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Guns Part 4: Moral Hazard · Revisionist History

0:15
Speaker 1: Pushkin Midnight, June fifth, nineteen sixty eight. Robert F. Kennedy
0:25
Speaker 1: is running for the Democratic presidential nomination. He's just been
0:28
Speaker 1: declared the winner of the California primary. He's now the
0:31
Speaker 1: front runner. The White House is in his sights.
0:35
Speaker 2: I want to express my gratitude to my dog, Freckles,
0:41
Speaker 2: who has been the line. I don't care what they
0:45
Speaker 2: say about me, but when they start to attack my dog.
0:50
Speaker 2: And I'm not doing this in the order of importance,
0:52
Speaker 2: but I also want to thank my wife, Beth full.
1:11
Speaker 3: And her patience during this whole effort is.
1:16
Speaker 2: Fantastic. Thank you very much. The Freckles has.
1:21
Speaker 3: Gone home to bed.
1:23
Speaker 2: He thought very early that we were going to win,
1:25
Speaker 2: so he retired.
1:27
Speaker 1: You can hear the supporters packing the room despite the
1:30
Speaker 1: hour and the sweltering heat.
1:34
Speaker 2: Hey, hey, hey, I want.
1:36
Speaker 4: To hear really loud.
1:38
Speaker 2: Boom's gonna be the next president of United States.
1:48
Speaker 3: Hey, here's a bad lessen.
1:54
Speaker 1: He leaves the stage out to the kitchen, pauses to
1:57
Speaker 1: shake the hand of a bus boy, and out of nowhere,
2:00
Speaker 1: a young man emerges holding a twenty two caliber revolver
2:04
Speaker 1: eight shots. Boom boom, boom, boom, boom boom, boom boom.
2:09
Speaker 1: It's chaos. You can hear it, can't you. There's a
2:12
Speaker 1: photograph of this moment. Kennedy sprawled on the ground, the
2:16
Speaker 1: bus boy crouched by his side, his face turned to
2:19
Speaker 1: the camera, picture of anguish.
2:23
Speaker 2: I don't know, I can't what happened to you know,
2:26
Speaker 2: nobody might.
2:27
Speaker 1: Have been shown.
2:30
Speaker 2: I'm not Jimmy plugged in. Jimmy plugged in. Please day back,
2:42
Speaker 2: everybody else, just please day back. Just a doctor come
2:44
Speaker 2: right here.
2:45
Speaker 5: Let's roll some videotape on this sat here for him.
2:48
Speaker 2: Some reason, would a doctor come right here? A doctor here,
2:56
Speaker 2: doctor right here.
2:57
Speaker 1: I'm not calling pay the video. My name is Malcolm Gobwell.
3:02
Speaker 1: You're listening to Revisionist History, my podcast about things overlooked
3:06
Speaker 1: and misunderstood. This episode is part four of our investigation
3:11
Speaker 1: of the messed up way Americans talk about guns. The
3:14
Speaker 1: Supreme Court just issued one of the most important gun
3:17
Speaker 1: rights cases in its history, and devoted pages to the
3:21
Speaker 1: fourteenth century, the seventeenth century, the eighteenth century, the nineteenth century,
3:26
Speaker 1: the Civil War, reconstruction, the Constitutional Convention, and an obscure
3:31
Speaker 1: disputatious merchant from Bristol, But nothing about the present day,
3:36
Speaker 1: as if the crisis of gun violence on our streets
3:39
Speaker 1: is beside the point. We get our ideas about guns
3:43
Speaker 1: from a television western written by screenwriters from Hollywood whose
3:47
Speaker 1: understanding of the American frontier is one hundred percent backwards.
3:51
Speaker 1: It's all a little weird, and in this episode, I
3:56
Speaker 1: want to offer an explanation for how things got so weird.
4:00
Speaker 1: One I think gets missed, that is, except by the
4:03
Speaker 1: people who treat gunshots for a living. Oh I see, okay, okay,
4:11
Speaker 1: So let's walk through what happens. Sir He Sir hen
4:16
Speaker 1: Is comes up to Kennedy backstage at the Ambassador Hotel
4:22
Speaker 1: and fires eight shots from a twenty two caliber revolver,
4:27
Speaker 1: three of which hit Senator Kennedy, right, that's our understanding, Yes,
4:33
Speaker 1: Jordan commisero trauma surgeon at Duke University. Where so where
4:38
Speaker 1: do those bullets go?
4:40
Speaker 6: So the bullet that that struck him in the head
4:46
Speaker 6: hit right behind his right ear sort of if you
4:51
Speaker 6: feel everyone has like a little bit of a bony prominence,
4:54
Speaker 6: so roughly around there, and the other two struck him
5:00
Speaker 6: in the axilla, and they think the chest. Although it
5:05
Speaker 6: would seem that from the accounts of the thoracic surgeons
5:08
Speaker 6: as they really laid them, those were of minimal consequence.
