Part 51

Dr. PERRY. On that day I had come over from the medical school for the usual 1 o'clock rounds with the residents, and Dr. Ronald Jones and I, he being chief surgical resident, were having dinner in the main dining room there in the hospital.

Mr. SPECTER. Will you describe how you happened to be called in to render assistance to President Kennedy?

Dr. PERRY. Somewhere around 12:30, and I cannot give you the time accurately since I did not look at my watch in that particular instant, an emergency page was put in for Dr. Tom Shires, who is chief of the emergency surgical service in Parkland. I knew he was in Galveston attending a meeting and giving a paper, and I asked Dr. Jones to pick up the page to see if he or I could be of assistance.

The CHAIRMAN. Doctor, at this time I must leave for a session at the Supreme Court, and the hearing will continue. Congressman Ford, I am going to ask you if you will preside in my absence. If you are obliged to go to the Congress, Commissioner Dulles will preside, and I will be available as soon as the Court session is over to be here with you.

(At this point, Mr. Warren withdrew from the hearing room.)

Representative FORD. Will you proceed, please?

Mr. SPECTER. What action did you take after learning of the emergency call, Dr. Perry?

Dr. PERRY. The emergency room is one flight of stairs down from the main dining cafeteria, so Dr. Jones and I went immediately to the emergency room to render what assistance we could.

Representative FORD. May I ask this: In the confirmation of the page call, was it told to you that the President was the patient involved?

Dr. PERRY. It was told to Dr. Jones, who picked up the page, that President Kennedy had been shot and was being brought to Parkland. We went down immediately to the emergency room to await his arrival. However, he was there when we reached it.

Mr. SPECTER. Who else was present at the time you arrived on the scene with the President?

Dr. PERRY. When Dr. Jones and I entered the emergency room, the place was filled with people, most of them officers and, apparently, attendants to the Presidential procession. Dr. Carrico was in attendance with the President in trauma room No. 1 when I walked in. There were several other people there. Mrs. Kennedy was there with some gentleman whom I didn't know. I have the impression there was another physician in the room, but I cannot recall at this time who it was. There were several nurses there.

Mr. SPECTER. Were any other doctors present besides Dr. Carrico?

Dr. PERRY. I think there was another doctor present, but I don't know who it was, I don't recall.

Mr. DULLES. Can I ask a question here, Mr. Specter?

Mr. SPECTER. Certainly.

Mr. DULLES. What is the procedure for somebody taking command in a situation of this kind? Who takes over and who says who should do what? I realize it is an emergency situation. Maybe that is an improper question.

Dr. PERRY. No, sir.

Mr. DULLES. But it would be very helpful to me----

Dr. PERRY. No, sir; it is perfectly proper.

Mr. DULLES. In reviewing the situation to see how you acted.

In a military situation, you have somebody who takes command.

Dr. PERRY. We do, too. And it essentially is based on the same kind of thing.

Mr. DULLES. I would like to hear about that.

If it doesn't fit in here----

Mr. SPECTER. It is fine.

Dr. PERRY. It is based on rank and experience, essentially. For example, Dr. Carrico being the senior surgical resident in the area, at the time President Kennedy was brought in to the emergency suite, would have done what we felt was necessary and would have assumed control of the situation being as there were interns and probably medical students around the area, but being senior would take it. This, of course, catapulted me into this because I was the senior attending staff man when I arrived and at that time Dr. Carrico has noted I took over direction of the care since I was senior of all the people there and being as we are surgeons, the department of surgery operates that portion of the emergency room and directs the care of the patients.

Mr. DULLES. Did you try to clear the room of unnecessary people?

Dr. PERRY. This was done, not by me, but by the nurse supervisor, I assume, but several of the people were asked to leave the room. Generally, this is not necessary. In an instance such as this, it is a little more difficult, as you can understand.

Mr. DULLES. Yes.

Dr. PERRY. But this care of an acutely injured and acutely injured patients goes on quite rapidly. Over 90,000 a year go through that emergency room, and, as a result, people are well trained in the performance of their duties. There is generally no problem in asking anyone to leave the room because everyone is quite busy and they know what they have to do and are proceeding to do it.

