Table of Contents, Appendix VII, Appendix IX
The President's wife refused to take off her bloody gloves, clothes. She did take a towel and wipe her face. She took her wedding ring off and placed it on one of the President's fingers.
Dr. Carrico noted the President to have slow, agenal respiratory efforts. He could hear a heartbeat but found no pulse or blood pressure to be present. Two external wounds, one in the lower third of the anterior neck, the other in the occipital region of the skull, were noted. Through the head wound, blood and brain were extruding. Dr. Carrico inserted a cuffed endotracheal tube. While doing so, he noted a ragged wound of the trachea immediately below the larynx.
At this time, Dr. Malcolm Perry, Attending Surgeon, Dr. Charles Baxter, Attending Surgeon, and Dr. Ronald Jones, another Resident in General Surgery, arrived. Immediately thereafter, Dr. M. T. Jenkins, Director of the Department of Anesthesia, and Doctors Giesecke and Hunt, two other Staff Anesthesiologists, arrived. The endotracheal tube had been connected to a Bennett respirator to assist the President's breathing. An Anesthesia machine was substituted for this by Dr. Jenkins. Only 100% oxygen was administered.
A cutdown was performed in the right ankle, and a polyethylene catheter inserted in the vein. An infusion of lactated Ringer's solution was begun. Blood was drawn for type and crossmatch, but unmatched type "O" RH negative blood was immediately obtained and begun. Hydrocortisone 300 mgms was added to the intravenous fluids.
Dr. Robert McClelland, Attending Surgeon, arrived to help in the Presiden'ts care. Doctors Perry, Baxtyer, and McClelland began a tracheostomy, as considerable quantities of blood were present from the President's oral pharynx. At this time, Dr. Paul Peters, Attending Urological Surgeon, and Dr. Kemp Clark, Director of Neurological Surger, arrived. Because of the lacerated trachea, anterior chest tubes were place in both pleural spaces. Thiese were connected to sealed unerwater drainage.
Neurological examination revealed the President's pupils to be widely dialted and fixed to light. His eyes were divergent, being deviated outward; a skew deviation from the horizontal was present. Not deep tendon reflexes or spontaneous movements were found.
There was a large wound in the right occipito-parietal region, from which profuse bleeding was occurring. 1500 cc. of blood were estimated on the drapes and floor of the Emergeny Operating Room. There was considerable loss of scalp and bone tissue. Both cerebral and cerebellar tissue were extruding from the wound.
Further examination was not possible as cardiac arrest occurred at this point. Closed chest cardiac massage was begun by Dr. Clark. A pulse palpable in both the carotid and femoral arteries was obtained. Dr. Perry relieved on the cardiac massage while a cardiotachioscope was connected. Dr. Fouad Bashour, Attending Physician, arrived as this was being connected. There was electrical silence of the President's heart.
President Kennedy was pronounced dead at 1300 hours by Dr. Clark
Kemp Clark, M. D.
Service of Neurological Surgery
cc to Dean's Offic, Southwestern Medical School
cc to Medical Records, Parkland Memorial Hospital
Sponge Counts: 1st - Correct, 2nd - Correct
I. V. Fluids and Blood: 111-500 cc whole blod, 11-1000cc D-5-RL
Condition of Patient: Satisfactory
The patient was brought to the OR from the EOR. In the EOR a sucking wound of the right chest was partially controlled by an occlusive dressing supported by manual pressure. A tube had been placed through the second interspace in the midclavicular line connected to a waterseal bottle to evacuated the right pneumothorax and hemathorax. An IV infusion of RL solution had already been started. As soon as the patient was positioned on the OR table the anesthesia was induced by Dr. Giesecke and an endotracheal tube was in place. As soon as it was possible to control respiration with positive pressure the occlusive dressing was taken from the right chest and the extent of the wound more carefully determined. It was found that the wound of entrance was just lateral to the right scapula close to the axilla yet had passed through the latysmus dorsi muscle shattered approximately ten cm of the lateral and anterior portion of the right fifth rib and emerged below the right nipple. The wound of entrance was approximately three cm in its longest diameter and the wound of exit was a ragged wound approximately five 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. The skin of the whole area was carefully cleansed with Phisohex and Iodine. The entire area including the wound of entrance and wound of exit was draped partially excluding the wound of entrance fro the first part of the operation. An elliptical incision was made around the wound of exit removing the torn edges of the skin and the damaged subcutaneous tissue. The incision was then carried in a downward curve up toward the right axilla so as to not have the skin incision over the actual path of the missile through the chest wall. This incision was carried down through the subcutaneous tissue to expose the Serratus anterior muscle and the anterior border of the latissimus dorsi muscle. The fragmented and damaged portions of the Serratus anterior muscle were excised. Small rib fragments that were adhering to periosteal tags were carefully removed preserving as much periosteum as possible. The fourth intercostal muscle bundle and fifth intercostal muscle bundle were not appreciably damaged.
