Famous Assassinations in History and Would They Survive Today? Joseph S. Blansfield, MS, NP, TCRN Trauma & Acute Care Surgery Program Manager Boston Medical Center Learning Objectives

• Review the historical aspects of several famous assassinations that have occurred in history. • Apply the standard of care at that time to the treatment these individuals received. • Compare the current state of the art in trauma care to these same cases and determine outcome Disclosure Statement

• I have no financial disclosures • However, I’m available Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Assassination: to kill suddenly or secretively, especially a politically prominent person; murder premeditatedly and treacherously  Steeped in political / cultural context  Alter history  Wrought with conspiracy  Historical data presented is a representative of the mainstream opinion / account of events  Fame by military conquest  Contemporary of and Cassus  Known for his elegant speeches –and his arrogance  Dictator of the  Was declared dictator perpetuo by the Senate  crosses the Rubicon 49 B.C.  Wins Civil War in  Consolidates power in Greece and Egypt  Becomes Dictator Perpetuo  Plot to Kill  At the Senate meeting  Only senators admitted  Daggers hid beneath togas  Beware the Ides of March  Calpurnia had visions in her dreams  Medical doctors advised against Senate meeting  Marc Antony slipped a warning note into Caesar’s hand  Brutus, “The Senate is waiting.” Marcus Junius Brutus Servius Sulpicius Galba Quintus Ligarius  At least 44 Roman senators  the Liberatores Lucius Minucius Basilus Gaius Servilius Casca  Gaius Cassius Longinus Publius Servilius Casca Longus  Marcus Junius Brutus Decimus Junius Brutus Albinus Lucius Tillius Cimber Gaius Trebonius Lucius Cassius Longinus Caius Cassius Parmensis Caecilius Bucolianus Rubrius Ruga Marcus Spurius Publius Sextius Naso Lucius Pontius Aquila Petronius Decimus Turullius Pacuvius Antistius Labeo • Near the • Senators surround Caesar •1st strike by Casca to Caesar’s neck  defensive block by Caesar • Senators stab Caesar • “Et tu Brute?” • Caesar attempted a get-away, but was blinded by blood • Lay defenseless on the steps  Non‐conspirator senators flee  Conspirators rejoice in the city with no audience  Grandnephew Gaius Octavius named sole heir  Brutus and Cassius warred against Octavius and Antony   Defeated at Phillipi  Antony marries Cleopatra and wars again Octavias   Octavius triumphs and becomes the first Roman Emperor, Caesar Augustus End of the Roman Republic  1st recorded autopsy by Physician Antistius  23 stab wounds  1st blow to the neck, 2nd blow to the chest  Only one determined to be “fatal”  Cause of death likely hemorrhagic shock  Hemopneumothorax?  Great Vessel Injury? Hemorrhagic Shock: • 1/3 of in‐hospital trauma deaths  Massive Transfusion (>10u in 24 h)  Mortality 30‐50%  Must try to avoid the lethal triad  Component Transfusion Therapy  Improve Resource Utilization  Reduce infectious disease transmission

Waters JH. Role of the massive transfusion protocol in the management of haemorrhagic shock. British Journal of Anaesthesia. 2014; 113(2):ii3-ii8.  Higher plasma : RBC ratio independently improves survival  Primarily decreases EARLY death

Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Journal of Trauma. Oct 2007; 63(4):805-813

• 1:1:1 decreased Hemorrhagic Death • Give Plasma and Platelets First • Redefine MTP from 10 units in 24 hours to 3 units in 1 hour LIVED DIED

 Post‐Civil War Reconstruction Era  Republican Party split between Grant and Blaine  Won the presidential election as a Dark Horse Candidate (10,000 votes)  Peacetime in the U.S.  Presidential security had become lax  Shot four months into presidential term  Failure; Insane; Committed by family but escaped  Claimed his (undelivered) speech won the election  Loitered at the White House requesting diplomatic job Banned by the Secretary of State  Bought a revolver and spent a month of target practice and stalking Garfield  Believed the assassination would re‐unite the Republican Party

“In the President’s madness he has wrecked the grand old Republican party, and for this he dies.”

