Rawhide Down (18 page)

Gens hung up the phone and sprinted out the door. He knew that someone needing four units of uncross-matched blood was in bad shape; ER doctors weren’t even taking the time to type-match the patient’s blood for a transfusion. Trauma surgery was like this—moments of tedium interrupted by crisis and the attendant flood of adrenaline. Gens was addicted to the rush: slight and intense, he had caught the trauma bug five years earlier, when, as a medical student, he had held a beating heart in his hands while another surgeon stitched closed a stab wound in the pumping organ. He liked the combination of quick thinking and delicate hands that trauma required, and it thrilled him when he sometimes saved a life that had seemed lost just minutes earlier.

On his dash to the ER, Gens was joined by Paul Colombani, another chief surgical resident. As they took a shortcut through the urology suite and crossed the threshold of the ER, Colombani looked out the hospital doors to his left and noticed a black limousine parked in the driveway. It had the presidential seal on one of its doors. “Look,” Colombani said, pointing to the car, but in the rush the meaning of the seal was lost on Gens.

As they entered the ER, Gens and Colombani were intercepted by Joyce Mitchell.

“Quick, come here,” she said waving them toward the two trauma bays. “The president’s been shot,” she said, pointing to 5A, the left bay. Then, pointing to the right, she told them that a second shooting victim was in 5B. Gens moved toward the left bay, Colombani toward the right.

When Gens arrived at the president’s side, he found Wesley Price standing to Reagan’s left. At the foot of the bed was William O’Neill, holding medical instruments. Another surgical resident who had arrived in the ER a minute or two earlier was standing nearby.

By virtue of his seniority as a chief surgical resident, Gens was now in charge of the president’s care.

“What do you have?” asked Gens.

“It’s the president of the United States,” one of the residents answered. “Looks like he’s been shot.”

“What’s his blood pressure?”

“It’s 110,” the resident replied. This was already a major improvement.

“Keep the fluids going until we get the blood,” Gens said, before turning to Price. “Did you hear any breath sounds?”

“No.”

“Go ahead with the chest tube,” Gens told Price, confirming that they would be following standard protocol for such a wound. With any luck, the lung would soon reinflate and clamp down on nearby blood vessels, thus stanching most of the bleeding. Whatever the problem, chest tubes usually took care of it: 85 percent of the time, surgery was not required after this type of trauma.

Price scrubbed Reagan’s lower left chest with Betadine, an antibacterial solution, and covered the surrounding area with sterile towels. He injected Xylocaine, an anesthetic, near the president’s fifth rib. Next he would slice open the skin and underlying tissue, after which he would burrow a hole large enough to allow him to insert a No. 36 tube, which was about half an inch in diameter. Then he would push the tube deep into Reagan’s chest cavity and begin to drain the accumulating blood.

Approximately seven minutes had passed since the president had walked through the emergency room doors.

CHAPTER 9

STAT TO THE ER

Dr. Joseph Giordano leaned against the wall of the hospital’s sixth-floor vascular laboratory, watching a nurse strap a blood pressure cuff around a patient’s penis. The nurse hadn’t wanted to work alone with the man, so she’d asked Giordano to attend the procedure. Giordano was a new breed of surgeon—a bit softer around the edges, he was kind to nurses and considered this sort of professional babysitting just another duty among many. He was the type of surgeon who learned his patients’ names and was obsessed with their outcomes. On many nights, the surgeries and patients invaded his dreams, startling him awake, sending his hand flashing reflexively for the phone on the nightstand. “How was the blood pressure?” he would ask the nurse on duty. “Any bleeding?”

He practiced vascular surgery, a demanding specialty that focused on repairing damaged blood vessels. That morning, he had removed a gallbladder, and he would perform another half dozen operations before the week was over. His vascular work was enough to keep him more than busy, but it wasn’t his only job at GW.