The ragged ends of the damaged fifth rib were cleaned out with the rongeur. The plura had been torn open by the secondary missiles created by the fragmented fifth rib. The wound was open widely and exposure was obtained with a self-retaining retractor. The right pleural cavity was then carefully inspected. Approximately 200 cc of clot and liquid blood was removed from the pleural cavity. The middle lobe had a linear rent starting at its peripheral edge going down towards its hilum separating the lobe into two segments. There was an open bronchus in the depth of this wound. Since the vascularity and the bronchial connections to the lobe were intact it was decidded to repair the lobe rather than to remove it. The repair was accomplished with a running suture of #000 chromic gut on atraumatic needle closing both pleural surfaces as well as two running sutures approximating the tissue of the central portion of the lobe. This almost completely sealed off the air leaks which were evident in the torn portion of the lobe. The lower lobe was next examined and found to be engorged with blood and at one point a laceration allowed the oozing of blood. This laceration had undoubtedly been caused by a rib fragment. This laceration was closed with a single suture of #3-0 chromic gut on a traumatic needle. The right pleural cavity was now carefully examined and small ribs fragments were removed, the diaphram was found to be uninjured. There was no evidence of injury of the mediastinum and its contents. Hemostasis had been accomplished within the pleural cavity with the repair of the middle lobe and the sutureing of the laceration in the lower lobe. The upper lobe was found to be uninjured. The drains which had previously been placed in the second interspace in the midclavicular line was found to be longer than necessary so approximately ten cm of it was cut away and the remaining portion was demonstrated with two additional openings. An additional drain was placed through a stab wound in the eight interspace in the posterior axillary line. Both these drains were then connected to a waterseal bottle. The fourth and fifth intercostal muscles were then approximated with interrupted sutures of #0 chromic gut. The remaining portion of the Serratus anterior muscle was then approximated across the closure of the intercostal muscle. The laceration of the latissimus dorsi muscle on its innermost surface was then closed with several interrupted sutures of #0 chromic gut. Before closing the subcutaneous tissue one million units of Penicillin and one gram of Streptomycin in 100 cc normal saline was instilled into the wound. The stab wound was then made in themost dependent portion of the wound coming out near the angle of the scapula. A large Penrose drain was drawn out throught this stab wound to allow drainage of the wound of the chest wall. The subcutaneous tissue was then closed with interrupted #0 chromic gut inverting the knots. Skin closed with interrupted vertical mattress sutures of black silk. Attention was next turned to the wound of entrance. Ti was excised with an elliptical incision. It was found that the latisimus dorsi muscle although lacerated was not badly damaged so that the opening was closed with sutures of #0 chromic gut in the fascia of the muscle. Before closing this incision palpation with the index finger the Penrose drain could be felt immediately below in the space beneath the latissimus dorsi muscle. The skin closed with interrupted vertical mattress sutures of black silk. Drainage tubes were secured with safety pins and adhesive tape and dressings applied. As soon as the operation on the chest had been concluded Dr. Gregory and Dr. Shires started the surgery that was necessary for the wounds of the right wrist and left thigh.
Dr. Robert Shaw
* There was also a comminuted fracture of the right radius secondary to the same missile and in addition a small flesh wound of the left thigh. The operative notes concerning the management of the right arm and left thigh will be dictated by Dr. Charles Gregory and Dr. Tom Shires.
