⬅ Ronald Reagan: Chronology of the Shooting

At first joking about his "flying entrance" into the car, Reagan starts coughing up bright red blood and becomes distressed as the limo passes through the tunnel under Dupont Circle. He later recalled feeling "the most paralyzing pain... as if someone hit you with a hammer." Because he felt the pain only after entering the car, he thinks it's a rib fracture caused by Parr. "But when I sat up on the seat and the pain wouldn't go away and suddenly I found that I was coughing up blood, we both decided that maybe I had broken a rib and punctured a lung." (Agent Parr must have been feeling pretty low at this point!)

In a crucial (and correct) decision, Parr tells the driver, agent Drew Unrue, to head for George Washington University Hospital (GW). Reagan recalled "By then my handkerchief was sopped with blood and he [Parr] handed me his. Suddenly I realized I could barely breathe. No matter how hard I tried, I couldn't get enough air. I was frightened and started to panic a little. I just was not able to inhale enough air."

The ER staff at GW is notified that three victims of gunshot wounds are inbound, but identities are not mentioned. The path to GW passes within a block of the White House.

Nurse Kathy Paul notes blood on Reagan. An intern, Dr. William O'Neill, observes that Reagan is in "acute distress" and believes it is a "life-threatening situation." A resident, Dr. Wesley Price, sees a clean slit-shaped bullet hole, slightly larger than 1 cm, below Reagan's left armpit -- in the fourth interspace of the posterior axillary line 5. No exit hole is visible, so it is assumed the bullet remains inside.

Nurse Wendy Koenig tries to take Reagan's blood pressure, but cannot, because of the noise caused by Secret Service agents and members of the trauma team. About 15 or 20 people are in the ER.

Reagan's personal physician, Dr. Daniel Ruge, was in the motorcade. He arrives in the ER and stays by Reagan's side throughout 5. Reagan later recalled "It was a very close call. Twice they could not find my pulse." Ruge, however, had his finger on Reagan's dorsalis pedis artery (on the top of the foot) and has said that Reagan's pulse never disappeared.

By palpation, Reagan's systolic blood pressure (i.e. "the top number") is 78. His usual blood pressure is 140/80. His pulse is rapid, he looks pale, and he is clammy. (Another reference says blood pressure was 80, pulse was 80 (which is not rapid), and respirations were 30/minute (which is rapid) 5.) The trauma team, now led by Dr. Joseph Giordano, inserts IV lines in both arms and starts infusing fluid (Ringer's lactate and normal saline). The team also places an arterial line in the left wrist and a Foley catheter in the bladder 5. [To come: Name of person who put in Foley 6.]

At some point, someone listens with a stethoscope to Reagan's chest and finds breath sounds are fainter on the left side 5. This suggests the left lung has collapsed. Reagan gets oxygen through a plastic tube below his nostrils.

An anesthesiologist administers oxygen to Reagan by facemask, but Reagan still complains of breathlessness and continues to cough up blood. His breathing is fast and labored. His blood pressure starts rising.

Reagan is now aware he has been shot. His wife, Nancy, arrives from the White House. She later remembered, "Ronnie looked pale and gray. ... Underneath the oxygen mask, his lips were caked with dried blood. He saw me, and pulled up the mask and whispered, `Honey, I forgot to duck.'"

Another reference says Giordano inserted one Argyle No. 36 straight chest tube in the anterior axillary line, which was then hooked to suction 5.

Another reference 5 says he had lost 2275 cc of blood, and had been given 3 liters of Ringer's and saline, and 2 3/4 units of packed red blood cells of types O-positive and O-negative. It further says his vital signs were now: blood pressure 160 systolic, pulse 90, respirations 25.

As Reagan is moved from his stretcher to the operating table, he says to the surgeons "Please tell me you're all Republicans." (Reagan was a Republican.) Giordano answers: "We're all Republicans today."

To ensure there is no damage in the abdomen, Dr. Joseph Giordano, Dr. Wesley Price, and Dr. David Gens perform a "peritoneal lavage" through a 3 cm incision in the skin just below the umbilicus (belly button), as follows: A liter of Ringer's lactate fluid is run into the abdomen. Reagan is tilted head-up, then head-down, and the fluid is then drained out. No blood is in the drained-out fluid, making it unlikely that any of the abdominal organs are bleeding. This takes 40 minutes.

With the clot removed, Aaron determines the site where the bullet entered the lung. The heart, great vessels, and esophagus appear undamaged.