Giordano joined the hospital’s staff in 1976 after a stint in the U.S. Army. A few weeks before his arrival, GW’s brusque chief of surgery called Giordano into his office and told him that the director of the emergency room had quit. He needed his new vascular surgeon to take over management of the ER.

“By the way,” the chief of surgery said, “the handling of trauma patients down there is a real mess. See if you can fix it.”

Giordano was stunned—he knew next to nothing about emergency medicine. Soon he was reading everything he could in medical journals and newspaper stories, seeking to learn more about a specialty that was still considered a backwater by the medical establishment. In the 1960s and 1970s, internists, gynecologists, even psychiatrists shared ER duty at most hospitals. The emergency room is one of the most intense and chaotic units in any hospital, but in those days it was often run by an intern or a nurse. Few civilian doctors had extensive training in trauma care; most hospitals didn’t have appropriate equipment. Administrators questioned the cost of ER medicine, which was often very high. Many ambulance systems were a hodgepodge of city shuttles and contracted morticians who picked up patients in converted hearses. Studies from that era showed that a soldier wounded in Vietnam had a better chance of survival than a man shot on a U.S. street corner.

As Giordano discovered, GW was no different. He spent a few weeks observing the ER and saw inexperienced interns leading inefficient medical teams. Chains of authority were conflicting and confusing. Care was often slow and haphazard. And when badly injured patients received inadequate treatment, follow-up was so lacking that it was nearly impossible to identify mistakes and assign responsibility.

His research taught Giordano that saving the lives of trauma victims required speed and coordination among doctors and nurses, and that this was particularly important in the effort to prevent the onset of shock, an insidious and deadly condition. A seriously injured person often bleeds profusely; blood flow to organs is reduced, and with it the oxygen supply. Deprived of oxygen, the heart, lungs, kidneys, and liver fail. Doctors had only recently discovered that they could reduce the impact of shock and save more lives by pumping patients full of fluid and blood and surgically stopping the bleeding. Only then, after stabilizing a patient’s blood pressure and eliminating heavy bleeding, should a trauma surgeon repair damaged organs and tissue. Gradually it became clear that if doctors prevented shock from setting in during the hour after a serious injury—a window of time that became known as the golden hour—survival rates improved dramatically.

Giordano wanted to observe this new approach to the treatment of trauma victims in action. Fortunately, a hospital in Baltimore, only thirty-nine miles up Interstate 95, was breaking new ground in trauma care. Officially called the Maryland Institute for Emergency Medical Services but more commonly referred to as Shock Trauma, the hospital was founded and run by R Adams Cowley, an innovative surgeon who was waging war on shock. With Cowley’s permission, Giordano spent a month in 1976 working at the state-of-the-art trauma center.

He was deeply impressed by the speed and precision of the center’s doctors and nurses, and by their comprehensive approach to treating patients, many of whom arrived in state police helicopters. As soon as a patient entered Shock Trauma’s assessment and resuscitation area, a team of experienced doctors and nurses went to work, inserting three IV lines—not just one—and delivering as much fluid as possible to stabilize blood pressure and prevent shock. The medical crews didn’t wait to type blood; they loaded patients full of universal-donor blood. X-rays were taken by a machine parked in the emergency room, not one down the hall in the radiology laboratory. Prepackaged kits for specific procedures lined the shelves, shaving precious seconds off response times. Shock Trauma’s mantra was to treat first, definitively diagnose later.

With the help of Craig DeAtley, an energetic twenty-six-year-old physician’s assistant, Giordano turned around emergency care at GW. He created specialized trauma teams, which consisted of doctors and nurses who already worked in the hospital. He established strict treatment protocols and gave surgeons and anesthesiologists pagers so they could respond promptly whenever they were needed in the ER. And because the Baltimore hospital received many more patients than GW, he mandated that every one of GW’s surgical residents spend a three-month rotation at Shock Trauma to learn how the system worked and to sharpen their skills.