Mr. DULLES. Thank you very much.

Mr. SPECTER. Upon your arrival in the room, where President Kennedy was situated, what did you observe as to his condition?

Dr. PERRY. At the time I entered the door, Dr. Carrico was attending him. He was attaching the Bennett apparatus to an endotracheal tube in place to assist his respiration.

The President was lying supine on the carriage, underneath the overhead lamp. His shirt, coat, had been removed. There was a sheet over his lower extremities and the lower portion of his trunk. He was unresponsive. There was no evidence of voluntary motion. His eyes were open, deviated up and outward, and the pupils were dilated and fixed.

I did not detect a heart beat and was told there was no blood pressure obtainable.

He was, however, having ineffective spasmodic respiratory efforts.

There was blood on the carriage.

Mr. DULLES. What does that mean to the amateur, to the unprofessional?

Dr. PERRY. Short, rather jerky contractions of his chest and diaphragm, pulling for air.

Mr. DULLES. I see.

Mr. SPECTER. Were those respiratory efforts on his part alone or was he being aided in his breathing at that time?

Dr. PERRY. He had just attached the machine and at this point it was not turned on. He was attempting to breathe.

Mr. SPECTER. So that those efforts were being made at that juncture at least without mechanical aid?

Dr. PERRY. Those were spontaneous efforts on the part of the President.

Mr. SPECTER. Will you continue, then, Dr. Perry, as to what you observed of his condition?

Dr. PERRY. Yes, there was blood noted on the carriage and a large avulsive wound on the right posterior cranium.

I cannot state the size, I did not examine it at all. I just noted the presence of lacerated brain tissue. In the lower part of the neck below the Adams apple was a small, roughly circular wound of perhaps 5 mm. in diameter from which blood was exuding slowly.

I did not see any other wounds.

I examined the chest briefly, and from the anterior portion did not see anything.

I pushed up the brace on the left side very briefly to feel for his femoral pulse, but did not obtain any.

I did no further examination because it was obvious that if any treatment were to be carried out with any success a secure effective airway must be obtained immediately.

I asked Dr. Carrico if the wound on the neck was actually a wound or had he begun a tracheotomy and he replied in the negative, that it was a wound, and at that point----

Mr. DULLES. I am a little confused, I thought Dr. Carrico was absent. That was an earlier period.

Dr. PERRY. No, sir; he was present.

Mr. DULLES. He was present?

Dr. PERRY. Yes; he was present when I walked in the room and, at that point, I asked someone to secure a tracheotomy tray but there was one already there. Apparently Dr. Carrico had already asked them to set up the tray.

Mr. SPECTER. Dr. Perry, backtracking just a bit from the context of the answer which you have just given, would you describe the quantity of blood which you observed on the carriage when you first came into the room where the President was located?

Dr. PERRY. Mr. Specter, this is an extremely difficult thing. The estimation of blood when it is either on the floor or on drapes or bandages is grossly inaccurate in almost every instance.

As you know, many hospitals have studied this extensively to try to determine whether they were able to do it with any accuracy but they cannot. I can just tell you there was considerable blood present on the carriage and some on his head and some on the floor but how much, I would hesitate to estimate. Several hundred CC's would be the closest I could get but it could be from 200 to 1,500 and I know by experience you cannot estimate it more accurately.

Mr. SPECTER. Would you characterize it as a very substantial or minor blood loss?

Dr. PERRY. A substantial blood loss.

Mr. SPECTER. Now, you mentioned the President's brace. Could you describe that as specifically as possible?

Dr. PERRY. No, sir; I did not examine it. I noted its presence only in an effort to reach the femoral pulse and I pushed it up just slightly so that I might palpate for the femoral pulse, I did no more examination.

Mr. SPECTER. In the course of seeking the femoral pulse, did you observe or note an Ace bandage?

Dr. PERRY. Yes, sir.

Mr. SPECTER. In the brace area?

Dr. PERRY. Yes, sir. It was my impression, I saw a portion of an Ace Bandage, an elastic supporting bandage on the right thigh. I did not examine it at all but I just noted its presence.

Mr. SPECTER. Did the Ace Bandage cover any portion of the President's body that you were able to observe in addition to the right thigh?