5:15
Speaker 1: Yeah, it's really the headshot that we're concerned with. Yes,
5:20
Speaker 1: and have you in your experience? Have you ever We'll
5:25
Speaker 1: come back to this, but I'm just curious whether you
5:27
Speaker 1: ever treated an analogous gunshot wound.
5:30
Speaker 2: To the head.
5:30
Speaker 1: Yes, you have. Yes, When a bullet strikes you behind
5:34
Speaker 1: the ear, what happens.
5:38
Speaker 6: Largely these are mostly fatal injuries.
5:42
Speaker 1: By the next morning, Kennedy was dead. I want you
5:46
Speaker 1: to imagine what would happen if Kennedy were shot today.
5:52
Speaker 1: One of the iron laws of medicine is that the
5:55
Speaker 1: more you treat a condition, the better you get it
5:57
Speaker 1: curing it. Practice makes perfect, You develop your skills, you
6:02
Speaker 1: start to anticipate anomalies and variations. You're more motivated to
6:05
Speaker 1: try new ideas, introduce new techniques, develop new technologies. And
6:10
Speaker 1: nowhere is that iron law more in evidence in the
6:13
Speaker 1: United States than when it comes to the treatment of
6:16
Speaker 1: gunshot wounds. If you're an American trauma surgeon, you get
6:20
Speaker 1: a lot of practice. World War One, World War Two, Korea, Vietnam, Iraq,
6:26
Speaker 1: on Iraq to Afghanistan. Every generation of trauma surgeon got
6:31
Speaker 1: a war of their own, the best kind of crash course.
6:34
Speaker 1: Then they come home to the other war, the one
6:37
Speaker 1: in the streets. This is an area of genuine American expertise.
6:44
Speaker 1: I was curious about this, so I went to see
6:47
Speaker 1: a man named Edward Cornwell. Third.
6:50
Speaker 7: I got to Hopkins in nineteen ninety eight as the
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Speaker 7: chief of Trauma, and my experience had been nine years
7:01
Speaker 7: at La County Hospital, which was among the busiest trauma
7:04
Speaker 7: centers in the country, five as a surgical.
7:07
Speaker 1: Resident around and everyone told me that if you ever
7:11
Speaker 1: got shot, Eddie Cornwall was your best hope for coming
7:13
Speaker 1: out in one piece. Mid sixties fit a little hint
7:17
Speaker 1: of Patrician about him. He grew up in Washington, d c.
7:21
Speaker 1: Trained at USC Medical School, and worked there in the
7:23
Speaker 1: nineties South Central in the middle of the crack epidemic.
7:27
Speaker 1: He opened the trauma center at Johns Hopkins University in
7:30
Speaker 1: nineteen ninety eight. Other American cities had seen a decline
7:34
Speaker 1: in a murder rate by that point, but not Baltimore.
7:37
Speaker 7: We have a protected conference that takes place every Department
7:40
Speaker 7: of surgery does so called morbidity immortality conference. We talked
7:43
Speaker 7: about every patient that died or had a complication in
7:46
Speaker 7: the prior week, and I showed that a table where
7:50
Speaker 7: we have five consecutive days on our trauma service, where
7:54
Speaker 7: every single day a twenty year old died gunshot to
7:57
Speaker 7: the chess dead on arrival, gunshot to the chess, dead
8:00
Speaker 7: on arrival, stab wounto the chess erthor ecademy. You need
8:03
Speaker 7: to have time to go to the operating rooms, literally
8:05
Speaker 7: opened their chests in the emergency department, declared dead. Five
8:09
Speaker 7: different surgeons, including myself. One day, a whole basketball team
8:12
Speaker 7: of twenty year olds essentially dead in the emergency department,
8:16
Speaker 7: prompting us to identify that we had this dramatic increase
8:21
Speaker 7: in the brazen nature of gunshot wounds more to the
8:24
Speaker 7: head or the chest or both.
8:27
Speaker 1: Then Cornwall came home to DC, once known as the
8:30
Speaker 1: murder capital of the United States, to head the trauma
8:33
Speaker 1: center at Howard.
8:35
Speaker 7: It's interesting I did my residency at La County Hospital,
8:39
Speaker 7: this huge eighteen story structure. I had a fifteen floor
8:43
Speaker 7: elevator ride from the er to the operating room in
8:47
Speaker 7: La County, and I was glad for it sometimes because
8:50
Speaker 7: I'm think should I go on the right chest, should
8:53
Speaker 7: I go on the left chest? Should I go on
8:54
Speaker 7: his abdomen? Then I get the Hopkins I had a
8:56
Speaker 7: seven floor elevator ride, shorter timeframe. I'm here, I have
9:00
Speaker 7: two floor elevator rights. So the more expert I was,
9:02
Speaker 7: the shorter the elevator ride. I was glad I had
9:04
Speaker 7: a fifteen floor elevator R. But by the time I
9:06
Speaker 7: get to Hopkins, I'd seen it all, so I didn't
9:09
Speaker 7: he need a fifteen seven floors is fine. I had
9:11
Speaker 7: two floors.
