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A VERY BAD 'ON CALL'
BY PROFESSOR CONOR MAGEE MD FRCS, CONSULTANT SURGEON
In common with many in the surgical trade I have had more than a few bad
weekends on call. The old saying “No matter the longest day, it still only has
24 hours” is of little benefit when you are on call for 72 hours… and the first
twelve have been awful.
Sometimes it’s the fact that you have very little sleep that makes the on-call bad,
but sometimes it’s the cases you are presented with. Which brings me onto one of
my most interesting tales of surgical woe.
On a bright, clear November day at the end of a busy week an American surgeon
was lecturing his junior doctors on surgical technique. Lunchtime meetings have
been the staple of medical education for decade s- a rare hiatus in the intense
workload of hospital medicine where a guaranteed meal is a godsend.
Except this time, a little after 12:30 it was rudely interrupted by a telephone call
urgently requesting the surgical team to come to the Emergency Room to attend
a 46 year old male gunshot victim. The date was Friday the 22nd of November,
1963. The man was President John Fitzgerald Kennedy and the surgeon on call
was Dr Malcolm Perry, who was about to start an incredible on call weekend.
President Kennedy was rushed into the Emergency Room at Parkland Memorial
Hospital with a massive headwound and compromised breathing. Dr Perry and
his team noted an exit wound from the President’s throat that was obstructing
his breathing. With great skill they enlarged this wound and inserted a breathing
tube (tracheostomy) as well as a drain into his chest. Despite their efforts the
gunshot wound to the head was unrecoverable and President Kennedy was
declared dead at 1pm.
Whatever your thoughts regarding conspiracy theories, a man in his prime died
that afternoon - a father to young children and a husband to a wife - leaving a
devastated family, and a nation in shock. Surgeons face death on a regular basis
- it comes in many forms and we all have our own personal coping strategies.
Sometimes we tell ourselves - well that’s as bad as it gets. But we also know that
the world is cruel and it can, and does, get worse.
I don’t know how Dr Perry reacted to JFK’s death - but I suspect he just wanted
the weekend on call to be over. A bad on-call, to be compartmentalised allowing
a brighter optimism for the next one to form. Except that wasn’t to be. The alleged
assassin of JFK was arrested shortly after his death - Lee Harvey Oswald was found
at a local cinema following the killing of a Police Office called JD Tippett. Within
hours Oswald was taken to the Dallas Police Headquarters for interrogation. At
11:21 on Sunday 24th November Oswald was escorted through a media scrum of
cameras and reporters, when a former nightclub owner approached him and fired
a single shot into his abdomen at close range. Oswald rapidly lost consciousness
and was taken by ambulance to Parkland Memorial Hospital, and to a waiting Dr
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Malcolm Perry - the surgeon who 48 hours earlier watched JFK die and was now
expected to save the life of the man that killed him.
Oswald was barely alive - he had no recordable blood pressure and a rapid,
weak pulse. The bullet had traversed his abdomen causing massive blood loss,
that if not staunched would kill him. The only chance of survival was emergency
surgery. An incision was made from the breastbone down to the pubic bone - as
soon as the abdomen was opened blood poured from the wound. The human
body has around 5 litres of blood, within seconds three litres of Oswald’s blood
was on the operating room floor.
What happens next is the most intense race - find the source of bleeding, stop
the bleeding - all whilst trying not to damage the most delicate structures in the
human body. The bullet had hit Oswald’s inferior vena cava - the largest vein
in the human body, around the width of a hosepipe. Unlike arteries that have a
muscular wall that can contract to stop bleeding, veins are literally hollow vessels
that only stop bleeding when the heart stops.
Surgeons talk of bleeding “you can hear”- bleeding from the vena cava causes
the most awful sound. The vena cava lies alongside the spine in the deepest,
most challenging part of the human body known as the retroperitoneum. Dr
Perry and his team managed to identify and close the hole in the vena cava and
almost miraculously found and addressed other injuries caused by the bullet.
The pancreas and intestine were badly damaged, the major artery to the bowels
needed repairing. During the operation over 15 litres of blood and fluids were
given. Oswald had lost three times his circulating volume.
Through their enormous skill the surgeons stabilised Oswald’s bleeding but he
still continued to deteriorate. In desperation, they opened his chest but found no
bleeding. Open cardiac massage was performed with Dr Perry holding Oswald’s
heart and then injecting it with Adrenaline. Despite everything that could be
done for Lee Harvey Oswald, he was pronounced dead at 1:07pm.
That left another 24 hours left of Dr Perry’s on call shift. I don’t think even he
remembers those last 24 hours. The challenge of surgery are such that you never
know what is around the corner - you have your training, your experience and
most importantly your team. It was a team that worked on Oswald, knowing the
crime he was accused of. A team that pulled out all the stops and did everything
in their power to save his life. In the same way every surgical team in every
hospital up and down this country do.
Now when is my next weekend on-call?
Professor Magee operates at Spire Murrayfield Hospital and can be contacted
there. He can be followed on Twitter @mageefrcs.