Dr. PERRY. No, sir; I did not go any further. I just noted its presence right there at the junction at the hip. It could have been on the lower trunk or the upper thigh, I don't know. I didn't care any further.

Mr. SPECTER. Would you continue to describe the resuscitative efforts that were undertaken at that time?

Dr. PERRY. At the beginning I had removed my coat and watch as I entered the room and dropped it off in the corner, and as I was talking to Dr. Carrico in regard to the neck wound, I glanced cursorily at the head wound and noted its severe character, and then proceeded with the tracheotomy after donning a pair of gloves. I asked that someone call Dr. Kemp Clark, of neurosurgery, Dr. Robert McClelland, Dr. Charles Baxter, assistant professors of surgery, to come and assist. There were several other people in the room by this time, none of which I can identify. I then began the tracheotomy making a transverse incision right through the wound in the neck.

Mr. SPECTER. Why did you elect to make the tracheotomy incision through the wound in the neck, Dr. Perry?

Dr. PERRY. The area of the wound, as pointed out to you in the lower third of the neck anteriorly is customarily the spot one would electively perform the tracheotomy.

This is one of the safest and easiest spots to reach the trachea. In addition the presence of the wound indicated to me there was possibly an underlaying wound to the neck muscles in the neck, the carotid artery or the jugular vein. If you are going to control these it is necessary that the incision be as low, that is toward the heart or lungs as the wound if you are going to obtain adequate control.

Therefore, for expediency's sake I went directly to that level to obtain control of the airway.

Mr. SPECTER. Would you describe, in a general way and in lay terms, the purpose for the tracheotomy at that time?

Dr. PERRY. Dr. Carrico had very judicially placed an endotracheal tube but unfortunately due to the injury to the trachea, the cuff which is an inflatable balloon on the endotracheal tube was not below the tracheal injury and thus he could not secure the adequate airway that you would require to maintain respiration.

(At this point, Mr. McCloy entered the hearing room.)

Mr. SPECTER. Dr. Perry, you mentioned an injury to the trachea.

Will you describe that as precisely as you can, please?

Dr. PERRY. Yes. Once the transverse incision through the skin and subcutaneous tissues was made, it was necessary to separate the strap muscles covering the anterior muscles of the windpipe and thyroid. At that point the trachea was noted to be deviated slightly to the left and I found it necessary to sever the exterior strap muscles on the other side to reach the trachea.

I noticed a small ragged laceration of the trachea on the anterior lateral right side. I could see the endotracheal tube which had been placed by Dr. Carrico in the wound, but there was evidence of air and blood around the tube because I noted the cuff was just above the injury to the trachea.

Mr. SPECTER. Will you now proceed to describe what efforts you made to save the President's life?

Dr. PERRY. At this point, I had entered the neck, and Dr. Baxter and Dr. McClelland arrived shortly thereafter. I cannot describe with accuracy their exact arrival. I only know I looked up and saw Dr. Baxter as I began the tracheotomy and he took a pair of gloves to assist me.

Dr. McClelland's presence was known to me at the time he picked up an instrument and said, "Here, I will hand it to you."

At that point I was down in the trachea. Once the trachea had been exposed I took the knife and incised the windpipe at the point of the bullet injury. And asked that the endotracheal tube previously placed by Dr. Carrico be withdrawn slightly so I could insert a tracheotomy tube at this level. This was effected and attached to an anesthesia machine which had been brought down by Dr. Jenkins and Dr. Giesecke for better control of circulation.

I noticed there was free air and blood in the right mediastinum and although I could not see any evidence, myself any evidence, of it in the pleura of the lung the presence of this blood in this area could be indicative of the underlying condition.

I asked someone to put in a chest tube to allow sealed drainage of any blood or air which might be accumulated in the right hemothorax.

This occurred while I was doing the tracheotomy. I did not know at the time when I inserted the tube but I was informed subsequently that Dr. Paul Peters, assistant professor of urology, and Dr. Charles Baxter, previously noted in this record, inserted the chest tube and attached it to underwater seal or drainage of the right pneumothorax.

Mr. DULLES. How long did this tracheotomy take, approximately?