9:12
Speaker 1: Here South Central East Baltimore, Central Washington. I mean I
9:18
Speaker 1: spent a morning with him at the hospital with a
9:20
Speaker 1: colleague of his, a next Army surgeon named Mallory Williams.
9:24
Speaker 1: It was a Tuesday. He'd worked the weekend and operated
9:27
Speaker 1: on two kids, nineteen and twenty who'd been in a
9:30
Speaker 1: gun battle.
9:31
Speaker 7: I take the nineteen year old to the operating room.
9:33
Speaker 7: He's clearly tender, he clearly has evidence of contamination. To
9:37
Speaker 7: go to the operating room, spend three and a half
9:38
Speaker 7: hours doing the things that I mentioned, the liver, the stomach,
9:41
Speaker 7: small and testain coal in the record, but let's still
9:43
Speaker 7: lease that out well, let me just say one last
9:46
Speaker 7: thing about him, because it's like wild wild West. In retrospect,
9:49
Speaker 7: it becomes obvious to me that one bullet enters here
9:53
Speaker 7: and goes through his stomach his liver is large intestine,
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Speaker 7: and goes out here. Another bullet enters in his upper
10:01
Speaker 7: gluteus buttocks and goes across the ouven and hits some
10:04
Speaker 7: small intestinal injuries, bounce off the pelvic That bullet is
10:08
Speaker 7: deformed and lodge's abdominal wall.
10:11
Speaker 1: But while he's treating the nineteen year old, he's worrying
10:14
Speaker 1: about the twenty year old because there must be something
10:16
Speaker 1: going on between the two of them, right, And now
10:19
Speaker 1: the two of them are in the same hospital.
10:22
Speaker 7: I made sure that the other kid doesn't go to
10:24
Speaker 7: the IC where which typically put these patients, because I
10:26
Speaker 7: don't want the two families down there.
10:28
Speaker 6: You know, I see you.
10:30
Speaker 3: You know.
10:30
Speaker 7: So we have them remote locations in the hospital from
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Speaker 7: each other.
10:34
Speaker 1: Do that for forty years and learn from all the
10:36
Speaker 1: other trauma surgeons around the country who are doing the
10:39
Speaker 1: same thing, and you get good. Yeah, what's what flaw
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Speaker 1: a medical standpoint? What would you looking forward? What is
10:49
Speaker 1: the hypothetically if I gave you if I was a
10:53
Speaker 1: if I gave you a wish, I said you could,
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Speaker 1: you could, you could solve one problem in your field
11:00
Speaker 1: that would.
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Speaker 7: Well reduce gun gun deaths.
11:03
Speaker 1: No, no, I mean what's in your Yeah, they would
11:07
Speaker 1: reduce gundest So what medically speaking, what is one one
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Speaker 1: medical trick that you could I could give you that
11:15
Speaker 1: would have the biggest impact on how many people die
11:17
Speaker 1: from a gun shoggler?
11:18
Speaker 7: My trick wouldn't be medical. Yeah, it's not medical for me.
11:22
Speaker 7: It would be two parents in every home. That almost
11:25
Speaker 7: sounds today to say that today it sounds you might.
11:30
Speaker 1: Say that you think we have progressed as far as
11:38
Speaker 1: you think we're We've done most. We've got most of
11:40
Speaker 1: the low hanging flute in terms of how to save
11:43
Speaker 1: somebody once they arrive.
11:44
Speaker 7: Yeah, I got some slize of share there, but I
11:48
Speaker 7: don't think we have another peak in my lifetime. So
11:51
Speaker 7: once you get to ninety five percent, there aren't any
11:54
Speaker 7: The fruit is high up on the tree, right.
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Speaker 1: That's how good trauma surgeons are now. They're looking for
12:02
Speaker 1: solutions outside the hospital. Now, think about the implications of
12:07
Speaker 1: that in a place like Washington, DC. In the last
12:10
Speaker 1: thirty years, the number of homicides in Washington in a
12:13
Speaker 1: typical year has been cut in half. People look at
12:17
Speaker 1: that statistic and say, oh, the city's gotten a lot safer,
12:20
Speaker 1: But isn't some part of that decline simply that Eddie
12:24
Speaker 1: Cornwall and Malory Williams and all the other trauma surgeons
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Speaker 1: of Washington, DC are now saving lives that were once lost.
