noted at 100/70. The explosion-proof x-ray machine was moved in and x-rays taken of the chest, right arm, and left thigh and leg. Blood was drawn for typing and crossmatching, and the hemoglobin was reported at 1.52 gm per 100 cc; urine was normal. Respirations were controlled, the endotracheal tube was checked by auscultation of the chest and reference to the x-rays. The governor was placed in a semi-lateral position with the wounded side up. The right arm, by a sling over the chest, was supported from the operating table. The skin incision was made at 1:34 p.m., 55 minutes after the governor arrived in the operating room.
Drs. Shaw, Boland, and Duke operated for 1 hour and 45 minutes. The patient's position was changed to supine, and Drs. Gregory and Osborne operated on the arm, with Drs. Shires, Baxter, and McClelland operating on the left thigh simultaneously.
The cyclopropane was turned off at 4:45 p.m., and 50 mg meperidine was given intravenously. The governor regained consciousness during the application of the cast to the right arm and forearm. The endotracheal tube was irrigated with 50 ml normal saline in 10 ml increments, followed by suctioning, which yielded moderate amounts of blood mucus. The oropharynx was cleaned. Upon extubation, Governor Connally spoke immediately, saying he felt well, but he was somewhat restless.
The immediate postoperative course was satisfactory, without hypotension, and with only a hint of cyanosis, which resolved over the following three to four hours, during which time he complained of soreness of his right shoulder and a sensation of needing to urinate, caused by the urethral catheter.
During surgery the governor received 1,000,000 units of penicillin after it was determined that he was not sensitive following a discussion with his wife and a call to W.B. Swift, MD, of Fort Worth. In addition, he received 500 mg tetracycline. He had received 0.5 cc tetanus toxoid in the emergency room prior to transfer to the main operating suite.
Dr. Shaw: Dr. Shaw performed a thoracotomy, removed rib fragments and debrided the chest wound. Diagnosis of the chest condition was gunshot wound of the chest with comminuted fracture of the fifth rib, laceration of the middle lobe, and hematoma of the lower lobe of the right lung. . . . It was found that the bullet had made a wound of entrance just lateral to the right scapula, close to the axilla, had passed through the latissimus dorsi muscle, shattered approximately 10 cm of the lateral and anterior portion of the right fifth rib, and emerged below the right nipple. The wound of entrance was approximately 3 cm in its longest diameter and the wound of exit was a ragged wound approximately 5 cm in its greatest diameter. The skin and subcutaneous tissue over the path of the missile moved in a paradoxical manner with respiration indicating softening of the chest. [Dr. Shaw described in detail the operations to repair the chest damage, noting that as soon as the operation on the chest had been concluded, Drs. Gregory and Shires began surgery necessary for the wounds of the right wrist and left thigh.]
Dr. Gregory: There was comminuted fracture of the governor's right distal radius which occurred when the bullet passed through the chest and struck the arm. Dr. Gregory debrided the wound and reduced the fracture. . . . The wound of entry on the dorsal aspect of the distal right forearm at the junction of the distal fourth of the radius and its shaft was approximately 2 cm. in length and rather oblique, with a loss of tissue and with considerable contusion at its margins. There was a wound of exit along the volar surface of the wrist about 2 cm. above the flexion crease of the wrist in the midline. [He then described further details of his findings and the operation.] Small bits of metal were encountered at various levels throughout the wound. . . . there were noted fine bits of cloth like mohair. Dr. Gregory was told that the patient was wearing a mohair suit at the time of injury thus accounting for the deposition of such organic material within the wound.
Dr. Shires: [Dr. Shires performed the surgery for exploration and debridement of the gunshot wound of the governor's left thigh.] . . . there was a 1 cm punctate missile wound over the juncture of the middle and lower third, medial aspect, of the left thigh. X-rays revealed a bullet fragment imbedded in the body of the femur in the distal third. The wound was excised and the bullet tract explored. [Further detail of his findings and the repair.] The governor's postoperative convalescence was good. On the sixth postoperative day, the cast on his right arm was windowed and a routine delayed primary closure with through-and-through stainless steel alloy wire was performed. On the 14th postoperative day, the arm was x-rayed and a new cast was applied. On the 19th postoperative day, after ambulation, the governor developed a superficial saphenous thrombophlebitis in the right ankle. This was the site of a sterile cutdown done in the operating room at the time of the initial injury for the administration of blood, fluids, and antibiotics. For this he was placed on a regimen of bed rest, elevation, heat, and heparin for a period of two weeks.
Also on hand at the hospital on Nov. 24 when Lee Harvey Oswald arrived were physicians who had treated the governor and the president. Dr. Shires, in charge of the surgical team, and Dr. Jenkins, in charge of the anesthesia team, dictated detailed reports.
Dr. Shires reported that the surgery on Mr. Oswald, who had been shot in the upper abdomen and chest, was performed by Drs. Shires, Perry, McClelland, and Jones, and included an exploratory laparotomy, thoracotomy, and efforts to repair the aorta, vena cava, and multiple organ injuries. Despite repeated attempts to save his life, Mr. Oswald was pronounced dead at 1:07 p.m. Mr. Oswald, Dr. Shires said, was never conscious from the time of his arrival in the emergency room. The subcutaneous bullet was extracted from the side during the attempts at defibrillation that were rotated among the surgeons. The cardiac massage and defibrillation attempts were carried out by Drs. McClelland, Perry, and Jones, with assistance from the cardiologist, Dr. Bashour.
