Health and Medical History of President

Ronald Reagan: Chronology of the Shooting

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shot
Reagan was shot on March 30, 1981. A long-nosed .22 caliber bullet, fired from a pistol, ricocheted off the Presidential limosine and entered Reagan's chest, under his left arm. The bullet was of the exploding type, but it did not explode. The main threat to Reagan's life was from blood loss and a collapsed lung 3a.

After entering Reagan's body, the bullet ricocheted off his left-sided seventh rib. By now the bullet was deformed into a dime-shaped mass, and when it entered Reagan's left lung, it did considerable damage to the lung tissue. The lung began bleeding, and collapsed. The bullet lodged about one inch from the heart. To see the full chronology of events, click here: BELOW

The first-line treatment for a collapsed lung is a chest tube -- a plastic tube that is inserted through the skin, between the ribs, and into the chest cavity where the lungs sit. This is not a difficult procedure, and medical students are often allowed to insert a chest tube (under supervision) after having seen just once how to properly do it. Dr. Zebra was told that a medical student at the George Washington University School of Medicine, doing a rotation in the emergency room, had earlier that day seen a chest tube inserted. Furthermore, the resident supervising the student told him, "OK, you get to put in the chest tube on the next case that comes in." Shortly thereafter, an ashen Reagan walked through the door and collapsed. The resident immediately looked at the student and said: "No!" 6.

It has been noted that Reagan's wound was, at the outset, "much more life-threatening than that of Garfield or McKinley, who would both have almost certainly survived" had modern surgical care been available to them 3b.

Throughout the episode, the President's staff was, in the words of Reagan's physician, Dr. Daniel Ruge, "anxious to portray the president as being well. ... But nobody is very well after being shot, and having had an anesthetic, and having lost a lot of blood and having it replaced" 1a. (Reagan lost over half of all the blood in his body 1b.) Ruge felt that Reagan did not recover completely until October, i.e. 6-7 months after the shooting 1a.

Former aide Michael Deaver says Reagan became more stubborn after the shooting. Reagan believed that he was "chosen" for his role by a higher power, and that the shooting was a reminder of this. He therefore decided to more closely follow his own instincts 4.


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The initial part of this account is from 1c, except where noted. After Reagan enters the operating room, the account also includes 2. Times, shown in the leftmost column, start at 2:30 p.m. on March 30.
2:30 2 Shots are fired outside the Hilton Hotel in Washington, DC. Reagan is pushed (hard) into his limosine and swears when Secret Service agent Jerry Parr lands on top of him. The limo heads for the White House (at high speed, one would presume), ten minutes away.

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.

2:35 Reagan's limosine arrives at the entrance of the GW Emergency Room. No stretcher is waiting. Helped by Secret Service agents, Reagan walks about 45 feet into the building, whereupon his "eyes rolled upward, and his head went back, his knees buckled and he started to collapse," according to a witness. Gasping for air, Reagan fell to one knee and said "I can't breathe." He is placed on a stretcher, nurses start cutting his $1000 suit off, and he is wheeled into the emergency room.

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 2. 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 2. 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) 2.) 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 2. [To come: Name of person who put in Foley 5.]

At some point, someone listens with a stethoscope to Reagan's chest and finds breath sounds are fainter on the left side 2. This suggests the left lung has collapsed. Reagan gets oxygen through a plastic tube below his nostrils.

2:40 With three IV lines now in place, blood transfusion begins, apparently with two units of O-negative blood. (In other words, the trauma team did not wait to check Reagan's blood type -- they used "universal donor" blood).

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.'"

2:45 - 3:00 Dr. Giordano inserts two plastic tubes into Reagans left chest cavity, one through a small incision just beneath the collar bone, and one through an incision between the seventh and eighth ribs. A large volume of blood comes out through the chest tubes.

Another reference says Giordano inserted one Argyle No. 36 straight chest tube in the anterior axillary line, which was then hooked to suction 2.

2:50 Reagan received 900, then 1200, then 1800 cc of blood. Dr. Giordano recalled: "The man had a blood pressure of 70/0.... He had an enormous amount of blood in his chest, more than I have seen in most injuries of this type.... He had initially something like 2200 or 2400 cc of blood that came out [through the chest tubes]. There is no doubt in my mind that another five or ten minutes and he may have been at the point of no return."
2:58 A chest x-ray shows the bullet behind the heart and blood in the left chest cavity ("a hazy left hemothorax"). An x-ray of the abdomen is also obtained, because it was not clear that the bullet in the chest matched the gun used, but no bullet was seen.
3:05 Blood loss continues. Dr. Benjamin Aaron, the chief of thoracic surgery at GW, decides surgery is necessary to stop it.
3:20 Reagan is made ready for surgery.
3:24 Reagan is wheeled into the operating room. To this point he has lost 2100 cc of blood and has received 4 1/2 units of blood.