12:32
Speaker 1: A city's murder rate is not a measure of the
12:35
Speaker 1: number of people victimized by potentially lethal violence. No, it's
12:39
Speaker 1: a measure of the number of people victimized by potentially
12:43
Speaker 1: lethal violence minus how good a job doctors do at
12:47
Speaker 1: saving that person's life once they get to the hospital.
12:51
Speaker 1: So how important is the second half of that equation?
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Speaker 1: Do people like Eddie Cornwall move the needle on homicide
12:58
Speaker 1: rates a lot or just a little? Which is why
13:02
Speaker 1: when I got back from DC, I called up Jordan Commissera,
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Speaker 1: trauma surgeon at Duke University, to talk about the assassination
13:10
Speaker 1: of Robert Kennedy, because it seemed like looking at Kennedy's
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Speaker 1: injuries through the lens of the present day would be
13:17
Speaker 1: a good way to try and answer this question. There
13:30
Speaker 1: is a long tradition among trauma surgeons of speculating about
13:34
Speaker 1: which famous shooting of a political figure would have turned
13:37
Speaker 1: out differently given today's medical nohow. If you flip through
13:41
Speaker 1: trauma surgery journals, you can find all kinds of examples.
13:45
Speaker 1: By the way, you can't play this game if you're
13:48
Speaker 1: a trauma surgeon in Canada because they've never had any
13:51
Speaker 1: of their leaders assassinated, or England because they've had just one.
13:55
Speaker 1: France had one president's stab to death in eighteen ninety four,
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Speaker 1: and in nineteen thirty two, President Paul Dumaer was gonned
14:02
Speaker 1: down by a Russian anarchist. Germany not really no one
14:06
Speaker 1: major unless you want to count the killing of the
14:08
Speaker 1: Form Minister in nineteen twenty two. But in the United
14:11
Speaker 1: States you can play this game for days. You've got
14:16
Speaker 1: Abraham Lincoln in eighteen sixty five, shot to the head
14:19
Speaker 1: from a forty four derringer pistol. Does he live today?
14:23
Speaker 1: A couple of years ago, a group of neurosurgeons at
14:25
Speaker 1: Brigham and Women's Hospital in Boston re examined his autopsy
14:29
Speaker 1: records and concluded, probably not. It was the worst kind
14:33
Speaker 1: of head injury. What about James Garfield twentieth President of
14:36
Speaker 1: the United States, shot twice. The second bullet hit him
14:40
Speaker 1: in the back, missing the spinal cord and embedding itself
14:43
Speaker 1: behind his pancreas. He's rushed to the hospital. It's a
14:46
Speaker 1: minor injury, but they get obsessed with taking out the
14:49
Speaker 1: bullet and that contaminates the wound. He's shot in June.
14:53
Speaker 1: He dies in September because of a sepsis infection. He
14:56
Speaker 1: survives today easy. William mc kinley is next September sixth,
15:02
Speaker 1: nineteen oh one, shot twice in the abdomen. He lives today.
15:07
Speaker 1: JFK no. He's dead on arrival at the hospital, but go.
15:14
Speaker 7: To nineteen eighty. Ronald Reagan a sixty nine year old
15:17
Speaker 7: man with a gunshot wound to the left chest. He
15:21
Speaker 7: doesn't survive. In nineteen hundred, he doesn't survive in nineteen twenty.
15:25
Speaker 7: He might have survived in nineteen forty whose blood transfusion
15:29
Speaker 7: he needed blood. I am nineteen sixty, but certainly a
15:33
Speaker 7: sixty nine year old gunshot womb. The chess were the
15:36
Speaker 7: first one hundred plus years of our history would largely
15:39
Speaker 7: be largely be fatal.
15:42
Speaker 1: If Ronald Reagan had died of his wounds. The way Lincoln,
15:45
Speaker 1: McKinley and Garfield did, the world would have been very different.
15:50
Speaker 1: He shot in March nineteen eighty one. He's just two
15:53
Speaker 1: months into one of the most consequential presidencies in American history.
15:57
Speaker 1: Does the Berlin Wall fall in nineteen eighty nine without
16:00
Speaker 1: Reagan in office? Maybe, but maybe not. History is shaped
16:06
Speaker 1: not just by assassin's bullets, but also by the ability
16:09
Speaker 1: of doctors to treat the damage done by assassin's bullets.
16:13
Speaker 1: It's the Robert Kennedy case though, that caught my eye.
16:18
Speaker 1: I wanted just to start, how did you come to
16:21
Speaker 1: be interested in revisiting the assassination of Robert Kennedy?
