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The Kennedy Brothers

Two tales of trauma that made presidential politics personal for many Americans.

The Kennedy family name conjures up memories for many people. As a family they have dominated politics and the press for decades.

While there are many photographs of happy and victorious times for the Kennedys, there are also equally heartbreaking ones--notably in 1963 and again in 1968.

At no time during the past century have two brothers attained the status that John and Robert Kennedy did, nor met the fate that they did.

This article will briefly describe the injuries and care that they received, and discuss the medical achievements made in the time since their assassinations.

President John F. Kennedy
(May 29, 1917 - Nov. 22, 1963)

President Kennedy was the second of nine children of Joseph and Rose Kennedy. He had always hoped to be a college history professor, but with the death of his older brother in World War II, and at the urging of his father, he entered politics.

He was a junior congressman from Massachusetts who after one term in the U.S. House of Representatives ran for the Senate and in 1960 ran for the U.S. Presidency. He won by one of the slimmest margins in history, and became the youngest president to enter the Oval Office.

The year 1963 was a sad one for JFK. He and his wife lost their third child, 3-day-old son Patrick, in early August due to complications from his premature birth. It was hoped that the beginning of his re-election campaign would distract the President from his grief.

A campaign trip was planned to Dallas in late November. 

Fateful Day in Dallas

Within moments of the shooting, the phone rang in Parkland Hospital's emergency room and staff members were informed that the police dispatcher had just called with the message that the president had been shot and was on the way to the hospital.

Quickly two trauma rooms were set up. JFK arrived at the hospital approximately 5 minutes after being shot.

The President was brought in by the Secret Service. He was lying half on the floor and half on the back seat with Mrs. Kennedy and Secret Service agents lying over top of him.

There was blood everywhere in the back seat of the car. JFK was placed on a stretcher and rushed into trauma room No. 1, and his clothes were cut off.

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JFK Assessed

Initial assessment revealed that his color was bluish to ashen, the President had slow voluntary movement, his eyes were open and his pupils were fixed and dilated.

There was no palpable pulse and there were only a few chest sounds audible by stethoscope that the staff thought were heartbeats.

JFK had a small bullet wound in the front lower neck and a large, gaping head wound.

A tracheal incision was made on either side of the neck wound so that a surgical airway could be secured. Bilateral chest tubes were inserted but there did not appear to be a tension or hemothorax on either side. Large-bore IVs were inserted and IV fluid was infused.

Mrs. Kennedy was asked if she knew her husband's blood type, since the Secret Service agent who had this information was guarding the outside parking lot; she could not remember, so he was typed and crossed. JFK was given a shot of cortisone for his Addison's disease by a Navy physician who was traveling with the motorcade.

The OR was called and told to set up for a craniotomy. Within minutes there were four general surgeons, four anesthesiologists, a neurologist, a neurosurgeon, an oral surgeon, a heart specialist and a urologist in the room working on the president.

In the end, they all agreed that there was nothing they could do and so at 1 p.m., JFK was pronounced dead. At 1:58 p.m., his body was removed by the Secret Service from Parkland's ER, taken to Loveland Air Force Base and placed on Air Force One for return to Washington, DC.

The Autopsy

Upon arrival in Washington, JFK's autopsy was done at Bethesda Naval Hospital. However, the physicians involved with the autopsy had no training in autopsy procedures, further compounding the many confusing issues of this assassination.

There was no bullet tracking procedure performed due to orders from high-ranking officials. A bullet tracking procedure follows the path of a bullet and is considered one of the basic steps in an autopsy when death occurs due to a gunshot wound (GSW).

The notes and films taken during this historic homicide investigation (the Parkland Hospital records, the autopsy records, X-rays, etc.) were burned immediately after the autopsy and thus were never reviewed. Because of the destruction of the medical records, controversy continues to surround JFK's death.

The autopsy results released through the investigation indicate two bullets. The fatal missile entered the skull above and to the right of the external occipital protuberance. The second missile entered the right superior posterior thorax above the scapula and traversed the soft tissues of the right side of the neck and produced contusions of the right lung.

If it Happened Today

Occasionally, the question is posed: Would JFK have lived if he sustained his injuries today?

Medical experts agree that the outcome would be the same today. The bullet that entered his skull produced a fatal injury that literally destroyed part of JFK's head.

However, as a result of JFK's assassination a coordinated government effort took place to provide the president with the highest level of healthcare available.

Whenever the president, vice president or other high-ranking government officials travel, there are designated hospitals and healthcare teams who travel with them.
These teams contain nurses and physicians whose sole function is to provide care either to the president or assist those rendering care to him.

Another question that is frequently asked is what the teams would have done differently today that was not done in 1963. The answer is probably nothing. The same protocols that were utilized for JFK (with the exception of the cortisone injection) would probably be used today.

He was in a trauma center less than 5 minutes after being shot and he was immediately given a surgical airway.

Today, however, his medical records would be considered evidence in a legal case. There would be an autopsy with a bullet tracking procedure done in the jurisdiction where the homicide took place and the topic of organ procurement would also be addressed.

Senator Robert Francis Kennedy
(Nov. 20, 1925 - June 6, 1968)

Robert F. Kennedy was the seventh of nine children of Joseph and Rose Kennedy. He went to law school and became his older brother John's campaign manager, adviser and ultimately the attorney general of the U.S. from 1960-64.

After JFK's assassination, he entered politics on his own and became a senator from New York (1965-68). He was in the process of securing the Democratic Party's nomination for the presidency when he was assassinated.

RFK was campaigning during primary season and had just won the California contest on June 4, 1968. The victory celebration was held at the Ambassador Hotel in Los Angeles. His campaign was rapidly picking up momentum and the California primary was a huge victory for him.