Giordano and DeAtley also overcame opposition from some doctors in other departments who feared losing turf; they faced down skepticism from cost-conscious administrators at the George Washington University Medical Center, which oversaw the hospital, the university’s medical school, and the staff who worked at both of them. But once the two mustered sufficient support for their project, Giordano began to reconfigure the emergency room itself. The hospital, completed in 1948, was a massive six-floor bandbox-style concrete building that occupied an entire city block. Its layout was antiquated, and the emergency room, at just three thousand square feet, was tiny for a big-city hospital. With so little space, Giordano couldn’t create a Shock Trauma–style center; instead, he cordoned off a 150-square-foot area in one corner of the ER and dedicated it exclusively to trauma care. He bought high-tech medical equipment and suspended it from two large pods in the ceiling, saving space and making doctors and nurses less likely to trip over wires and tubes snaking through the trauma bay. He set up shelves in the bay and lined them with prepackaged kits for every imaginable procedure, just as at Shock Trauma. He shaved about three minutes off the time required to move a patient from the ER to the operating rooms by having maintenance workers knock out a wall and install a doorway to provide a more direct route.

Within two years of Giordano’s arrival at GW, the hospital’s emergency room was providing much better supervision, training, and treatment. In 1979 the District of Columbia’s government designated GW as an official trauma center, adding it to a growing list of such units across the country. GW had long been the Secret Service’s first-choice hospital if someone in or near the White House needed medical attention; now it actually could provide appropriate care in the event of an emergency.

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T
HAT
M
ONDAY
,
AS
he stood in the vascular laboratory and watched the pressure cuff inflate, Joe Giordano was already many hours into another exhausting day. His days and nights at GW were often frantically busy: though he had handed off the responsibility of running the ER to another capable doctor, he was still in charge of the hospital’s trauma teams. Whenever a major trauma case arrived, whether at three p.m. or three a.m., he tried to get down to the ER. Between his vascular practice and his trauma duties, he was always on the run, which was probably why, with a receding hairline and a perpetual five o’clock shadow, he looked at least a half decade older than his thirty-nine years.

Just after 2:35 p.m., Giordano heard his name being called over the hospital intercom system. “Dr. Giordano, STAT to the ER. Dr. Giordano, STAT to the ER.” That was unusual. He couldn’t remember the last time he had been paged over the intercom—the ER usually called him on the phone. Something big must be happening.

Because of his long involvement in managing GW’s trauma teams, Giordano had been aware that a president might one day come through his doors, and in fact he had envisioned the moment a number of times. Even so, the scene he confronted when he reached the trauma bay was startling: a scrum of about fifteen doctors, nurses, and Secret Service agents stood in or near the bay, and the din of many voices reverberated off the ER’s tiled walls. But once Giordano slipped through the crowd and reached Reagan’s side, he felt strangely calm.

The first thing he noticed about the president was not the gunshot wound but his hair. It seemed too dark and thick to be natural.
I wonder if he dyes it,
Giordano thought. Then he focused his attention on his patient and the doctors treating him.

“How are you doing, Mr. President?” Giordano asked.

“I’m having trouble breathing,” Reagan replied through his oxygen mask.

Giordano felt Reagan’s femoral arteries on both sides of the groin. The pulse was strong. Bags of crystalloid fluid drained into the president’s arms, and his blood pressure was hovering around 100 or 110. After being introduced to Dan Ruge, Giordano asked for Reagan’s normal pressure.

“One forty over eighty,” Ruge said.

David Gens, who had been at the president’s side for about three minutes, gave Giordano a brief report on the situation. He explained that Reagan had been shot in the left lung, that they had not found an exit wound, and that the injured lung seemed to have collapsed. Gens then told Giordano that Wesley Price had just injected Xylocaine and was about to insert a tube that would drain blood from the president’s chest.

Without hesitating, Giordano looked at Gens and Price and said, “You better let me do this one.” Normally he would have let them handle the procedure—in fact, he hadn’t inserted a chest tube in years. But he thought it would be irresponsible to put such pressure on the two residents. If mistakes were made, he wanted to be the surgeon to own them.