Dr. PERRY. I don't know that for sure, Mr. Dulles. However, I have--a matter of 3 to 5 minutes, perhaps even less. This was very--I didn't look at the watch, I have done them at those speeds and faster when I have had to. So I would estimate that.

At this point also Dr. Carrico, having previously attached and assisting with the attaching of the anesthesia machine was doing another cut down on the right leg; Dr. Ronald Jones was doing an additional cut down, venous section on the left arm for the insertion of plastic cannula into veins so one may rapidly and effectively infuse blood and fluids. These were being done.

It is to Dr. Carrico's credit, I think he ordered the hydrocortisone for the President having known he suffered from adrenal insufficiency and in this particular instance being quite busy he had the presence of mind to recall this and order what could have been a lifesaving measure, I think.

Mr. SPECTER. Would you identify who Dr. Baxter is?

Dr. PERRY. Yes. Dr. Charles Baxter is, when I noted when I asked for the call, is an assistant professor of surgery also and Dr. McClelland.

Mr. SPECTER. And is Dr. McClelland occupying a similar position at Parkland Memorial Hospital as Dr. Baxter?

Dr. PERRY. That is correct.

Mr. SPECTER. Would you identify Dr. Jenkins?

Dr. PERRY. Dr. M. T. Jenkins is professor and chairman of the department of anesthesiology and chief of the anesthesia service, and Dr. Giesecke is assistant professor of anesthesiology at Parkland.

Mr. SPECTER. Have you now identified all of the medical personnel whom you can recollect who were present at the time the aid was being rendered to the President?

Dr. PERRY. No, sir; several other people entered the room. I recall seeing Dr. Bashour who is an associate professor of medicine and chief of the cardiology section at Parkland.

Dr. Don W. Seldin, who is professor and chairman of the department of medicine, and I previously mentioned Dr. Paul Peters, assistant professor of urology, and I believe that Dr. Jackie Hunt of the department of anesthesiology was also there, and there were other people, I cannot identify them, several nurses and several others.

Mr. SPECTER. Dr. William Kemp Clark arrived at about that time?

Dr. PERRY. Dr. Clark's arrival was first noted to me after the completion of the tracheotomy, and at this point, the cardiotachyscope had been attached to Mr. Kennedy to detect any electrical activity and although I did not note any, being occupied, it was related to me there was initially evidence of a spontaneous electrical activity in the President's heart.

However, at the completion of the tracheotomy and the institution of the sealed tube drainage of the chest, Dr. Clark and I began external cardiac massage. This was monitored by Dr. Jenkins and Dr. Giesecke who informed us we were obtaining a satisfactory carotid pulse in the neck, and someone whose name I do not know at this time, said they could also feel a femoral pulse in the leg. We continued external cardiac massage, I continued it as Dr. Clark examined the head wound and observed the cardiotachyscope. The exact time interval that this took I cannot tell you. I continued it until Dr. Jenkins and Dr. Clark informed me there was no activity at all, in the cardiotachyscope and that there had been no neurological or muscular response to our resuscitative effort at all and that the wound which the President sustained of his head was a mortal wound, and at that point we determined that he had expired and we abandoned efforts of resuscitation.

Mr. SPECTER. Would you identify Dr. Clark's specialty for the record, please?

Dr. PERRY. Dr. Clark is professor and chairman of the department of neurosurgery at the University of Texas Southwestern Medical School, and chief of the neurosurgical services at Parkland Hospital.

Mr. SPECTER. Now, you described a condition in the right mediastinum. Would you elaborate on what your views were of the condition at the time you were rendering this treatment?

Dr. PERRY. The condition of this area?

Mr. SPECTER. Yes, sir.

Dr. PERRY. There was both blood, free blood and air in the right superior mediastinum. That is the space that is located between the lungs and the heart at that level.

As I noted, I did not see any underlying injury of the pleura, the coverings of the lungs or of the lungs themselves. But in the presence of this large amount of blood in this area, one would be unable to detect small injuries to the underlying structures. The air was indicated by the fact that there was some frothing of this blood present, bubbling which could have been due to the tracheal injury or an underlying injury to the lung.