Dr. Jenkins, writing about the anesthesia and other procedures in the operating room, noted that members of the resuscitation team were himself and Dr. Akin, with an anesthesia machine and full resuscitative equipment for the maintenance of ventilation. Gerry Gustafson, MD, Dale Coln, MD, and Charles Crenshaw, MD, residents in surgery, were prepared to introduce cannulae into the veins via cutdowns or percutaneous puncture. Dr. Jones was in the operating room with chest drainage equipment; Dr. Osborne, resident in orthopedic surgery, for necessary orthopedic services; and William Risk, MD, resident in urology, for evaluation of possible urological damage. Dr. Perry was present to direct the surgical approach. There were many other medical personnel present, he said, in addition to these, but the physicians named figured importantly in the initial resuscitative experience.
The bullet, Dr. Jenkins observed, which was palpable in the right posterior axillary line, was removed and sent by the operating room supervisor, Miss Audrey Bell, to be turned over to the legal authorities. He wrote further that all methods of resuscitation were instituted expeditiously and efficiently, and that the trauma Mr. Oswald had sustained was too great for resuscitation.
The events of Nov. 22 and 24, 1963, would leave each person with fragments of indelible memories: Secret Service and other personnel with their guns; Mrs. Kennedy's bloody clothes and the placement of her wedding ring on her husband's hand; her constant circling of the area where he was being treated; her handing a massive chunk of his brain tissue, which she had been nursing in her hands, to Dr. Jenkins; surprise by some at seeing that the president, his feet overhanging the gurney, was much larger than they thought; his massive shock of hair, redder than it seemed on television; the huge brace "tightly laced with wide Ace bandages making a figure-of-eight loop" around his trunk and thighs; Vice President Lyndon Baines Johnson sequestered for safety before being sworn in as president of the United States aboard the official airplane, Air Force One, by Judge Sarah T. Hughes of Dallas; and Governor Connally placed in a secure area to recuperate from surgery.
As for the medical care of the patients that day, the details were recorded for history in the words of the doctors themselves. The same physicians also would be deposed at length by others in the future, particularly the Warren Commission, which produced the official report on the assassination of President Kennedy. They would become a part of the progress of medicine over the next several decades and would see great evolution. Asked, for example, how anesthesia had changed since the early 1960s, Dr. Giesecke responded with a good-natured laugh: "Almost everything, from 'Hello, how are you feeling, governor?'" He uses the treatment of the day to illustrate to his students the importance of attending meetings and keeping abreast of change. He cites a few examples: Virtually all drugs and machines are different. Cyclopropane, which is explosive, is obsolete and cannot be found. Anesthesia is now administered intravenously. Succinylcholine, dating to 1935 and considered "the granddaddy drug," is still around but rarely used. "No one likes to use it unless they have to." Electrocautery is used to stop bleeding. "Very beneficial," he noted.
"The anesthesia machine used in 1963 was primarily plumbing; machines now are electronic. Although they convey gases, the process is done with great precision. We can calculate doses precisely now. . . . it was not possible then," he recalled. "Monitoring is similar. With the pulse oximeter, we can measure saturation of blood delivery to the finger. Then, we looked at the patient, and if blue, we knew he was not getting enough oxygen."
In addition, there are other more precise ways to monitor cardiac output and the performance of the cardiovascular system that are not very invasive and are easier to use. "The electronic revolution and the space program have contributed to that," he said. "We use the same cardiovascular monitor that is used in space without impairing the astronauts."
The Bennett intermittent pressure apparatus available in the emergency room in 1963 functioned by cycling air. It drove air or oxygen into the lungs until it built up positive pressure that caused it to shut off. When someone was doing cardiopulmonary resuscitation (CPR), chest compressions would increase the pressure inside the chest and, if doing good CPR, the patient never got a breath. Thus, Dr. Jenkins had called for the anesthesia machine used in an operating room to help resuscitate the president. It had a reservoir bag, Dr. Giesecke pointed out, and the anesthesiologist could squeeze it by hand to deliver air into the chest. Enough pressure thus could be delivered to the chest to overcome whatever was happening.
"Today," Dr. Giesecke added, "the design of ventilators allows the delivery of a volume, allowing one to set maximum pressure, and the machine will deliver sufficient air."
Although it was a period of chaos and uncertainty, "Once you get the patient," Dr. Giesecke said, "it doesn't matter, the patient becomes the total focus of attention. Working on him was the most important thing going on." As for Dr. Giesecke, he is proud to have had a "small role" on Nov. 22, 1963 -- the day that the life of the governor of Texas was saved.
Marilyn M. Baker, CAE, is the author of two books, Caring for the Children: The History of Pediatrics in Texas and The History of Pathology in Texas . She is coauthor with Ruth M. Bain, MD, of Doors Will Open for You: Memorable Experiences in My Life as a Doctor . She also is a former editor of Texas Medicine .
January 2003 Texas Medicine Contents
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