16:25
Speaker 6: So I was walking through the hallway one day came
16:27
Speaker 6: across Ted Pappis, who's one of our general surgeons, and
16:30
Speaker 6: he had done a series of historical works, and he said,
16:38
Speaker 6: you know, have you ever heard about Robert Kennedy? And
16:41
Speaker 6: which seems like kind of an odd question because everyone's
16:43
Speaker 6: I would think I heard about Robert Kennedy. And he said, well,
16:46
Speaker 6: I think I may have gotten a hold of some
16:48
Speaker 6: of the original documents related to his assassination. Would you
16:52
Speaker 6: be interested in combing through them with me?
16:55
Speaker 1: So Commsero sits down with his colleagues. It goes through
16:58
Speaker 1: what papus has found, autopsy reports, testimony from the surgeons
17:02
Speaker 1: who treated Kennedy, and they reconstruct the case. So walk
17:07
Speaker 1: me through what happens to him at he shot.
17:11
Speaker 6: Yeah, so you know, I've always sort of envisioned this
17:14
Speaker 6: chaotic scene where you know, his limited security and his
17:18
Speaker 6: chief of staff went and saw sought the available the
17:22
Speaker 6: assistance of the available physicians.
17:26
Speaker 1: He's lying on the ground in the kitchen of the
17:27
Speaker 1: Ambassador Hotel. Today they would be Secret Service protection, contingency plans,
17:33
Speaker 1: an ambulance on call. There was nothing like that in
17:36
Speaker 1: nineteen sixty eight. For bodyguards. Kennedy has two celebrity athletes,
17:40
Speaker 1: the football player Rosie Grier and the Olympic gold medal
17:43
Speaker 1: decathlete Ray for Johnson. No one is prepared for this
17:47
Speaker 1: kind of emergency.
17:48
Speaker 6: And then this is sort of where the Senator then
17:55
Speaker 6: gets on lucky and where a lot of victims get
17:58
Speaker 6: on lucky. Is he is taken to sort of the
18:01
Speaker 6: closest hospital, but not necessarily the facility that's best equipped
18:06
Speaker 6: to care for someone who had been shot in the head.
18:09
Speaker 1: Kennedy gets taken to Central Receiving Hospital on sixth Street,
18:13
Speaker 1: just west of downtown. They stabilize him there, but they
18:16
Speaker 1: don't have a neurosurgeon, so he has to be retransported
18:20
Speaker 1: to Good Samaritan Hospital just stuff Wilshire. And what did
18:24
Speaker 1: that that mistake cost him? How much time.
18:28
Speaker 8: I calculated in the paper and let me double check.
18:37
Speaker 8: So he got to the operating room a Good Samaritan
18:40
Speaker 8: two and a half hours after the shooting.
18:43
Speaker 1: Two and a half hours. In your world, two and
18:45
Speaker 1: a half hours is a long time, is.
18:47
Speaker 6: A very long time.
18:49
Speaker 1: Yeah, So he gets he gets to Good Samaritan to
18:53
Speaker 1: what happens.
18:54
Speaker 6: So they finish stabilizing him, they inspect for his other runds,
18:59
Speaker 6: and then they decide pretty quickly to take him to surgery.
19:03
Speaker 6: And they they wound up removing you know, roughly about
19:08
Speaker 6: a five centimeter two and a half inch piece of
19:11
Speaker 6: bone surrounding where he was shot in the back of
19:14
Speaker 6: the head, right behind the ear, and to breed which
19:20
Speaker 6: was the standard of the day, sort of everything that
19:22
Speaker 6: looked abnormal along the bullet track, tried to remove fragments
19:28
Speaker 6: of his skull and then brought him back to the
19:32
Speaker 6: intensive care unit where they tried to cool him, which
19:36
Speaker 6: was a sort of common practice at the time, to
19:39
Speaker 6: reduce swelling in the brain. They gave him medications, specifically
19:43
Speaker 6: steroids in something called manitol, which is a diuretic. Both
19:47
Speaker 6: of those are aimed at reducing swelling of the brain,
19:50
Speaker 6: one of which manatol, is still very commonly used today.
19:55
Speaker 6: Dexamethasone is no longer used for this type of injury,
19:57
Speaker 6: based upon data from large clinical trials that occurred long
20:03
Speaker 6: after this.
20:03
Speaker 1: Of course, he was in a coma. He never came
20:07
Speaker 1: out of it. He was pronounced dead at one forty
20:11
Speaker 1: four am the next morning. So now let's redo this.
20:16
Speaker 1: But it's twenty twenty three. There's no delay today. Right today,
20:19
Speaker 1: he's if you're shot in the Ambassador Hotel in La today,
20:22
Speaker 1: where do you go? Where's the nearest trauma center?
20:26
Speaker 6: I believe the closest Level ones trauma center is probably
20:31
Speaker 6: USC But yes, you would go straight to a Level
20:33
Speaker 6: one trauma center.
