by Allen Childs
Dr. Carrico was the first physician to see the president. A 1961 graduate of Southwestern Medical School, he is 28 and a resident in surgery at Parkland.
He reported that when the patient entered the emergency room on an ambulance carriage he had slow agonal respiratory efforts and occasional cardiac beats detectable by auscultation. Two external wounds were noted; one a small wound of the anterior neck in the lower one third. The other wound had caused avulsion of the occipitoparietal calvarium and shredded brain tissue was present with profuse oozing. No pulse or blood pressure were present. Pupils were bilaterally dilated and fixed. A cuffed endotracheal tube was inserted through the laryngoscope. A ragged wound of the trachea was seen immediately below the larynx. The tube was advanced past the laceration and the cuff inflated. Respiration was instituted using a respirator assistor on automatic cycling. Concurrently, an intravenous infusion of lactated Ringer’s solution was begun via catheter placed in the right leg. Blood was drawn for typing and cross-matching. Type 0 Rh negative blood was obtained immediately.
In view of the tracheal injury and diminished breath sounds in the right chest, tracheostomy was performed by Dr. Malcolm O. Perry and bilateral chest tubes inserted. A second intravenous infusion was begun in the left arm. In addition, Dr. M. T. Jenkins began respiration with the anesthesia machine, cardiac monitor and stimulator attached. Solu-Cortef (300 mg.) was given intravenously. Despite those measures, blood pressure never returned. Only brief electrocardiographic evidence of cardiac activity was obtained.
Allen Childs, MD
I remember Jim when I was a junior med student and he, then in his third year of surgical training, was my resident. Years later I was gratified he remembered me, and we had a laugh about how we smoked in the halls between patient rooms. During rounds, a Phillip Morris was always lit in an ashtray on the rolling chart rack.
But what was most compelling about this bigger-than-life person was his kindness toward the patients. He would apologize for a painful procedure and I once heard him tell a diagnostically obscure patient, “I still don’t know what’s wrong with you.” His humility was as evident as his deeply felt caring, and it imprinted upon students like me an ideal we could try to emulate.
James Carrico, MD
(oral history courtesy of the Sixth Floor Museum)
Mrs. Kennedy was kind of standing by the door. My recollection is that there were two men in the room, and I assume they were the driver or Secret Service people. They very rapidly stepped aside when we came in.
There was a nurse, Diana Bowron, and two interns, including Marty White who is now head of the organ bank here in Dallas . . . there’s a lot of people still around, and an oral surgery resident whose name I don’t remember right now. Oral surgery intern . . . so that was the team. Your job is a patient who is extremely injured, it kind of goes in the steps . . . do what it takes to keep the patient alive, then you go back and evaluate the injuries in more detail, and kind of make a long-term plan. And to keep him alive, first you’ve got to have a way to breathe, second you’ve got to be breathing, third your heart’s got to be pumping, and fourth your head has to be working, your nervous system has got to be working.
So, your job is exactly that. You see what’s going on with the air ways, you see what’s going on with the breathing, you see what’s going on with the circulation. And then, you look at neurological function. Usually, one person kind of takes charge and everybody else . . . one team gets some . . . the IVs going to support circulation, the nurse kind of gets the patient undressed and keeps things flowing.
And that’s pretty much what we did. Marty White and the other intern started doing a cutdown on the president’s right ankle, I think. Cutdown is where you start an IV by actually making an incision and putting the tube . . . or a big tube in the vein so you can give a lot of blood fluid if you need to. Diane and I looked at the president overall, saw that he was not breathing . . . he (was) breathing very erratically. We call it agonal respiration . . . a kind of gasping.
We looked at him, and he still had some breathing and he still had some heartbeat. He had a terrible looking wound, but that wound you kind of really deferred to later in terms of evaluating in detail.
