Help Needed

[Bob Prudhomme]

Is agonal breathing effective enough to get air down to the wound site on the trachea? If so, that might explain the presence of bloody air bubbles. (I'm not arguing with your main thesis, here, just trying to make sure the observations of the doctors you point out are in fact probative of it.)

This has puzzled me before: Why 2 chest tubes? If only 1 lung was "bruised" into pneumothorax, what medical benefit is cutting the patient open for the other lung? I'm guessing that the mere medical necessity of a second chest tube suggests more extensive damage to the entire lung area, than "a near miss to one lung" by the "pristine bullet".

I was puzzled by the insertion of two chest tubes (left and right) as well, until a doctor explained things to me.

First off, the only indications Perry had of a possible pneumothorax were 1) deviation of the trachea to the left and 2) air bubbling in the mediastinum.



From Wikipedia:

"The mediastinum lies within the thorax and is enclosed on the right and left by pleurae. It is surrounded by the chest wall in front, the lungs to the sides and the spine at the back. It extends from the sternum in front to the vertebral column behind, and contains all the organs of the thorax except the lungs. It is continuous with the loose connective tissue of the neck."

The wound site in JFK's trachea would have been open to the atmosphere through the accompanying wound in his neck. When JFK drew breath in (even if it was only agonal breathing toward the end) this would act as a tracheotomy site and allow air to enter the trachea through these wounds. When he exhaled, the air that did not go out his mouth and nose would escape through the trachea wound. However, as the wound in his throat allowed this exhaled air access to the atmosphere, it had no chance of building up any pressure in the mediastinum. The bubbles seen by Perry were most likely originating from built up air pressure due to pneumothorax caused by a bullet. Knowing this, Perry requested the insertion of bi-lateral chest tubes.

As to why Perry inserted two chest tubes, instead of just one in the right cavity (as would be indicated by the leftward deviation of the trachea), it must be remembered that Perry had no idea of how many times JFK had been shot, or the full extent of the damage to his lungs. While it may have presented as solely a pneumothorax in the right lung, the left lung could also be damaged, but to a lesser degree. As soon as assisted ventilation was begun, air would be forced into JFK's lungs at greater than atmospheric pressure, quickly exacerbating any pneumothoraces present.

Simply put, the placement of a chest tube, plus the connection to sealed water drainage, is a very quick procedure and, considering the benefits (plus the liability if one is needed and not put in) it is cheap insurance against the unknown to put tubes in both sides.