Another reference 2 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."

3:40 Dr. George Morales and Dr. Manfred Lichtman anesthetize Reagan with intravenous sodium Pentothal (thiopental). They also give a muscle relaxant. They then put a breathing tube into Reagan's airpipe (trachea) and connect it to a mechanical respirator.

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.

4:20 Reagan is turned on his right side. Dr. Benjamin Aaron, Dr. Kathleen Cheney, and Dr. David Adelbery perform a left anterior thoracotomy: they open the chest through a six-inch incision in the fifth interspace (the groove between ribs 5 and 6). Retractors spread the ribs. Aaron can feel that the seventh rib was splintered. He removes a clot of blood from outside the lung (apparently about 500 cc worth), bringing total blood loss to 3100 cc at this point.

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.

5:00 Aaron is unable to see or feel the bullet. He almost gave up trying to remove it. Dr. Zebra recalls reading (somewhere) that the surgeons (and others?) discussed the medical necessity of removing the bullet. The symbolic effects of allowing a President to walk around carrying an (attempted) assassin's bullet is raised, and so the decision is made to find it and remove it.

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."

6:00 - 6:20 Aaron begins closing the chest. The operation ends with placement of chest tubes in the apex and base of the chest.

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.

6:20 - 6:45 Closely watched in the operating room. Is still on the ventilator.
6:45 Almost 3 1/2 hours after entering the operating room, Reagan is moved to the recovery room. A chest x-ray shows the lower lobe of the left lung is collapsed, plus blood in the chest cavity, and patches of unexpanded lung. He is still connected to the respirator, which is delivering oxygen via positive pressure (a sign that his lung function was poor).

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 2 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.)

7:30 Regaining consciousness as the anesthetic wears off. Visits briefly with his wife (but is unable to speak because of the breathing tube).
8:00 Given morphine for chest pain.
8:50 To loosen mucus plugs in his large airways (bronchi), fluid is put into his breathing tube. This causes coughing. Reagan scribbles "All in all, I'd rather be in Philadelphia."

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

2:15 a.m. His oxygen and carbon dioxide levels improve, so he is disconnected from the ventilator. The breathing tube remains in his airpipe. it is not clear that Reagan understands he has had surgery.
2:50 a.m. The endotracheal (breathing) tube, the nasogastric tube, the arterial line, and the Foley (bladder) catheter are all removed. Shortly before this time, one of the medical team members says "This is it." Hearing this, Reagan "blanched, clutched a pad of paper and scribbled a note to a nearby nurse: `What does he mean -- this is it?'" The situation is explained, and Reagan calms down.
3:00 a.m. Awake much of the rest of the night. Talking to recovery room staff. Dozes intermittently.
6:00 a.m. Is moved to intensive care unit. Is getting oxygen through his nose. Is prescribed deep-breathing exercises. Gets physical therapy.
6:45 a.m. Propped up in bed. Brushes his own teeth.
7:15 a.m. Gets morphine for chest pain. Not long afterwards, signs farming legislation. Comment: Given the tenuous state of Reagan's mental function (see below), this was a travesty of government.

Later
9:00 p.m. (Day 2) (Mar. 31) Moved from intensive care unit to a suite in the hospital.

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.

Day 3
(Apr. 1)
Bladder catheterization performed because he has been unable to urinate. Continues to cough up blood. Oxygen therapy re-started in the morning. Appetite good -- ate a normal breakfast and lunch. Falls asleep about 9:00 p.m., and sleeps until 6:00 a.m. the next morning.
Day 4
(Apr. 2)
Intravenous tubes are removed in the morning. Surgeons remove the stitches in the abdomen. Chest tubes and nasal oxygen continue. Is able to walk a bit.

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.

Day 5
(Apr. 3)
Fever is up and down in the 101-102 degree range. A portable chest x-ray is of inadequate quality. Dr. David Rockoff, the chief of chest radiology, urged a chest x-ray be taken in the radiology department. This is done after the Secret Service sweeps the area. The x-ray shows a problem in the left lower lung, but yields no specific diagnosis.