The principle is, if you’ve got somebody who’s got what looks like a terrible injury and is not dead, the first thing you do is you do the things I talked about. You get the airway going, you get him breathing . . . then you see . . . then you have time to evaluate the extent of the injury. My . . . I’ve told folks before that the thoughts that I remembered going through my head takes longer to describe them than it took to have them. The first one I had was . . . the president’s had it. I mean, he’s not going to make it. And that was right. Second is, we’ve got to do something. That was the political and the medical thoughts. You know, we can’t just let the president die. [smiling] Third thought was . . . gosh, what if we get him alive and then he’s a vegetable? And the rational thought was treat this patient like anybody else. Get his airway under control, get him breathing, get his circulation going . . . then, you can decide about all that other situation. So, that’s what we did.
Oh, those brief thoughts . . . and, you know, it took a long time to say them, it took about that long to have them [snapping fingers] . . . were the non-medical thoughts. I guess my major thoughts were . . . you know, I really didn’t think about the historical impact, what this is going to do. I thought, “Our job is to take care of the president.” And we’ve got kind of this reputation of medicine and everything else on our back for a second there, and then that’s when the rational thoughts took over. And I said, “OK, we know how to do this, I mean, whether this is the president or whoever. We know how to take care of this guy.” And so, it became pretty much unemotional and auto . . . not automatic, but dispassionate at that point.
So, there was that short personal emotional “what am I going to do?” feeling, and then the professional aspect, as you say, kicked in, and you know what to do. It’s what you’re trained to do. So, the procedure then is to first see if the president is breathing . . . see if he has an airway. And he really didn’t. When we looked at him, he had . . . we saw this wound in the side of his head [holding right side of head], a great big wound.
The president was lying on his back . . . I could see the whole wound in his head. And that’s important, because it really doesn’t fit perfectly with what we wrote down later. So, that meant it had to be in the . . . well, it was about right here as I recall [placing hand on right side of head, toward the back], and it was about as big as I’m showing it with my hand [opening hand about grapefruit size]. You know, a big chunk of bone and scalp missing, and the fact that you could see all of it from the front meant that it involved the parietal bone which is this big skull bone and the temporal bone which is this big skull bone. So, we saw that hole. We saw he had a little hole. . . .
By the time I looked, Diane, the nurse, had started taking his clothes off . . . which was her job. So, I really don’t know whether it was through the collar or not but it was certainly through the collar line. Just above right there [placing finger right at the edge of his collar line], just to the right of the trachea and just certainly where his collar should have been.
OK. Anyway, so the next thing, since he wasn’t breathing very well, the next to do is to try to get him breathing better, and that involves putting in the tracheal tube, which is a tube that goes through the mouth down into the windpipe, and you can breathe through it. So, he got that done. And at that time, we could see that there was some blood beside the larynx, which is done deep in the throat. From the inside.
When I looked down there, I could see that there was some bruising and some abnormal swelling off over to the right side of the windpipe, and we were able to slip the tube into his trachea, and he should have been able to breathe better at that point.
The other is that that wound [holding his head], this wound certainly looked like an exit wound. I mean, just because things were r
eally blown away. It looked like, I mean, you’ve got . . . wounds go in and wounds go out. This was an out, that’s what it looked like. There was nothing about it that would say whether the entrance had come from the front or from the back. This looked like where a bullet went out [holding side of head].
See, you try to keep the patient alive, you try to treat their wounds, then in the patients where you are not successful, then we would work with the medical examiner to try to help them figure out the forensics. They do the . . . they were really the forensic experts. We provided the clinical information.
. . . the only wounds I saw . . . the only wounds we saw were this wound here [pointing to center of neck] and this big hole here [placing right hand on side of head]. We never saw the wounds in the president’s back. And the medical process is, we get his airway going, then we hooked him up to the ventilator and were trying to help him breathe. Then, you’ve got to answer, “How’s his breathing going?” And to answer that, you’ve got to ask, “Are there any major holes in his chest wall, like the governor had in his chest wall, which would impair his breathing?” So, you don’t always roll the patient over to look at that, particularly in the situation we’re in, you don’t roll him over. You just put your hands around the patient’s back, down about the belt and then you kind of move up, feeling to try to make sure the body cavities are intact. And in doing that, I did not detect any big holes and obviously did not see what turned out to be two small wounds . . . one kind of over his shoulder and one back here . . . way back in the lower back of the head. So, we never saw those two wounds in the back. And that’s the long answer to a short question [smiling].
