Emergency in Room 5A

By Anastasia Toufexis

As the world watched, calm doctors performed their ritual

It is the kind of emergency familiar to trauma teams across the nation, particularly at places like New York City's Bellevue Hospital Center and Chicago's Cook County Hospital. The difference this time was the victim: not some dope dealer or faithless lover, but the President of the U.S. But even with the world watching, the medical ritual was the same.

As soon as Ronald Reagan was carried into Room 5A of George Washington University Hospital's emergency unit, a hastily assembled team of more than a dozen doctors plus paramedics, nurses and aides swung into action. Seemingly in disorganized fashion, but actually with speed and precision, they moved toward one goal: stabilizing the patient as quickly as possible. Oxygen was administered to aid the President in breathing, and fluids were given intravenously to raise his blood pressure. A reading indicated that the systolic pressure (when the heart contracts) had dropped below 100, alarmingly low. Simultaneously, his clothing was cut away; as soon as the jacket and shirt were off, an oozing, slitlike bullet hole was discovered just under the left armpit.

Because Reagan was coughing up bright red blood and complaining of chest pain on his left side and difficulty in breathing, doctors immediately suspected that his lung had been injured and probably collapsed, a common result of gunshot wounds to the chest. Normally, the pressure in the space between the lung and the chest wall is less than atmospheric pressure, and this keeps the lung expanded; when the chest wall is pierced, air enters and forces the lung to collapse. To reinflate it, doctors made two small incisions, one just below the collarbone and the other between the seventh and eighth ribs, and inserted tubes to suction off air and any blood that might have accumulated from damage to the heart, lungs or major blood vessels in the chest. About two pints of blood spilled out. Immediately doctors started transfusing blood, using O negative, a blood type any person can accept. (Later they began using Reagan's own type, O positive.) All this was accomplished within five minutes of his arrival.

That done, the trauma team could proceed more deliberately. X rays of the chest and abdomen were taken to try to lo cate the bullet; blood samples were analyzed for gases to help determine how much oxygen was getting into the blood. To see whether there was bleeding in the abdominal cavity as well, the team performed a procedure known as peritoneal lavage. Surgeons Benjamin Aaron and Joseph Giordano, who headed up the trauma team, made a small incision just below the President's navel, inserted a tube and infused several liters of fluid, filling the abdominal cavity. Then the fluid was withdrawn and examined for blood. It was clear, indicating that Reagan had suffered no injury to abdominal organs.

But during the 45 minutes of peritoneal lavage, blood continued draining out of the chest tube, an unusual occurrence. In the majority of bullet wounds to the chest, bleeding stops soon after the lung is reinflated. By now Reagan had required a transfusion of five units of blood; that meant he had lost about 2% quarts of blood, almost half the total amount circulating in his body. Continued bleeding can be a sign that a bullet has caused major damage to organs and blood vessels in the chest cavity. To assess the extent of the injury and to locate the source of bleeding, doctors decided to operate. "It was a major bleed," said Hospital Spokesman Dr. Dennis O'Leary. "That was why surgery was required." If Reagan had not bled so heavily, surgery might not have been done immediately. But an operation would probably have been necessary eventually. Though bullets are frequently left inside the body when they do not threaten further damage, a bullet in the lung can travel to the heart and obstruct the flow of blood.

Reagan was rolled next door into an operating suite. Under the watchful eyes of two scrubbed and gowned Secret Service agents and the President's personal physician, Dr. Daniel Ruge, doctors began anesthetizing the President. They inserted a tube into his mouth and down his windpipe and put him on a mechanical respirator. Then he was gently turned onto his right side and placed at a 45DEG angle. In the operation, called a thoracotomy, surgeons made a 6-in. incision extending from just below the left nipple, along the ribs to just below the left armpit. Spreading the ribs and the overlying muscles apart, they first noticed a massive blood clot and removed it. Then they checked the heart and major blood vessels for damage but found none. They tried to follow the path of the bullet to locate the slug. This proved difficult so another X ray was taken.

The doctors finally retrieved the bullet from the lower lobe of the left lung. Said Aaron: "It was flattened almost as thin as a dime, and about the size of a dime too."

From their examination, doctors concluded that the bullet plowed through the chest wall at an angle, struck the seventh rib and ricocheted down 3 in. into the lung. Its oblique path kept it a good 3 in. away from the heart.

Reagan was fortunate that his assailant used a small-caliber, low-velocity gun. A .45-cal. bullet, twice as wide and five times as heavy as a .22, would have torn up the President's flank and probably killed him quickly, if not instantly. But he could have been luckier: if his arm had been hit, the bullet might not have reached his torso; if the bullet had not glanced off the rib, it might have just passed on through the chest wall and out of the body without hitting any internal organ.

After the three-hour operation, which the President "sailed through with vital signs absolutely rock stable," according to O'Leary, Reagan was taken to the hospital's fourth-floor intensive-care unit, where he spent a restless night. So does almost everyone in such a unit: the lights are kept on; nurses and doctors move about constantly, checking vital signs and taking blood samples; monitors hooked up to patients beep incessantly. Reagan was given antibiotics to combat possible infections and pain medication to ease his moderate discomfort, more the result of the operation than the bullet injury. Dur ing the night, doctors removed the wind pipe tube that had been left in place after surgery to facilitate breathing.

The next morning, Reagan was moved to a quiet, eight-room suite on the third floor. He had a pulse rate of 70 and blood pressure of 130/80, numbers that would please a healthy man. He was encouraged to cough to help get secretions out of his lungs. Though breathing hurt, he required little pain medication. He continued to receive oxygen through a nose catheter. White House aides visit ing that morning found Reagan sitting up and brushing his teeth. He spent the day sleeping and reading newspapers; meals were soup and gelatin. The next day he switched to solid foods and walked a few steps. Toward the end of the week he was walking down the hospital corridor, and doctors were predicting that barring complications he might return to the White House this week and be able to resume all physical activities, including riding, within three months. One complication surfaced at week's end: Reagan ran a fever of 102DEG. Said Aaron: "It's a little bit of a setback."

Though Reagan seems to be progress ing nicely, controversy continues over the seriousness of his condition when he entered George Washington University Hospital. Some witnesses paint a grim pic ture: the President was stumbling, gasp ing for air, blood stained his teeth and lips, and most serious, his blood pressure was very low, a sign of impending shock.

Coupled with this was the considerable amount of blood lost in the first few hours.

Some doctors are convinced that the President was in "a life-threatening situation."

Says a Washington, D.C., surgeon, an ex pert in bullet injuries: "A gunshot wound to the chest is always serious, especially in a 70-year-old. I am sure that Reagan's doctors were a lot more concerned at the time than they acknowledged."

But O'Leary and others who attend ed Reagan insist that he was never in danger. The President, they point out, was conscious and coherent and was stabilized quickly. He was never in shock. Says O'Leary: "With blood, a little goes a long way. I'm sure he looked bad, but at no point was he anywhere close to being in extremis. " As to the blood loss, O'Leary agrees it was large (almost four quarts) but says the rate of loss is more important than the vol ume. Reagan's blood loss was steady, not gushing, and doctors had no trouble in compensating with transfusions. The ma jority of gunshot victims come into a hos pital much worse off, O'Leary says. In fact, he contends that the President would probably have been all right even if treat ment had been delayed by as much as 20 minutes. Fortunately, Ronald Reagan and the nation did not have to test that judgment.

-- ByAnastasia Toufexis.

Reported by Peter Staler/Washington

With reporting by Peter Stoler

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