‐ Charles Guiteau • Garfield arrived at the Baltimore and Potomac Railroad Station • Was on his way to alma mater, Williams College to deliver a speech • Was the start of his summer vacation • Accompanied by 2 sons, Secretary of State, and Secretary of War • Garfield entered the waiting room of the station  Guiteau fired 2 shots from behind • A united country mourns Garfield’s death • Larger than Lincoln… liked by both North and South • Vice President Chester A. Arthur succeeded as President • Approved the Pendleton Civil Service Act • Guiteau was tried, found guilty, and hanged • Argued that the doctors, not his bullet killed Garfield • First use of Insanity defense in criminal court  Shot twice in back close range  1st grazed shoulder  2nd to back, just right of L1  Brought upstairs in the train station  T 99.4 HR 108 RR 19  Abdomen peritoneal  Taken to the White House  Daily medical bulletins  Physicians probed the wound to extract the bullet  With unsterilized metal instruments or bare hands  A.G. Bell devised a metal detector  Internal bleeding ensued  Thought to be due to probing the liver  Local operations to remove the bullet  Placed drains  Persistent fevers, unable to tolerate oral intake  Weight loss: >200 lbs to 135  Given nutrient enemas  Brought to Jersey Shore in hope cooler climate would aid recovery  Pneumonia  Bacteremia  Abdominal abscesses  Died September 19th, 1881  Bilateral pneumonia  Multiple abdominal abscesses  Bullet transversed L1  Lodged in retroperitoneal fat just behind pancreas  Ruptured splenic artery pseudoaneurysm Trimodal distribution of Prehospital Care Immediate Deaths trauma deaths:  Late deaths: Early Resuscitation  Multi‐organ system Early Deaths failure Critical Care Late Deaths  Sepsis

Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventative efforts, speedier surgery and further research. Scientific American. Aug 1983; 249(2):28-35. Moving to a bimodal distribution?

Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Baylor University Medical Center Proceedings. Oct 2010; 23(4): 349-354.

 Hospitals were “Houses of Death”  Surgical mortality around 50%  White coats were “badges of honor” and never washed between cases  Sterile technique introduced by Joseph Lister in the mid‐1860s  Hand‐washing before procedures and cleaning of instruments  Not widely accepted in the U.S. at that time  William Halsted creates surgical gloves in 1890  Initially to impress the chief nurse, who later became his wife  First surgeon in chief at Johns Hopkins Hospital  Which antibiotics?  Duration of antibiotics  EAST Guidelines for penetrating abdominal wounds  Single pre‐operative prophylactic antibiotic dose  Should not be continued for >24h in presence of hollow viscus injury  Absence of hollow viscus injury requires no further antibiotics

1. Goldberg SR, Anand RJ, Como JJ, et al. Penetrating abdominal trauma, prophylactic use in. Journal of Trauma. Nov 2012; 73(5):S321-S325. 2. Kirton OC, Oneill PA, Kestner M, Tortella BJ. Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days. Journal of Trauma. Nov 2000; 49(5):822-832.  Trauma / Burn patients require higher nutritional support  Hypermetabolic state  1.5x caloric need

 Enteral feeding is better than parenteral feeding  Nutritional protein markers restored better with enteral feeding  Decreased infectious complications

 Specialized feeding  Immune‐enhancing formulas: Arginine, Glutamine, Omega‐3  Oxepa: showed improved outcomes in critically‐ill patients with ARDS

Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma – reduced septic morbidity. Journal of Trauma. Jul 1989; 29(7):916-922. LIVED DIED  Archduke of Austria  Heir to the throne  Appointed Inspector General of the Armed Forces of Austria‐Hungary  Married Sophie (Duchess of Hohenberg)  Franz had been forbidden to be seen in public with Sophie because she was a lower class royalty  Traveled to Sarajevo in Bosnia  Army Inspection  19 year‐old  Part of a group of 6 assassins  Motives consistent with the movement that later became known as Young Bosnia  Weapons supplied by the Black Hand, a Serbian terrorist organization • Archduke Franz Ferdinand and Sophie arrive in Sarajevo at 9:28am • First conspirator throws a car bomb and misses at 10:10am • Visit shortened, alternate route taken home • Driver has to make a U-turn  stopped in front of Princip • 2 shots fired • Killed both Franz Ferdinand and his wife Sophie  Austria‐Hungary ultimatum to Serbia  Rejected by Serbia  Austria‐Hungary declares war July 28, 1914  Leads to the First World War  9 million soldiers and 7 million civilians died  Assassin group tried in Sarajevo in October 1914  3 members executed  Princip too young for death penalty  20‐year sentence  Contracted tuberculosis and died in jail in 1918  1st shot to Franz Ferdinand’s left neck  2nd shot to Sophie’s abdomen  The royal couple slumped down in their seats  Brought by car to the Hotel Konak  Carried to their hotel suite, clothes removed  Left neck wound  Left Jugular Vein Injury  Determined DOA  Sophie thought to have fainted  found to have GSW to RLQ  DOA Pre‐Hospital Transport: “Scoop and Run” for trauma patients Transport providers:  Basic Life Support  Advanced Life Support For penetrating trauma:  MedFlight Increased field  Nonmedical, police 1st responders interventions  increased pre-hospital time  poor outcomes