And the reason we didn’t is that that was, at least at that point, not part of an appropriate medical exam to try to find . . . that would have actually required rolling the patient over, washing the blood off, etc. And clearly in somebody that you’re struggling to keep alive, you can’t do that. After we got the tube in, tried to breathe for him, he still wasn’t breathing very well, and his heart rate was slowing down. And his heart actually stopped. When his heart stopped, by that time, Dr. Perry, Dr. Jones, Dr. Jenkins, Dr. Giesecke that assisted chief of anesthesia, Dr. Baxter . . . a number of people were there. They started CPR. Because there were concerns of whether he had [indecipherable medical term] and we hadn’t had time to get an x-ray, they actually put chest tubes in both chests, those are things so that if you do have a collapsed lung, it can expand it, and you can breathe. Concern about whether or not the tracheal tube was where it should be because of the tracheal wounds. Dr. Perry did a tracheotomy, which is where you make an incision in the neck to get a shorter tube in more directly into the trachea so there’s no question it’s in place. And I guess all that is important in terms of explaining what was done, and a lot of things happened in those twenty minutes. As I’m sure you’re aware, the tracheotomy wound was right through this wound [pointing to side of neck] . . . I’m sorry, this wound in the neck [moving finger to center of neck]. And that caused some confusion later, but that’s where a tracheotomy had to be. Then, we gave him some steroids because we had remembered from some stuff in the press that he probably had abnormal adrenal glands.
At this point, we had gotten his airway under control, had gotten him breathing, trying to make his circulation better . . . his circulation wasn’t getting better. It was getting worse. His heart had stopped, but we had done all we could to get things stable. Kemp Clark, who was the chief of neurosurgery, evaluated the situation, evaluated the head wound in much more detail than I did. Kemp Clark was the one [who] actually pronounced him dead. Dr. Clark said . . . he basically said, “It’s time to stop the resuscitation.” For whatever reason, the decision was made to not actually pronounce the president dead until after the priest had come in and given him the Last Rites. So, we stopped treatment, but Dr. Clark didn’t pronounce him till after the Last Rites.
Well, from that point, my part . . . the medical part, I guess, the patient care part of my job was over . . . had two things to do. One thing we had to do, as we do for all patients, was write a brief report for the emergency room records of the treatment, what we saw and what we did. And my other job was to find those three patients who I had been working on before the president came in and take care of them. We did sit down [smiling]. Well, I remember one thing that’s probably . . . walked out of the trauma room #1 at the end of the big emergency room which twenty minutes before had been a big city county emergency room full of people being treated, etcetera. All the patients were gone when I walked out. They had been moved elsewhere. The people in the room were by-and-large, men with coats off, shirts and ties on, and guns on their hips. And a couple were on the phone talking to Washington. That’s when, I guess really, the whole thing hit me, you know? Up till then, except for that brief moment, it had been professional work. I walked out there and realized that not only had my little world changed . . . that the whole world had changed. It had changed that quick [snapping fingers]. So, I smoked at that time as a lot of us did. We thought it was a cute thing to do, right? So, I started to light a cigarette, and imagine lighting a cigarette in an emergency room now? [laughing] But that was common in 1963. So, I started to light a cigarette and realized I was trembling so that I really couldn’t . . . had trouble getting the match to the cigarette. But kind of got that under control, and I sat down to write my recollections. . . .
William Zedlitz, MD
After the repair was finished on a patient I was attending and the patient was taken to the recovery room and post-op orders had been written, I was sitting in the surgery office talking to one of the other residents when a page came in on the overhead speaker asking for Dr. Shires to go to the emergency room stat. Since Dr. G. Tom Shires was chief of surgery and chairman of the department of surgery, no one pages him to go anywhere, and since I knew Dr. Shires was not in town at that time, I decided to go down to the ER to see what the urgency was.