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.

Day 6
(Apr. 4)
Reagan is tired. Sleeps much of the day. A coughing fit brings up bright red blood, different from the dark blood of earlier. Fever is lower.
Day 7
(Apr. 5)
Temperature is 39.3 C, white cell count rises to 16,100, and chest x-ray shows patchy densities along the bullet track.

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 normal blood lead level for a human is zero (or darn close), so it would have been better to say the blood lead level was unremrakable.

Day 9
(Apr. 7)
Temperature nearing normal. Antibiotics continue. Chest x-ray shows improvement.
Day 10
(Apr. 8)
Reagan is able to work about two hours per day. He has been signing documents without fully reading them. Briefings have been condensed for him.
Day 11
(Apr. 9)
Temperature is normal. Reagan feels much better. Tobramycin is stopped. It is obvious that Reagan has lost weight.
Day 13
(Apr. 11)
Temperature is 36.6 C (within normal range), hemoglobin 11.6, hematocrit 33.2%, white cell count was 10,000.

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.

Day 14
(Apr. 12)
Reagan awakens at 6:50 a.m. to watch the first flight of the U.S. space shuttle (R.I.P. Columbia). He rests most of the day and works for about two hours.

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.

Day 18
(Apr. 16)
Vice President George H.W. Bush is performing various official duties of the President, including leading Cabinet meetings.
Day 20
(Apr. 18)
About this time, Reagan increases his work to 4-5 hours a day. It is claimed he can now do as much paperwork each day as he did before the shooting.
Day 23
(Apr. 21)
Dr. Aaron sees a pajama-clad Reagan for about 30 minutes. Reagan favors his left side when breathing and says it hurts a little. Aaron recalled, "maybe he did reflect a lack of stamina and a lack of concentration."
Day 26
(Apr. 24)
Attends first Cabinet meeting since the shooting.
Day 27
(Apr. 25)
Reagan is not well enough to attend his daughter's (third) marriage.
Day 49
(May 17)
Goes on his first trip outside Washington since the shooting (to Indiana).
Day 79
(June 16)
Holds his first news conference since the shooting. States he feels well.
October Dr. Ruge considers that Regan did not fully recover until October, recalling: "We were at the ranch in October, and the president said to me, `Now I really feel like I am all the way.' He felt better than he did in June."
-- Ultimately, Reagan was left with 2:
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.
Day ? The donors of the blood products infused into Reagan, and the blood products themselves, were checked for hepatitis; all tests were negative 2. (It is unclear to Dr. Zebra if these donors were contacted in person; this would be very unusual, but the language in the reference does not rule it out.)
Resources
Cited Resources
  1. Abrams, Herbert L. "The President Has Been Shot": Confusion, Disability, and the 25th Amendment in the Aftermath of the Attempted Assassination of Ronald Reagan. New York: W. W. Norton & Company, 1992.0393030423 Libraries 91-15846. ap. 74 bp. 64 cpp. 54-74
  2. Beahrs, Oliver H. The medical history of Ronald Reagan. Journal of the American College of Surgeons. 1994; 178: 86-96. Pubmed 7512407.
    Comment: Dr. Zebra has not checked the correspondence about this article that appeared as J Am Coll Surg. 1994 Dec;179(6):763; author reply 763-4 (Pubmed 7952492 and 7952493).
  3. Bumgarner, John R. The Health of the Presidents: The 41 United States Presidents Through 1993 from a Physician's Point of View. Jefferson, NC: MacFarland & Company, 1994.0899509568 Libraries 93-42000. app. 282-283 bp. 283
    Comment: Devotes one chapter to each President, through Clinton. Written for the layperson, well-referenced, with areas of speculation clearly identified, Dr. Zebra depends heavily on this book. Dr. Bumgarner survived the Bataan Death March and has written an unforgettable book casting a physician's eye on that experience.
  4. Deaver, Michael. [Interview]. Charlie Rose Show. KQED-TV, San Francisco, 14 June 2004.
  5. Pekkanen, John. The saving of the President. Washingtonian Magazine. August 1981; 113ff.
    Comment: A fascinating moment-by-moment chronology of the events in the George Washington University Emergency Room. An account from Dr. Wesley Price appears on p. 116 of the same issue.
  6. Zucker, Howard. Personal communication. Baltimore, Maryland. circa 1987.
    Comment: Zucker was in the emergency room at GW that day.
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