After the Big Win

After giving his acceptance speech late on June 4, RFK attempted to leave the crowded hotel ballroom and it was suggested that he try to exit through the kitchen.

Just after midnight on June 5, shots rang out in the kitchen and RFK sustained multiple GSW from a .22 caliber handgun at very close range.

Reportedly, his hands went up toward his face, and he staggered back and fell onto the gray concrete floor on his back.

In the chaos that ensued, his wife, Ethel, was brought to his side and he reportedly turned his head and seemed to recognize her. His eyes were still open and he appeared conscious, but he was not speaking.

When the ambulance arrived at 0023, Kennedy was picked up and said "Oh, no, no, don't." He appeared to be in pain. He was then strapped onto the stretcher and lost consciousness.

An oxygen mask was placed over his face and he was taken to Central Receiving Hospital, a mile from the Ambassador Hotel.

CPR Initiated

Upon arrival in the ED, CPR was initiated since RFK had suffered cardiac arrest in the ambulance. He had closed cardiac massage, was intubated and had adrenalin injected intracardiac.

After 10-12 minutes there were feeble breaths and Kennedy's heart began to beat. A quick exam revealed that one bullet had entered the mastoid area behind his right ear on a path to the brain. At 0050, a press release was issued stating that the decision had been made to transfer RFK to Good Samaritan Hospital several blocks away, where there were neurosurgical capabilities.

Upon arrival at Good Samaritan, he was taken to the fifth floor ICU, where he waited until the OR was ready, and then was moved to the ninth floor for his surgery. He underwent a long procedure where physicians attempted to not only determine the extent of his cerebral injury, but remove all of the missile fragments from RFK's brain.

Their efforts to save RFK were unsuccessful, and he was pronounced dead at 0144 on June 6.

The Autopsy

RFK's autopsy was done very differently from JFK's. First of all, it was done in the appropriate jurisdiction (Los Angeles) and not halfway across the country. The individuals who performed the autopsy were highly trained professionals who knew how to do a bullet tracking procedure, and appropriately care for evidence and records.

RFK's autopsy showed that he had sustained three GSWs. The first bullet was a "through and through" GSW with the entry underneath and slightly to the back of the right armpit. The bullet traveled at an angle and exited through the front right shoulder. This bullet was never recovered and was presumed lost somewhere in the Ambassador hotel kitchen.

The second bullet also entered under the right armpit, about an inch from where the first bullet entered. It traversed RFK's back and lodged in the soft tissue of the paracervical region at the level of C-6. The retrieval of this bullet was not attempted during RFK's brain surgery since it was not considered life threatening, but it was removed during the autopsy.

The third bullet entered the skull an inch to the left of RFK's right ear in the mastoid region, where it shattered. Numerous bullet fragments were recovered during the surgery, but a large one had lodged in the midline of the brain and was not recovered until the autopsy.

Unfortunately, the damage caused by the bullet, combined with the effects of a long OR procedure and the effects of secondary brain injury (increased ICP, hypoxia, cerebral swelling, etc.) were too much to overcome.

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What if it Happened Today?

Many medical personnel have questioned whether Sen. Kennedy would have lived if he had sustained his injuries today.

This is a difficult question to answer because so much has changed since 1968 in the way that we care for penetrating head injury patients.

However, it is known that had he survived his injuries, he would have required intense brain injury rehabilitation and still have had significant cognitive deficits.

When a comparison is done of RFK's care, the first thing that has changed is how much more developed EMS systems and protocols have become.

RFK would have been intubated as soon as he lost consciousness (in the kitchen of the Ambassador Hotel) rather than when he reached the hospital. He would have had ACLS drugs and protocols initiated enroute to the hospital when he arrested rather than having to wait for advanced life support measures to be initiated by the ER physician.

In addition, with the advent of trauma center designations, RFK would have been taken immediately to a trauma center rather than the closest hospital. The emergence of trauma systems has removed the delay caused by interfacility transfer, tracking down neurosurgeons and waiting for an operating room team to assemble.

The only diagnostic testing that physicians could offer RFK in 1968 was an X-ray. A skull film was all they had to determine how many bullets/fragments they were dealing with as well as the course that they took. The CT scan had not yet been invented, so there was no way of telling how much bleeding or swelling was occurring in RFK's brain. There was nothing they could do except operate to determine how extensive the damage was.

Intensive care units in 1968 were not what they are today. There were no PA catheters, arterial lines, ICP monitoring equipment or neuromuscular blockades and other types of pharmacological agents that we now utilize today on severe head injury patients. They could only offer a room with a cardiac monitor and a ventilator; mannitol and steroids were the drugs of choice. The restriction of fluids for head injury patients was just beginning to be studied. Additionally, today the topic of organ procurement would be discussed with the family.

The day after RFK died, Congress passed legislation that every individual who declares his candidacy for U.S. President will have Secret Service protection during the course of his campaign.

Cynthia Blank-Reid a trauma clinical nurse specialist in Philadelphia.

Historic Trauma Cases Archives
  Last Post: September 12, 2012 | View Comments(1)

This is interesting to talk about some of the beloved "martyred" Democrats a few months before the presidential election. If we're going to discuss the trauma aspects of the Kennedy deaths, which were truly tragic and history changing, why don't we also talk about the trauma aspects of the drowning death of Mary Jo Kopechne.

You know, the woman that one of the beloved Kennedy's deserted while still alive in a car that was quickly taking on water?

You may think I'm a conspiracy nut and ban me if you wish, but this seems a little too close to the election and too pro-Democrat to be a coincidence.

I have been wrong before, anyway peace and love to everyone.

James ,  RN, FNPSeptember 12, 2012


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