Aaron recalled: "At the time we loooked in, there was a lot of blood in the chest -- mostly clotted -- maybe a liter or more. The entrance hole in the lung, out of which dark dark red blood was trickling fairly briskly, was very large. ... The major bleeding was occurring right there locally, at a point not too far from the pulmonary artery. We were able to take a suture locally and control the bleeding; we didn't have to do anything major. That was it as far as the lung bleeding was concerned."

Aaron is concerned about the amount of destroyed lung tissue, however, and considers removing the lower lobe of the lung. He elects not to, because "it wasn't bleeding that bad [and because] most of the lung looked pretty good." This is a "calculated risk," in Aaron's words.

An angled x-ray is taken. It shows a metal fragment in the lower part of the lung, just behind the heart. With this information, Aaron finds the bullet, flattened into the size and shape of a dime, lying in tissue about one inch from the heart. Aaron recalled: "The bullet had traversed the lung and was lying against the pleura on the other side; rather than fish clear through the lung, we made an exit hole for it."

While in the operating room, Reagan had received an additional 2700 cc of Ringer's lactate and normal saline, along with 5 1/4 units of packed red cells, 3 units of fresh frozen plasma, and 290 cc of pheresed platelets (to stem bleeding).

All told, Reagan had lost 3400 cc of blood -- over half of the blood in his body. A total of eight units of packed red cells had been transfused.

At perhaps this time, Reagan is breathing 80% oxygen, but has a blood oxygen level of only 115. Aaron attempts to bronchoscope him through the endotracheal (breathing) tube, but fails because of a bend in the tube. (This is confusing in 5 because it also says Reagan was getting oxygen nasally, which makes no sense when an endotracheal tube is in place.) Dr. Samuel Spagnolo and Dr. Jack Zimmerman consult. Hyperinflation (probably meaening positive pressure), saline lavage (perhaps this refers to 8:50 events, below), and tracheal suction are all tried, and improve Reagan's oxygenation somewhat.

The administration of cefamandole (an antibiotic) at a dose of one gram every six hours, intravenously, is started. (It goes for 48 hours.)

Sleeps little during the night. Requires morphine for chest pain.

One of the surgeons remembered: "We pushed to get him out of the ICU because we knew he'd be better some place that was quieter. The environment was getting him a little disoriented." Comment: In retrospect, this disorientation was probably an early symptom of Alzheimer disease.

Late in the day, less than 24 hours after going off antibiotics, Reagan's temperature rises to 102-103 degrees F. His white blood cell count was high, his color was poor, he felt tired, and is couging up "a little" blood. Dr. Aaron views this fever "with great alarm." Chest x-ray shows haziness in the left lower chest. The two leading diagnoses are infection and bleeding. Aaron was prepared to remove the lower left lobe of Reagan's lung if the bleeding became "aggressive."

Instead, Reagan is started on new antibiotics. (Either that, or cefamandole is restarted.) No organism is ever cultured from him.

Dr. Aaron performs bronchoscopy, and removes bronchial casts. Reagan gets chills in the evening, raising the probability of infection. A broad-spectrum antibiotic is added. (Possibly cefamandole is restarted.) Reagan's breathing exercises are increased, and his schedule cut back. He sleeps well.

The chief of infectious diseases, Dr. Carmelita Tuazon, is consulted. Cefamandole is stopped. Penicillin (1 million units every four hours) and tobramycin (80 mg every 8 hours) are given intravenously. Hyperimmune B. globulin (? beta globulin) (5 cc) and gamma globulin (5 cc) are given intramuscularly (i.e. a shot in the buttocks). Respiratory therapy is increased.

Because the bullet was lead, a blood lead level is checked. It is "normal" for an adult. Comment: The physiologically normal blood lead level for a human is zero, so it would have been better to say the blood lead level was unremrakable.

Reagan is discharged from the hospital at 10:44 a.m. At the White House, he walks from the limosine into the building and into an elevator. At close quarters, he appears weak and drawn.

To a visitor, and to Secretary of State Alexander Haig, Reagan is "pale and disoriented ... walking with the hesitant steps of an old man." When Reagan sits in a chair, he goes down heavily. He can remain attentive for only about an hour a day.

Intravenous penicillin is switched to oral penicillin, which continues for a week.

stable, mild dyspnea associated with moderately severe exertion. On subsequent examinations, the results of expansion of the chest appear to be normal. A well-healed left anterior axillary thoracotomy scar is present with a barely audible pleural friction rub under the area of the scar... Air movement is good bilaterally without rales, rhonchi or wheezes.