1. Seamon MJ, Doane SM, Gaughan JP, et al. Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support. Injury. May 2013; 44(5):634-638. 2. Branas CC, Sing RF, Davidson SJ. Urban trauma transport of assaulted patients using nonmedical personnel. Academic Emergency Medicine. June 1995; 2(6):486-493. • Regionalized trauma care1 – Foundation from experiences in the Korean War Mean Transport Time Mortality WWII: 240 mins 4.5% Korea: 85 mins Vietnam: 27 mins 1.9%

• Mortality is lower at trauma centers2 – Primarily confined to patients with more severe injuries

Nathens AB, Brunet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. The Lancet. May 2004; 363(9423): 1794-1801.  Recommendation that “initiation of resuscitation and stabilization should be performed in the field followed by rapid transport to the closest appropriate facility”  What is the closest “appropriate” facility  2.8x higher risk of death if transferred initially to non‐trauma center  Designation of trauma facilities is geopolitical process  The ACS does not designate trauma centers  The ACS does complete verification  Resources for the Optimal Care of the Injured Patient

Nirula R, Maier R, Moore E, Sperry J, Gentilello L. Scoop and run to the trauma center or stay and play at the local hospital: Hospital transfer’s effect on mortality. The Journal of Trauma: Injury, Infection, and Critical Care. Sept 2010; 69(3):595-601.

LIVED DIED  United States Senator (New York)  Brother of assassinated President John Fitzgerald Kennedy  Lyndon B. Johnson became President after the assassination of JFK  Presidential campaign for the 1968 election:  Lyndon B. Johnson announced he would not seek re‐election  Time of social unrest: MLK assassination, opposition to Vietnam  Robert Kennedy was a strong advocate for Israel based on experiences visiting Palestine  24 year‐old Palestinian immigrant  Detailed description of personal obsession with killing Kennedy  Date picked for assassination was the 1st anniversary of the Six Day War  RFK had just won the California Democratic primary election  Addressed supporters at the Ambassador Hotel in Los Angeles  Walked through the kitchen to get to another press conference  Sirhan fired shots  6 wounded  Hubert Humphrey won the Democratic nomination  Lost the election to Richard Nixon  Prompted the protection of presidential candidates by the US Secret Service  Sirhan Sirhan initially sentenced to death  California repealed the death sentence  currently serving a life sentence in prison  3 gunshot wounds  1st right post‐auricular  2nd right posterior‐axillary line  exit from chest  3rd right posterior‐axillary line  Brought to Central Receiving Hospital  Tracheostomy performed  CPR initiated with SROC  Transferred to the Good Samaritan Hospital  Transferred to the Good Samaritan Hospital ~30 minutes after shooting  Plain x‐rays of Head/C‐spine/Chest  OR: R posterior craniectomy (3 hours after shooting)  ICU: by late afternoon likely brain dead  Ventilator turned off by decision of wife, Ethel Kennedy  Died at 1:44AM, 26 hours after shooting  1st GSW entered mastoid bone  severed superior cerebral artery  lodged in the brain stem  2nd GSW posterioaxillary line  exited upper portion of chest  3rd GSW posterioaxillary line  lodged near C6 paracervical  4th GSW  entered and exited through the Senator’s clothes Traumatic Brain Injury: Monroe Kellie Doctrine (1783) Cranial volume = Brain + CSF + Blood CPP = MAP –ICP Management focuses on decreasing ICP Medical Therapy:  Hyperosmolar therapy  Hypothermia  Barbituate coma Surgical Therapy:  Craniotomy/Craniectomy

