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Could JFK have survived with today’s advanced emergency care?

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This week, more than 50 years ago, US President John F Kennedy died in Parkland Memorial Hospital in Dallas, following severe bullet wounds to the head and neck, no palpable pulse, and agonal respiration Could Kennedy have survived if it happened today?

MedpageToday writes that “emergency physician” wasn’t a formal specialty in that era; the first doctor to see him was a general surgery resident.

In fact, Parkland’s trauma team in 1963 managed to provide virtually the same care to the fatally injured president that someone with similar injuries would get now, said Dr Terry Kowalenko, chairman of emergency medicine at the Medical University of South Carolina, told the American College of Emergency Physicians annual meeting.

In the few moments before Kennedy would be given last rites and declared dead, the team cut down veins in his arm and leg for IVs, intubated him via a tracheotomy, and hooked him up to a ventilator. And the team performed chest compressions, Kowalenko said.

“The care was very reasonable and appropriate. Probably not much more would have been done differently if it happened today,” Kowalenko said in an interview with Medpage Today. “It was a last-ditch effort.”

Kennedy and Texas Gov. John Connally were shot at about 12:30 p.m. as they rode in an open car through downtown Dallas. The uninjured driver drove them to nearby Parkland Memorial, arriving within a couple minutes.

According to Kowalenko, the president had two obvious wounds: an injury to the lower third of the anterior neck and a large avulsion to the right occipital area.

It would be extraordinary to see a head wound so extensive in an urban hospital, even in our era of gun violence, said Kowalenko, who worked in Detroit when it was known as the nation’s murder capital. That’s because the assassin used a military/hunting rifle, Kowalenko said, instead of handgun or shotgun.

The first physician to assess Kennedy was resident surgeon C James Carrico, who was assessing a patient in the ED for admission and then briefly cared for Connally when he came in. The president was unresponsive, had slow agonal respirations (gasping) and no palpable pulse or blood pressure, Kowalenko said.

Carrico intubated Kennedy via tracheostomy by expanding a bullet exit wound in his neck. The anaesthesiologist hooked him up to a ventilator and administered 300 mg of hydrocortisone, remembering that the patient had Addison’s disease.

This approach makes sense to Kowalenko. “If a patient comes in and we know they have adrenal suppression, we do give steroids if the patient is hypotensive.”

More physicians arrived. Kennedy had no deep tendon reflexes and his eyes were fixed, dilated and deviated laterally. A cardiologist detected electrical activity in the heart, a 28-year-old Carrico told the investigatory Warren Commission but it stopped, and “close cardiac massage was begun. Using this, and fluids and airway we were able to maintain fairly good colour, apparently fairly good peripheral circulation as monitored by carotid and radial pulses for a period of time. These efforts were abandoned when it was determined by [the cardiologist] that there was no continued cardiac response.”

The team pronounced Kennedy dead at 1 pm after a priest performed last rites.

Today, Kowalenko said, emergency physicians might have intubated the president through the mouth and bagged the president instead of performing a tracheostomy. And physicians today would likely put in a central line, he said. “But for the most part, everything would have been done pretty much the same.”

There is one big difference between 1963 and today: Now, Kowalenko said, Secret Service medical teams meet with local hospitals wherever the president or vice president go. “They don’t take anything for granted,” he said. And there’s much better documentation in the ED. As Kowalenko noted, lack of written documentation about his treatment led to confusion during JFK’s autopsy.

Then as now, he said, the massive head wound have been unsurvivable, although the president could have survived the neck wound in either era.

In his testimony before the Warren Commission, Carrico said the identity of the patient didn’t disrupt his treatment: “We have seen a large number of acutely injured people, and acutely ill people, and the treatment has been carried out enough that this is almost reflex, if you will. Certainly everyone was emotionally affected. I think, if anything, the emotional aspect made us think faster, work faster and better.”

Carrico also told the commission that he’d written a letter to his children about the assassination, “just a little homespun philosophy. I just said that there was a lot of extremism both in Dallas and in the nation as a whole, and in an attitude of extremism, a warped mind can flourish much better than in a more stable atmosphere.”

In a blog commentary to the MedpageToday article, cardiologist Dr Joe Goldrich recalls being a fourth-year medical student on his neurosurgery rotation at Parklands Memorial on the day.

“I was the most junior person actively participating in the JFK resuscitation efforts. The description of the events in trauma room one is essentially correct. The only omission is that defibrillation was attempted.

“I know that with certainty because I retrieved the defibrillator which was sitting at the other end of the emergency room. It was on casters and as big as a home refrigerator. There was never any native cardiac activity.

“As for the purported exit wound in the neck, the wound, before it was enlarged for the tracheostomy, had very clean margins and its size was about that of a nickel. The possibility that it might be an entrance wound haunted me for many years.

“Only after watching the Zapruder film hundreds of times was I able to convince myself that it would have been impossible for the head and neck wounds to occur simultaneously unless the neck wound was an exit wound.”

 

Full MedpageToday report

 

Carrico’s Warren Commission testimony transcript

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