In October 2018 I was lucky enough to attend the Emergency Nurses Association conference in Pittsburgh, PA. By FAR my favorite session there was Assassinations Throughout History: Would They Survive Today, originally given by Joseph Blansfield. As a trauma junkie, the idea that modern medicine has evolved to a place where even some of the most deadly assassinations could actually be saved peaked my interest. The injuries sustained by the following well-known men rendered them dead at the time of their occurrence. But if they were injured in the exact same manner today…could we save them?
James Garfield
Septicemia in the Trauma Patient
“Things don’t turn up in this world until somebody turns them up.” – James Garfield
James Garfield was the 20th president of the United States and likely not a president you’ve heard a whole lot about. This is mostly due to the fact that 4 short months into his presidency, Garfield was assassinated making him the 2nd US president to be killed while in office. There are, to date, four US presidents who have been assassinated; the 1st being Abraham Lincoln (1865) followed by Garfield, William McKinley (1901) and John F. Kennedy (1963).
Garfield was born November 19th, 1831 and was elected into office in March 1881. His real claim to fame (aside from being assassinated) is that he was the 1st sitting member of Congress to be elected into the role of president and, to this day, remains the only sitting House of Representatives member to become President. Garfield took over office kind of against his will, so the story goes. He was allegedly pushed into becoming president but really didn’t want the job even though he came to office in a peaceful time in American history (post-Civil War).
Garfield was shot on July 2nd, 1881 while at a train station by Charles Guiteau who was a crazy dude who stalked the White House attempting to find a job there. Guiteau felt that because of his own hard work, Garfield had won the American presidency; therefore, he was now owed a position in the WH. When he was banned from the White House all together, he kicked his wacko status up a notch and decided it was his mission to murder James Garfield. He finally got his chance that summer day and shot Garfield twice, once in the shoulder and once in the back. These shots, however, were not fatal.
Fun fact: Present that day at the train station when the assassination occurred was Robert Todd Lincoln, former president Abraham Lincoln’s son. Ironic, yes?
Immediately after Garfield was shot, he was taken back to the White House where a team of 15 physicians led by Dr Willard Bliss (surgeon) inserted ungloved fingers into his torso wound in an attempt to extract the bullet [to be fair, some used gloves but NOT sterile ones]. This resulted in increased internal bleeding, not to mention MASS infection. In the following weeks, James Garfield experienced high fevers, massive amounts of weight loss and was unable to hold down any oral hydration. His team of physicians even gave him nutrient enemas mixed with alcohol and opiates…how generous.
On July 23rd, Garfield spiked a high fever and began to show signs of worsening. Dr Willard Bliss elected to take Garfield to surgery where he was able to drain an abscess around his wound and place a drain to help remove more of the infection. He also, however, took this opportunity to further probe the wound with his fingers in an attempt to again remove the bullet. This was unsuccessful. Oh and this entire surgery…you guessed it, was NOT done under sterile conditions.
Garfield miraculously had a period of improvement for a while and was even able to complete some of his presidential duties again. Unfortunately, he soon worsened and on September 5th he was relocated to a beautiful seaside mansion in New Jersey so he could live out the rest of his days in peace. On September 19th, Garfield suddenly complained of severe chest pain and then went unconscious. He died approximately 25 minutes later and officially became the 2nd president of the United States of America to be assassinated.
Fun fact: Charles Guiteau was the first defendant to use the insanity plea. He was found guilty anyway and hung June 30th, 1882.
Across the pond, some huge discoveries were being made by a man named Joseph Lister, a British surgeon who is now commonly known as the “Father of Modern Surgery”. Lister was a pioneer of antiseptic surgery, commonly using carbolic acid (also known as phenol) to sterilize his instruments used in surgery. Because of his intuition and research, we now know how important sterile technique is in the care of all trauma patients.
Changes in care today: Sterile technique is used in all operating rooms and with many invasive procedures done in the trauma care setting.
Fun fact: Listerine, the common household mouthwash, is named after Joseph Lister.
Did you know that the most common cause of late death in a trauma patient today is sepsis? According to the Mayo Clinic website, sepsis is defined as “a potentially life-threatening condition caused by the body’s response to an infection which causes an imbalance of chemicals in the body resulting in damage to multiple organ systems.” AKA: not good. As emergency care providers, we move quickly and focus on the task immediately in front of us, especially in the face of a complex trauma. What we may not think about: 5 days down the road when the Foley catheter that we placed under less than sterile technique causes a massive urine infection resulting in sepsis that kills our patient. What is the point of putting all of our resources and work into saving someone if we are just delaying their death by a few days because of our negligence?
As emergency department staff, we have tons of opportunities to introduce contamination into our patient. Being cognizant of the consequences of our actions will lead to better overall care of the patient which will help set them up for success in their healing process. Special consideration should be taken when ED or surgical staff:
– place a Foley catheter
– place a chest tube or other wound drains
– place a central line or access peripheral IVs
USE STERILE TECHNIQUE!!! It is not the ER way to pull short cuts and throw sterile technique by the wayside. That is crappy, lazy ER care and should never be considered the standard just because it is an ER and not an OR. I’ll say it louder for the people in back: YOUR ACTIONS HAVE HUGE CONSEQUENCES.
Changes in care today: Close attention to the monitoring and auditing of CAUTIs (catheter associated urinary tract infections) and CLABSIs (central line associated blood stream infections) is done routinely. At most hospitals, in fact, there are specific committees and teams dedicated to lowering the numbers of these infections by auditing charts, creating new policies and educating staff.
Wound care is another huge part of improving trauma care today. There are enormous amounts of research out there indicating that special consideration needs to be taken if a patient has an open wound associated with a fracture OR if a wound to the abdomen has likely resulted in a perforation of gastric contents. If a patient needs surgery after a traumatic incident, which they usually will, this is another type of trauma [albeit more organized and controlled] on top of the original trauma.
Another consideration that is now known, is the fact that a trauma patient’s body cannot defend itself like a healthy person’s could. After trauma, the number of leukocytes, monocytes and T cells (all different types of white blood cells…you know, the ones that fight infection) are significantly reduced. Post trauma, phagocytosis function lowers [think back to science class…this is the process of attracting white blood cells to the area of infection where they will essentially “eat” the infectious agent]. This sets the patient up for a difficult fight anyways so doing our part to protect our patient is vital. As a healthcare provider, you always protect and advocate for your patient; educate yourself on all the quietly hidden dangers of trauma. It isn’t always all about blood, guts and adrenaline.
Changes in care today: When a trauma patient presents to the emergency department, we now know that early blood/wound culture obtainment, antibiotic therapy and wound cleansing is super important. Time is of the essence and special attention is now paid to these interventions.
Fun fact: If a patient has to have a splenectomy [removal of the spleen], their risk for infection goes way up.
During Dr Willard Bliss’ team’s care of James Garfield, many attempts were made to remove the bullet from Garfield’s wound. One technique was done by none other than Alexander Graham Bell who utilized a metal detector to attempt to find the bullet. Buzz kill: it didn’t work.
Changes in care today: X-ray machines were invented in 1895 [14 years too late for Garfield] which have the capability of visualizing metal in the human body without any invasive procedures.
In conclusion, James Garfield’s bullet wounds were not fatal. One was an in and out wound to the shoulder resulting in nothing more than soft tissue damage. The second was a shot to the back which transversed his L-1 vertebrae and lodged behind his pancreas hitting NO major organs or vasculature. President James Garfield died of bilateral pneumonia and multiple abdominal abscesses resulting in systemic sepsis. Would he live if he sustained these same wounds today? Simple answer: absolutely.
Historical Travels <3