Honeybul S. Decompressive craniectomy for severe traumatic brain injury: A review of its current status. Journal of Neurology and Neurophysiology. S9. doi:10.4172/2155-9562.S9-001.  Cerebral perfusion  Poor outcomes are associated with brain hypoxia after severe TBI  Direct Brain Oxygen Monitors  Now included in the TBI Management Guidelines  Invasive (ie Licox, Neurotrend)1  Noninvasive (CerOx)2  Pupilometer

1. Maloney-Wilensky E, Gracias V, Itkin A, et al. Brain tissue oxygen and outcome after severe traumatic brain injury: A systematic review. Critical Care Medicine. 2009; 37(6):2057-2063. 2. Rosenthal G, Furmanov A, Itshayak E, et all. Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury. Journal of Neurosurgery. April 2014; 120(4):901-907.  Almost half of the ~50,000 TBI‐related deaths are due to firearms  Study from Maryland looked at 786  61.5% of these patients were dead on arrival or did not survive hospitalization  Good prognostic factors: GCS > 8, normal pupillary reaction to light, lack of transgression of x,y,z planes

Aarabi B, Tofighi B, Kufera JA, et al. Predictors of outcome in civilian gunshot wounds to the head. Journal of Neurosurgery. May 2014; 120(5):1138-1146. LIVED DIED  One of the founding members of The Beatles  Married to Yoko Ono in 1969  The Beatles break‐up in 1970  Involved in political and peace activism  Lennon returns to the music industry in 1975  Released joint album with Yoko Ono: Double Fantasy  25 year‐old security guard from Honolulu, Hawaii  Had travelled to New York to murder Lennon in October, but changed his mind  Completed photo shoot with Rolling Stone, then left for a recording session with his wife Yoko Ono  Signed an album for Chapman  Returned to the Dakota at 10:50pm  Chapman fired shots at Lennon  Chapman awaited the police the Dakota reading J. D. Salinger’s Catcher in the Rye  Outpouring of grief worldwide  10 minutes of silence on December 10th  30,000 in Liverpool  225,000 in New York City’s Central Park  Every radio station in New York City went off the air  Yoko Ono continues to release music  Chapman sentenced to life in prison in New York  has been denied parole 8 times  5 gunshots fired  1st missed Lennon  2nd/3rd struck left back  4th/5th struck left shoulder  Lennon staggered into the lobby  Police transferred to Roosevelt Hospital  Trauma Bay at 11:00pm: No pulse, No respirations  15 minutes of CPR + ED thoracotomy  Pronounced dead at 11:15pm  Left lung injury  Left subclavian artery shredded Resuscitative thoracotomy:  Left anterolateral thoracotomy  Evacuate cardiac tamponade  Control hemorrhage  Thoracic aortic crossclamping  Access for cardiac massage

Typically performed in the Emergency Department Often not performed by cardiothoracic surgeons  Obligatory procedure  Selective application  Who Benefits?  Penetrating injuries have better outcomes than blunt injury  Stab wounds have higher survival than gunshot wounds  Cardiac injuries have better outcomes than non‐cardiac thoracic, abdominal or multiple (regardless of mechanism)  Presence of “signs of life”  Focus on mechanism of injury, location of injury, and signs of life

Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. Journal of the American College of Surgeons. Mar 2000; 190(3):288-298.  To the patient  nothing but benefit  100% mortality of a trauma patient who remains in cardiac arrest  Hospital charge for resuscitative thoracotomy  $892 to $7,200  Review of 273 EDT, 10 survivors1  Average cost $3413 / Charge of $93,175 per successful EDT  If restricted to penetrating injury + SOL  $20,137 per successful EDT  Needlestick Injuries2  HIV seropositivity in trauma patient population as high as 24%  Universal precautions during trauma resuscitations as low as 16%  Wasted blood products2  Average use of pRBC 7u (+/‐ SD 9)

1. Mazzorana V, Smith RS, Morabito DJ, Brar HS. Limited utility of emergency department thoracotomy. The American Surgeon. Jul 1994; 60(7):516-520. 2. Passos EM, Engels PT, Doyle JD, et al. Societal costs of inappropriate emergency department thoracotomy. Journal of the American College of Surgeons. Jan 2012; 214(1):18-25. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. Journal of Trauma and Acute Care Surgery. Dec 2012; 73(6):1359-1363. LIVED DIED Joseph S. Blansfield, MS, NP, TCRN Boston Medical Center Boston, MA. 02118

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