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[Drew Phipps]

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".

[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.

[Bob Prudhomme]

An overwhelming number of the ER staff at Parkland reported that not only were bi-lateral chest tubes inserted into both of JFK's pleural cavities, they were also connected to sealed water drainage, as was the standard practice for continued relief of tension pneumothoraces. As I stated in my last post, this is a fairly quick procedure and, as there were doctors working on each chest tube, it is possible they would have been finished this task before Perry had completed the tracheostomy and subsequent intubation.

It is therefore somewhat puzzling to read the autopsy report, and see Humes describe very shallow subcutaneous (barely beneath the skin) bi-lateral incisions in JFK's upper chest. In the autopsy report, he describes these as incisions to relieve subcutaneous emphysema, a non-life threatening condition never reported by a single physician at Parkland Hospital, and not apparent at all in any of the autopsy photos.

This is the only time Humes ever describes these incisions as treatment for subcutaneous emphysema. After this, he always recognizes them as the beginnings of incisions for the purpose of inserting chest tubes. However, this is almost as laughable as his "subcutaneous emphysema" story, considering that, once the subcutaneous incisions were made, they were only one or two scalpel strokes away from entering the pleural cavity and completing the procedure. If something stopped the two teams of doctors that were making the incisions at this point, doesn't it seem odd that both teams were so synchronized, they were stopped at exactly the same point in the procedure?

Humes lied.

[Drew Phipps]

Can air in the pleural cavity (which includes the lungs) travel to the mediastinum (which does not) and vice versa, or does the parietal pleura prevent this?

[Bob Prudhomme]

Can air in the pleural cavity (which includes the lungs) travel to the mediastinum (which does not) and vice versa, or does the parietal pleura prevent this?

Yes. With damage to the lung typically including a massive and localized rupture of alveoli, built up air pressure in the pleural cavity is able to track back around the outside of blood vessels and the bronchi into the mediastinum. This is assuming, of course, that the parietal pleura is intact, and still maintaining a barrier between the pleural cavity and the mediastinum. A compromise here will also allow air from a pneumothorax to enter the mediastinum.

The build up of air in the mediastinum is referred to as a "pneumomediastinum".

[Drew Phipps]

Would a hole in the parietal pleura imply a second wound track?

[Bob Prudhomme]

Would a hole in the parietal pleura imply a second wound track?

It could but, it could also be a result of a bullet breaking up, and the resulting cone of damage from energy being transferred to surrounding tissues. The right lung is quite narrow at its apex, as seen below.

[Bob Prudhomme]

Pictured below is the "hilum" of the lungs, through which the bronchi and major blood vessels pass from the mediastinum to the pleural cavities and the lungs.



It is easier to see, from this diagram, how air pressure built up in the pleural cavity can leak into the mediastinum, and why Perry called for the insertion of chest tubes to relieve this pressure, after he saw air bubbles in the mediastinum.

[Drew Phipps]

second wound track

is not the same as "second bullet" track.

[Bob Prudhomme]

second wound track

is not the same as "second bullet" track.

Did you mean a track from a fragment of the original bullet?