20:35
Speaker 1: A Level one trauma center is a recent invention, a
20:38
Speaker 1: high tech, on demand medical unit attached to a traditional
20:42
Speaker 1: hospital with every kind of specialist on call twenty four
20:46
Speaker 1: hours a day, and you would get there, I.
20:49
Speaker 6: Mean today, rather rapidly.
20:50
Speaker 1: Today he gets So he arrives at at a level
20:52
Speaker 1: one trauma center. Let's just say for the sake of argument,
20:55
Speaker 1: it's fifteen minutes. Yeah, the and in your so the
21:00
Speaker 1: difference between two and a half hours and fifteen minutes
21:03
Speaker 1: in your.
21:03
Speaker 6: World is might as well be a year.
21:07
Speaker 1: Yeah, yeah, And when he gets there, he's treated very differently.
21:14
Speaker 6: So at Duke, the neurosurgery team that's in the hospital,
21:20
Speaker 6: which is for us always a resident and potentially always
21:24
Speaker 6: a faculty member. The rest of the trauma team would
21:27
Speaker 6: be paged ahead of time and waiting for the patient
21:31
Speaker 6: when they arrived.
21:32
Speaker 1: In the resuscitation day, Kennedy got an X ray once
21:36
Speaker 1: he arrived, a one dimensional image that made it hard
21:39
Speaker 1: for the surgeons to know exactly where his bullet was. Today,
21:43
Speaker 1: he'd get an immediate CT scan in three D, an
21:47
Speaker 1: extraordinarily detailed image.
21:50
Speaker 6: In most trauma centers, including Duke, there is a CT
21:53
Speaker 6: scanner that is about ten feet from where the patients
21:56
Speaker 6: first arrive, so there's very little care, very little delay.
22:00
Speaker 1: You finish the CT scan, you're how many how many
22:04
Speaker 1: minutes in are you from the moment the patient has
22:06
Speaker 1: arrived at the hospital.
22:09
Speaker 6: Unless the patient was so unstable in terms of their
22:13
Speaker 6: blood pressure or heart rate that that required additional stabilization
22:16
Speaker 6: that should be occurring within ten or fifteen minutes.
22:19
Speaker 1: Commasaro began to talk through the difference between how a
22:22
Speaker 1: brain injury like Kennedy's was treated in nineteen sixty eight
22:26
Speaker 1: versus today. He gave me close to an hour of
22:29
Speaker 1: technical description, step by step. So in sixty eight, given
22:36
Speaker 1: standard of care and the extent of his injuries, he
22:39
Speaker 1: has zero chance of survival.
22:43
Speaker 6: About as close to zero as you can get.
22:45
Speaker 1: Yeah, what's what's his percent survival chance today? He's not
22:48
Speaker 1: dying at two forty five the next morning under this protocol?
22:52
Speaker 6: I think it is far less likely he is dying
22:54
Speaker 6: at two forty five the next forty Yeah.
22:56
Speaker 2: Yeah.
22:57
Speaker 1: Listening to you describe the differences between sixty eight and
23:01
Speaker 1: the present day, it sounds like night and day. You
23:05
Speaker 1: have the same intention today as they did in sixty eight,
23:09
Speaker 1: reduced to swelling in the brain, repair, stop the bleeding,
23:13
Speaker 1: but the ways in which you're going out about doing
23:15
Speaker 1: that are markedly different, totally, markedly different. How do I
23:21
Speaker 1: describe the leap that's been made between then and now?
23:24
Speaker 1: What's it like. Is it like I've driven in a
23:27
Speaker 1: car from nineteen sixty eight. It doesn't seem like it
23:29
Speaker 1: belongs to a different paradigm than a car today.
23:35
Speaker 6: It's the difference between a bicycle and an electric car.
23:40
Speaker 1: Oh okay, yeah, that makes a lot of sense. Oh
23:46
Speaker 1: that's huge. So what does commasarows? What if on the
23:51
Speaker 1: Kennedy assassination tell us that medicines contribution to falling homicide
23:57
Speaker 1: rates is a very big deal bicycles to electric cars.
24:03
Speaker 1: Here's a back of the envelope calculation on how big
24:06
Speaker 1: this effect is from the University of Massachusetts in two
24:11
Speaker 1: thousand and two. Estimated improvements in traumacare probably lower the
24:15
Speaker 1: death rate from serious injury about two point five to
24:18
Speaker 1: four percent a year. So if nothing else changes, if
24:23
Speaker 1: there's still just as many would be murderers walking around,
24:27
Speaker 1: that's how much your murder rate is going to fall
24:29
Speaker 1: every year on its own. Let me quote to you
24:32
Speaker 1: from their conclusion. Compared to nineteen sixty, the year our
24:37
Speaker 1: analysis begins, we estimate that without these developments in medical technology,
24:42
Speaker 1: there would have been between forty five thousand and seventy
24:46
Speaker 1: thousand homicides annually. The past five years instead of an
24:51
Speaker 1: actual fifteen thousand to twenty thousand. Those estimates are insane.
