‘He Groaned, His Knees Buckled . . . He Collapsed’ : Politics: A firsthand account of President Ronald Reagan’s shooting shows the tension--and humor--of his medical care. It also reignites questions about relieving a leader of power.

Ben Aaron was watching the blood pour out of Ronald Reagan’s chest, more than a cup of it every 15 minutes. Unlike the bright hue of freshly oxygenated blood, this blood was a dark ruby color--”ominously dark,” Aaron thought.

It was a rainy afternoon on March 30, 1981, and Dr. Benjamin Aaron, chief of cardiothoracic surgery at George Washington University Hospital, was “concentrating mightily” on the medical problem--not the person--in front of him.

Still, there was no denying that the patient on the gurney was in fact the President of the United States.

“In the back of my head, this little voice kept saying, ‘Don’t screw up on this one!’ That went through my mind a lot,” Aaron recalls now.

In today’s edition of the Journal of the American Medical Assn., Aaron and his hospital colleague, Dr. S. David Rockoff, offer “the only authoritative, firsthand account” of Reagan’s medical care after the 1981 assassination attempt.

The account varies little from many previous reports, but it does provide new details about Reagan’s irrepressible humor (even while on a ventilator), his brush with hepatitis from possibly contaminated blood, and his surgeon’s concern about public reaction to the idea of leaving a bullet in a President’s chest.

While Aaron and Rockoff do not mention the controversy that developed later over their famous patient’s ability to govern, their report also reignites the debate over how and when a disabled leader should be relieved of power.

As testimony to the growing urgency of such questions, JAMA editors frame the medical report on Reagan’s gunshot wound with an extraordinary set of commentaries and editorials on the vulnerability of U.S. Presidents and the national need for better ways to deal with an incapacitated President.

“The problem is not simply hypothetical,” writes former President Jimmy Carter in a special essay for the medical journal. “We must find a better way.”

For Carter and other contributors to the JAMA debate, one way might be to create an independent panel of medical experts to decide when a President is not fit to govern.

According to Carter, who once fainted in office from exhaustion, the possibility of a U.S. President becoming disabled--particularly by a neurological illness--presents a “continuing danger to our nation.”

*

Less than 10 minutes after Reagan; his press secretary, Jim Brady, and two others were ambushed outside the Washington Hilton, the President walked through the triple glass doors of the George Washington University Hospital emergency room.

No one--including the President--believed that he had been shot, only that he had been injured during the getaway from the chaotic scene.

“I feel I can’t catch my breath,” he told the nurses rushing toward him. His teeth were stained with blood and he was gasping for air.

“He groaned, his knees buckled, and he began to fall. . . . He dropped to one knee. He then collapsed and was carried to the trauma room,” according to the doctors’ report.

“When he came in, his blood pressure was nonexistent,” Aaron said in an interview this week. At first, doctors and nurses believed Reagan was having a heart attack. Not until his expensive blue suit and monogrammed shirt were cut away did it become clear that he had been shot. Beneath his left armpit was a buttonhole-like slit in the skin--the entry wound of the bullet.

The emergency room team began giving Reagan oxygen, intravenous fluids and type O Rh-negative blood from the hospital’s blood bank. Before the day was over, the President would receive almost four quarts of blood--more than half his body’s supply. It was not until April 4 that a federal laboratory reported that some of the blood Reagan received was “suspicious” for hepatitis B contamination.

“The screens we were running in the hospital in those days showed none of that,” Aaron told The Times. “Of course, until late 1984 or early 1985, there was no test for HIV either. All our blood was Red Cross-certified, and nobody seemed especially surprised that these extraordinary (additional) tests turned up some suspicions.”

To head off the hepatitis, Aaron injected the President with gamma globulin and hyperimmune beta globulin.

The more immediate concern for doctors was their inability to explain and control the bleeding inside Reagan’s chest at least twice during his hospital stay.

Even after the President’s injured lung had been re-expanded in the ER, the bleeding continued. X-rays taken by Rockoff, the hospital’s radiology chief, showed the bullet had lodged near the heart. “A decision had to be made about whether to operate,” Aaron said.

Deciding to perform exploratory surgery on a 70-year-old gunshot victim is never easy. When the patient is the leader of the Free World, it can be excruciating.

“I explained the reasons for going to the OR to Mrs. Reagan and to the President,” Aaron said, “and they agreed.” Although obviously worried and still unable to breathe easily, Reagan issued the most memorable of the many one-liners he would utter after the shooting.

Looking up at one of his surgeons, Reagan said: “Please tell me you’re a Republican.” The surgeon--an avowed Democrat, according to Aaron and Rockoff, answered: “Today, Mr. President, we’re all Republicans.”

(Later in the recovery room, Reagan would entertain his nurses with notes scribbled on a clip pad of pink paper. Despite his disorientation and the ventilator tube in his throat, Reagan quoted W.C. Fields, Winston Churchill and even some of his own lines as an actor.)

But as surgery entered its second, and then its third hour, with the bullet still somewhere in the President’s chest, the mood in the operating room was heavy. “With bleeding slowed and mounting anesthetic time, some consideration was given to closing the chest with the bullet in place,” Aaron and Rockoff report in JAMA.

It is not unusual to leave bullets behind, especially when the victim is stable.

Those in favor of leaving the bullet in Reagan’s chest--at least initially--included Reagan’s then-personal physician, Dr. Daniel Ruge. “I was in the OR at the time, and we did discuss this, but I felt I did not want to push (Aaron) into anything because he was the surgeon in charge,” Ruge told The Times in an interview this week.

But Aaron, who argued for removal, says he was concerned that the bullet might migrate into an artery or the heart.

Surprisingly for a physician, say some ethicists, Aaron also was motivated by “the obvious importance of obtaining the bullet for ballistics tests and as evidence in court.”

Then there was the “public perception” problem.

According to Aaron and Rockoff, “A less important and non-medical consideration for continuing (the surgery) was the perception that to leave a would-be assassin’s bullet in the chest of the President of the United States might be poorly accepted by the public.

“Fortunately, the bullet was found a short time later.”

*

As the world knows, Reagan went on to enjoy a full recovery. Or did he?

“There is no question that neurological disorders can be traced back to other medical problems,” Ruge said Monday.

Although he does not dispute the recent revelation that Reagan has Alzheimer’s disease, Ruge said failing memory can be attributed to other factors as well.

He says that Reagan’s fall from a horse and resulting subdural hematoma, and the anesthetics he had for prostate and colon surgeries all could have been factors.

“I do think something that happened a long time ago can have an effect later on. The loss of blood after the shooting, the period when his blood pressure fell to dangerous levels, certainly that may have contributed to his symptoms now,” said Ruge, now a retired neurosurgeon who was tapped for presidential duty after a long association with Nancy Reagan’s stepfather, Dr. Loyal Davis.

But neither Ruge, Aaron nor Rockoff believe that Reagan’s mental health showed any impairment immediately after the shooting.

“I would have to concede that he was not in a position to lead the country while he was under anesthesia during and immediately after the surgery,” Aaron said. “But if he was intellectually unstable at any other times, I know we would have heard about it.”

Dr. Herbert Abrams, a Stanford University scholar and author on presidential disability, disagrees.

He notes that Reagan’s doctors never formally evaluated his mental capacity, relying instead on routine doctor-patient conversation to assess his competence.

“You cannot assess cognitive capability by asking a person if he’s feeling well and if his bowels are moving,” Abrams said. “As for the humor, I do believe that Ronald Reagan could tell a joke in his sleep. That doesn’t have much to do with how a President makes the complex decisions of state.”