As I stepped off the elevator into the ER, a well-dressed man wearing a suit and tie and holding a rapid-fire weapon at his waist confronted me. He asked me if I were a doctor, and I told him I was. He then told me to follow him and he led me through the ER that was normally packed with people but now was entirely empty of patients and staff. We stopped at Trauma Room 1 and I hurried inside. As I passed through the door, I glanced at the clock on the far wall and it indicated it was twenty minutes until one o’clock. In the center of the trauma room and lying on the gurney unclothed was a large man. At that moment I recognized President John F. Kennedy as the man. There was another gurney pushed against the left wall of the room that contained the discarded clothes and suit remnants of the president (they had been cut off him as is standard procedure in such cases). Dr. Jim Carrico, a second year surgery resident, was at the head of the president’s cart with an endotracheal tube placed into the president’s mouth and throat, trying to resuscitate him by inflating his lungs with oxygen, and was pumping the bag of a respirator in order to do this.
At the head of the table on the president’s left was Dr. Charles R. Baxter who was a professor of surgery in the Department of Surgery. On the opposite side of the gurney was Dr. Malcolm O. Perry, also a professor in the department. They were looking at a small round hole in the anterior neck just at or slightly below the cricoid (a bone that helps to support the pharynx). This hole was approximately five to seven millimeters in diameter and was smoothly rounded. It was in the location in front of the trachea where you would normally place an opening in the trachea in the form of a tracheostomy to help a person breathe. Dr. Baxter and Dr. Perry were discussing the meaning of the presence of this hole and at this time Dr. Carrico stated that he was having difficulty ventilating the president and we should probably do a tracheotomy. Dr. Perry asked the nurse for a tracheostomy tray and began to make the incision for the tracheostomy through the small hole and to each side of it so a tube could be inserted directly into the trachea.
In the meantime a nurse was trying to get a blo
od pressure reading and an intern, Dr. White, was doing a cutdown to insert a catheter in a vein as a route to infuse fluid and medications as needed. I was trying to assess the situation and as far as I could tell, the patient had a massive head injury to the posterior and right occipital-parietal area of the head. His left eye seemed to be slightly bulging also as if there had been a great deal of pressure intra-cranially and perhaps distorting the left eye socket. By palpation, the large area in the back of the head on the right was spongy and covered with matted hair and blood, and I could feel a crepitus or a crackling as I touched the area like the bones were in pieces. This is much like a hard-boiled egg that has been dropped and the shell shattered but still held together by the tissue in the egg and you can feel the pieces of shell grating against one another.
Dr. Carrico was still saying that he could not effectively ventilate the patient and was concerned about a pneumothorax, or a collapse of the lung, and perhaps we should insert a chest tube to try to alleviate the collapse and expand the lung. As I started to make the incision in the right chest to insert the chest tube, Dr. Paul Peters came into the room and as he was part of the surgical staff (urology), he continued with the insertion of the chest tube. At this point in time, the trauma room was beginning to fill up with other residents and staff trying to help but mainly observing and I could see that it may actually impede the resuscitation if it became any more crowded so I left the room to see what else needed to be done.
Riyad Taha, MD
On November 22, 1963, I was in my second year of cardiac fellowship, working on emergency room cases that day. Suddenly we got a call that the president was in town, he was shot in the parade downtown, and the motorcade was on their way to Parkland. Everyone was very shocked and immediately we were all given duties to be prepared for when the president came in. I was in charge of bringing the cardiac monitor and pacemaker machine into the room. When they brought him in there was brain tissue all over his wife’s clothes. I stood and watched my professors and other doctors trying to do everything they could for him. Apparently the bullet had exploded in his brain, his heartbeat was very slow, and there was no way we could resuscitate him, he may have already been dead when they brought him in. Everyone was very sad; the emergency room was very quiet afterwards.