24:57
Speaker 1: If doctors hadn't up their game, the number of Americans
25:00
Speaker 1: being murdered every year in the United States might be
25:03
Speaker 1: as much as three or four times higher than it
25:07
Speaker 1: is now. Here's another example. It's from the trauma center
25:11
Speaker 1: at the University of Tennessee Medical Center in Memphis, a
25:15
Speaker 1: city with a pretty serious homicide problem. The Memphis trauma
25:19
Speaker 1: staff looked at every gunshot wound their hospital had treated
25:23
Speaker 1: from the mid nineteen nineties to twenty fifteen, and what
25:26
Speaker 1: they found is that every way you look at it,
25:30
Speaker 1: gun violence in Memphis got worse in that period. The
25:33
Speaker 1: number of gunshot wounds they saw increased. In fact, the
25:36
Speaker 1: number went up fifty nine percent just between twenty ten
25:40
Speaker 1: and twenty fifteen. The severity of the wounds they saw
25:44
Speaker 1: got worse. The number of people being wheeled in with
25:47
Speaker 1: multiple gunshot wounds more than tripled. In absolutely every sense,
25:52
Speaker 1: the patients coming into that hospital in those years showed
25:56
Speaker 1: that Memphis was becoming a dramatically more dangerous place. But
26:01
Speaker 1: what happened to the mortality rate of gunshot victims coming
26:05
Speaker 1: into that hospital during that period, it went down. It
26:09
Speaker 1: dropped by a third. The trauma doctors at the University
26:13
Speaker 1: of Tennessee Medical Center are so good that they made
26:17
Speaker 1: the increase in bloodshed on the streets of Memphis all
26:21
Speaker 1: but invisible. So what does the homicide rate in Memphis
26:25
Speaker 1: tell us about the level of violence in Memphis. Nothing.
26:30
Speaker 1: That's implication number one. We probably should stop using homicide
26:34
Speaker 1: rates as a measure of how safe and healthy a
26:37
Speaker 1: community is.
26:41
Speaker 5: Homicides or get all the attention, right, They get all
26:44
Speaker 5: the attention from the media. They get all the attention,
26:47
Speaker 5: you know, from the response, you know, like the mayor
26:51
Speaker 5: might show up on the scene, or the whole prosecutor
26:53
Speaker 5: might show up on the scene.
26:55
Speaker 1: That's Natalie Hippel, a criminologist at Indiana University.
26:59
Speaker 5: They tape off the whole scene, and not every non
27:01
Speaker 5: fatal shooting gets that kind of response. So those are
27:04
Speaker 5: the numbers that people are sensitive to, But I don't
27:08
Speaker 5: know that it means much.
27:10
Speaker 1: A few years ago, Hippo and a group of other
27:12
Speaker 1: criminologists argued that we should shelve the homicide statistic in
27:16
Speaker 1: favor of a measure of what they call bullet to
27:18
Speaker 1: skin contact. That is just a measure of how many
27:22
Speaker 1: bullets have hit people in a given community over the
27:25
Speaker 1: previous year. Which makes more sense, right because now we've
27:29
Speaker 1: corrected for the bias caused by doctors saving so many
27:32
Speaker 1: more lives. The problem is that that bullet to skin
27:36
Speaker 1: number doesn't exist. No one pulls that statistic out. The
27:40
Speaker 1: police lump all those cases in the general category of
27:44
Speaker 1: aggravated assault, mixed in with punches and shoves.
27:47
Speaker 4: They don't have a definition for a non fatal shooting.
27:49
Speaker 5: There's no way to pull those data out of those sets.
27:53
Speaker 1: Wait, there's stop there. You're telling me that we are
27:59
Speaker 1: the most wealthiest and most sophisticated country in the world
28:03
Speaker 1: that is simultaneously in the grip of a prolonged chronic
28:09
Speaker 1: of gun violence. We have no we have no hard,
28:14
Speaker 1: useful numbers on the total number of of shootings.
28:19
Speaker 4: Nope. So not that the federal government maintains.
28:25
Speaker 5: As soon as you drop down to aggravated assaults, they're
28:28
Speaker 5: really really messy, and so no, we don't.
28:31
Speaker 1: What hippol had to do was go through all the
28:33
Speaker 1: old aggravated assault records compiled by the Indianapolis Police Department
28:37
Speaker 1: and pull out the gunshot wounds by hand.
28:41
Speaker 5: The first thing we did was pull all the aggravated
28:43
Speaker 5: assaults that you know, and they report to they report
28:47
Speaker 5: to the FBI, and so they pulled all those case
28:48
Speaker 5: numbers and we started reading. I mean literally, this is
28:51
Speaker 5: just you know, in the bucket, out of the bucket,
28:53
Speaker 5: in the bucket, out of the bucket.