While still under general anesthesia and following a thoracotomy and repair of the chest injury by Dr. Robert Shaw, the right upper extremity was thoroughly prepped in the routine fashion after shaving. he was draped in the routine fashion using stockinette, the only addition was the use of a debridement pan. The wound of entry on the dorsal aspect of the right wrist over the junction of the distal fourth of the radius and shaft was approximately two cm in length and rather oblique with the loss of tissue with some considerable contusion at the margins of it. There was a wound of exit along the volar surface of the wrist about two cm above the flexion crease of the wrist and in the midlin. The wound of entrance was carefully excised and developed through the muscles and tendons from the radial side of the bone to the bone itself where the fracture was encountered. It was ntoed that the tendon of the abductor palmaris was transected, only two small fragments of bone were removed, one approximately one cm in length and consisted of lateral cortex which lay free in the wound and had no soft tissue connections, another much smaller fragment perhaps 3 mm in length was subsequently removed. Small bits of metal were encountered at various levels throughout the wound and these were wherever they were identified and could be picked up were picked up and have been submitted to the Pathology department fo riidentification and examination. Throughout the wound and especially in the superficial layers and to some extent in the tendon and tendon sheaths on the radial side of the arm small fine bits of cloth consistant with fine bits of Mohair. it is our understanding tha the patient was wearing a Mohair suit at the time of the injury and this accounts for the deposition of such organic material within the wound. After as careful and complete a debridement as could be carried out and with an apparent integrity of the flexor tendons and the median nervie in the volar side, and after thorough irrigation the wound of exit on the volar surface of the wrist was closed primarily with wire sutres while the wound of entrance on the radial side of the forearm was only partially closed being left open for the purpose of drainage should any make spontaneous appearance.
The presence of Mohair and organic material deep into the wound which is prone to produce tissue reactions and to encourage infection and this precaution of not closing the wound was taken in correspondance with our experience in that regard.
In view of the urgency of the Governor's original chest injury it was impossible to definitely ascertain the status of the circulation and the nerve supply to the hand and wrist on the right side. Accordingly, it was determined as best we could at the time of operation and the radial artery was found to be intac and pulsating normally. The integrity of the median nerve and the ulnar nerve is not clearly established but it is presumed to be present. Following closure of the volar wound and partial closure of the radial wound, dry strerile dressings were applied and a long arm cast was then applied with skinn tape traction, rubber band variety, attached to the thumb and index finger of the right hand. An attitude of flexon was created at the right elbow, and post operatively the limbus suspended from an overhead frame using tape traction. The post operative diagnosis for the right forarm remains the same and again I suggest that you incorporate this particular dictation together with other dictations which will be given to you by the surgeons conerned with this patient.
Charles Gregory, M. D.
Assistants: Drs. McClellend, Basxter, and Patmen
Scrub Nurse: Oliver
Circ. Nurse: Deming and Schroeder
Sponge Counts: 1st Correct, PS
There was a 1 cm. punctate missile wound over the juncture of the midddle and lower third, medial aspect, of the left thigh. X-rays of the thigh and leg revealed a bullet fragment which was imbedded im the body of the femur in the distal third. The leg was prepared with Phisohex and I. O. Prep and was draped in the usual fasion.
Following this the missile wound was excised and the bullet tract was explored. The missile wound was seen to course through the subcutaneous fat and into the vastus medialis. The necrotic fat and muscle were debrided down to the region of the femur. The driection of the missile wound was judged not to be in the course of the femoral vessal, since the wound was distal and anterior to Hunter's canal. Following complete debridement of the wound and irrigation with saline, the wound was felt to be adquately debrided enough so that three simple through-and through, stainless stell Aloe #28 wire sutures were used encompassing skin, subcutaneous tissue, and muscle fascia on both sides. Following this a sterile dressing awas applied. The dorsalis pedis and posterior tibial pulses in both legs were quite good. The thoracic procedure had been completed at this time, the debridement of the compound fracture in the arm was still in progress at the time this soft tissue injury repair was completed.
Tom Shires, M. D.
Circ. Nurse: Schrader, Bell, Burkett, Simpson
Sponge Counts: 1st, 2nd 2 counted sponges missing when body closed. Square pack count correct.
Drugs: Ca chloride - 3 vials, Cedilanid - 12, One molar lactate - 6, Isuprel - 24, Adrenalin 1:1000 - 3.