Since the morbidity attendant upon insertion of an anterior chest tube for sealed drainage is negligible and the morbidity which attends a pneumothorax is considerable, I elected to have the chest tube put in place because we were giving him positive pressure oxygen and the possibility of inducing a tension on pneumothorax would be quite high in such instances.

Mr. SPECTER. What is pneumothorax?

Dr. PERRY. Hemothorax would be blood in the free chest cavity and pneumothorax would be air in the free chest cavity underlying collapse of the lungs.

Mr. SPECTER. Would that have been caused by the injury which you noted to the President's trachea?

Dr. PERRY. There was no evidence of a hemothorax or a pneumothorax through my examination; only it is sufficient this could have been observed because of the free blood in the mediastinum.

Mr. SPECTER. Were the symptoms which excited your suspicion causable by the injury to the trachea?

Dr. PERRY. They were.

Mr. SPECTER. At what time was the pronouncement of death made?

Dr. PERRY. Approximately 1 o'clock.

Mr. SPECTER. By whom was death announced?

Dr. PERRY. Dr. Kemp Clark.

Mr. SPECTER. Was there any special reason why it was Dr. Kemp Clark who pronounced the President had died?

Dr. PERRY. It was the opinion of those of us who had attended the President that the ultimate cause of his demise was a severe injury to his brain with subsequent loss of neurologic function and subsequent massive loss of blood, and thus Dr. Clark, being a neurosurgeon, signed the death certificate.

Mr. SPECTER. In your opinion, would the President have survived the injury which he sustained to the neck which you have described?

Dr. PERRY. Barring the advent of complications this wound was tolerable, and I think he would have survived it.

Mr. SPECTER. Have you now described all of the treatment which was rendered to the President by the medical team in attendance at Parkland Memorial Hospital.

Dr. PERRY. In essence I have, Mr. Specter. I do not know the exact quantities of balance salt solutions or blood that was given. I mentioned the 300 mg. of hydrocortisone Dr. Carrico ordered and, of course, he was given oxygen under pressure which has been previously recorded. The quantities of substances or any other drugs I have no knowledge of.

Mr. SPECTER. In general you have recounted the treatment?

Dr. PERRY. That is correct.

Mr. SPECTER. Have you now stated for the record all of the individuals who were in attendance in treating the President that you can recollect at this time?

Dr. PERRY. Yes, sir; I have.

Mr. SPECTER. Will you now describe as specifically as you can, the injury which you noted in the President's head?

Dr. PERRY. As I mentioned previously in the record, I made only a cursory examination of the President's head. I noted a large avulsive wound of the right parietal occipital area, in which both scalp and portions of skull were absent, and there was severe laceration of underlying brain tissue. My examination did not go any further than that.

Mr. SPECTER. Did you, to be specific, observe a smaller wound below the large avulsed area which you have described?

Dr. PERRY. I did not.

Mr. SPECTER. Was there blood in that area of the President's head?

Dr. PERRY. There was.

Mr. SPECTER. Which might have obscured such a wound?

Dr. PERRY. There was a considerable amount of blood at the head of the cartilage.

Mr. SPECTER. Would you now describe as particularly as possible the neck wound you observed?

Dr. PERRY. This was situated in the lower anterior one-third of the neck, approximately 5 mm. in diameter.

It was exuding blood slowly which partially obscured it. Its edges were neither ragged nor were they punched out, but rather clean.

Mr. SPECTER. Have you now described the neck wound as specifically as you can?

Dr. PERRY. I have.

Mr. SPECTER. Based on your observations of the neck wound alone, do you have a sufficient basis to form an opinion as to whether it was an entrance wound or an exit wound,

Dr. PERRY. No, sir. I was unable to determine that since I did not ascertain the exact trajectory of the missile. The operative procedure which I performed was restricted to securing an adequate airway and insuring there was no injury to the carotid artery or jugular vein at that level and at that point I made the procedure.

Mr. SPECTER. Based on the appearance of the neck wound alone, could it have been either an entrance or an exit wound?

Dr. PERRY. It could have been either.

Mr. SPECTER. Permit me to supply some additional facts, Dr. Perry, which I shall ask you to assume as being true for purposes of having you express an opinion.