I. V. Fluids and Blood: 3-1000 cc lactated Ringer's solution, 16-500 cc. whole blood, 6-1000 cc. 5% dextrose in lactated Ringer's solution. Measured blood loss - 8,376 cc.
Condition of Patient: Expired at 1307
Previous inspection had revealed an entrance wound over the left lower lateral chest cage, and an exit was identified by subcutaneous palpation of the bullet over the right lower lateral chest cage. At the time he was seen preoperatively he was without blood pressure, heart beat was heard infrequently at 130 beats per minute, and preoperatively had endotracheal tube placed and was receiving oxygen by anesthesia at the time he was moved to the operating room.
Under endotracheal oxygen anesthesia, a long mid-line abdominal incision was made. Bleeders were not apparent and none were clamped or tied. Upon opening the peritoneal cavity, approximately 2 to 3 liters of blood, both liquid and in clots, were encountered. These were removed. The bullet pathway was then identified as having shattered the upper medial surface of the spleen, then entered the retroperitoneal area where there was a large retroperitoneal hematoma in the area of the pancreas. Following this, bleeding was seen to be coming from the right side, and upon inspection there was seen to be an exit to the right through the inferior vena cava, thence through the superior pole of the right kidney, the lower portion of the right lobe of the liver, and into the right lateral body wall. First the right kidney, which was bleeding, was identified, dissected free, retracted immediately, and the inferior vena cava hole was clamped with a partial occlusion clamp of the Satinsky type. Following this immobilization, packing controlled the bleeding from the right kidney. Attention was then turned to the left, as bleeding was massive from the left side. The inspection of the retroperitoneal area revealed a huge hematoma in the mid-line. The speen was then mobilized, as was the left colon, and the retroperitoneal approach was made to the mid-line structures. The pancreas was seen to be shattered in its mid portion, bleeding was seen to be coming from the aorta. This was dissected free. Bleeding was controlled with finger pressure by Dr. Malcolm O. Perry. Upon identification of this injury, the superior mesenteric artery had been sheared off of the aorta, there was back bleeding from the superior mesenteric artery. This was cross-clamped with a small, curved DeBakey clamp. The aorta was then occluded with a straight DeBakey clamp above and a Potts clamp below. At this point all major bleeding was controlled, blood pressure was reported to be in the neighborhood of 100 systolic. Shortly thereafter, however, the pulse rate, which had been in the 80 to 90 range, was found to be 40 and a few secons later found to be zero. no pulse was felt in the aorta at this time. Consequently the left chest was opened through an intercostal incision in approximately the fourth intercostal space. A Finochietto retractor was inserted, the heart was seen to be flabby and not beating at all. There was no hemopericardium. There was a hole in the diaphragm but no hemothorax. A left closed chest tube had been introduced in the Emergency Room prior to surgery, so that there was no significant pneumothorax on the left side. The pericardium was opened, cardiac massage was started, and a pulse was obtainable with massage. The heart was flabby, consequently calcium chloride followed by epinephrine-Xylocaine were injected into the left ventricle without success. However, the standstill was converted to fibrillation. Following this, defibrillation was done, using 240, 360, 500, and 750 volts and finally successful defibrillation was acomplished. Hoever, no effective heart beat could be instituted. A pacemaker was then inserted into the wall of the right ventricle and grounded on skin, and pacemaking was started. A very feeble, small, localized muscular response was obtained with the pacemaker but still no effective beat. At this time we were informed by Dr. Jenkins that there sere no signs of life in that the pupils were fixed and dilated, there was no retinal blood flow, no respiratory effort, and no effective pulse could be maintained even with cardiac massage. The patient was pronounced dead at 1:07 P. M. Anesthesia consted entirely of oxygen. No anesthetic agents as such were administered. The patient was never conscious from the time of his arrival in the Emergency Room until his death at 1:07 P. M. The subcutaneous bullet was extracted from the right side during the attempts at defibrillation, which were rotated among the surgeons. The cardiac massage and defibrillation attempts were carried out by Dr. Robert N. McClelland, Dr. Malcolm O. Perry, Dr. Ronald Jones. Assistance was obtained from the cardiologist, Dr. Fouad Bashour.
Tom Shires, M. D.
Table of Contents, Appendix VII, Appendix IX