28:55
Speaker 1: This is thousands and thousands, thousands.
28:57
Speaker 4: Yeah.
28:58
Speaker 1: How many people were engaged in this project?
29:02
Speaker 4: Gosh, well, I mean we had a full time.
29:03
Speaker 1: How many graduate students lives did you ruin in the Yeah.
29:08
Speaker 4: We have, well, each of us had our own. I mean,
29:11
Speaker 4: there wasn't a lot of funding.
29:13
Speaker 1: For newer cases. She got the police to help her out.
29:16
Speaker 1: Indiana has a reporting requirement.
29:18
Speaker 5: If you show up the emergency department and you're stabbed,
29:21
Speaker 5: or you're shot, or you're really badly bludgeoned or something,
29:25
Speaker 5: they are the medical facility is required to report that
29:29
Speaker 5: to the police.
29:30
Speaker 1: So every day the police would send her the list
29:32
Speaker 1: of reports they'd gotten from the trauma center the night before.
29:36
Speaker 5: The procedure was detective goes to the scene, figures out
29:40
Speaker 5: what's going on, and then writes up what they know
29:42
Speaker 5: about the incident. That happened that right then and there,
29:45
Speaker 5: and then that goes out, So that's usually within twenty
29:48
Speaker 5: four hours. But I got on that email list, so
29:50
Speaker 5: then I'm forwarding them to my research assistant.
29:53
Speaker 4: The two of us are reading every single one.
29:55
Speaker 1: How many are you getting a day?
29:57
Speaker 4: Oh, my email right now? Hundreds?
30:00
Speaker 1: Well, you're getting hundreds of.
30:02
Speaker 4: My email my police department emails off the hook.
30:04
Speaker 1: So this is all the bullet to skin reports from
30:08
Speaker 1: the city of the al Yeah.
30:09
Speaker 5: And Indianapolis is the seventeenth largest city in the country.
30:12
Speaker 5: They have they run about eight hundred thousand people, give
30:15
Speaker 5: or take, So you can only imagine what this must
30:18
Speaker 5: look like in Chicago or New York.
30:21
Speaker 1: What she's finding is what you'd expect she'd find. Indianapolis
30:25
Speaker 1: is just like Memphis. The curve for bullet the skin
30:28
Speaker 1: contact is going one way and the curve for homicides
30:32
Speaker 1: is going another. But the whole thing is absurd. Right
30:36
Speaker 1: in the hospitals of Indianapolis, the trauma surgeons have marshaled
30:40
Speaker 1: the very finest of twenty first century technology and spend
30:43
Speaker 1: millions upon millions of dollars to save every last life
30:47
Speaker 1: they can. But does the city know whether gun violence
30:51
Speaker 1: is going up or down, sure, but only because Natalie
30:54
Speaker 1: Hipple and her graduate students are going through their emails
30:57
Speaker 1: every morning. One last question. I don't mean this in
31:02
Speaker 1: a disparaging way. The way you describe your work sounds
31:05
Speaker 1: insanely depressing.
31:08
Speaker 5: Thank you for acknowledging that is depressing. I've started checking
31:12
Speaker 5: in on grad students. You know, I'm like, you're going
31:14
Speaker 5: to read alect but when I hire them, I'm like,
31:15
Speaker 5: this is this is not you know something that you
31:19
Speaker 5: have you know over coffee and donuts and do your
31:21
Speaker 5: work right.
31:22
Speaker 4: You're going to it's going to change your mood.
31:24
Speaker 1: Which brings us to the second implication of the homicide equation,
31:29
Speaker 1: which is that maybe these two things, how good the
31:31
Speaker 1: doctors are and how lackadaisical. The rest of society's response
31:35
Speaker 1: to the problem has been are connected. Economists love to
31:40
Speaker 1: talk about moral hazard. I'm sure you've heard that phrase.
31:43
Speaker 1: Its formal definition is the lack of incentive to guard
31:47
Speaker 1: against risk where one is protected from its consequences. Someone
31:52
Speaker 1: lives in a flood zone. You subsidize their flood insurance.
31:55
Speaker 1: So what happens when their home is washed away? They
31:58
Speaker 1: rebuild it in exactly the same place. Why should they
32:01
Speaker 1: give up their beautiful views of the ocean If someone
32:03
Speaker 1: else is picking up the tab, that's moral hazard. Or
32:08
Speaker 1: here's another example. The rate of people dying in car
32:11
Speaker 1: accidents fell dramatically for years, which makes sense. Cars got
32:15
Speaker 1: a lot safer, more people wore their seatbelts. But recently
32:20
Speaker 1: the death toll has started to climb again. And why.
32:24
Speaker 1: Maybe it's because your car is filled with all kinds
32:26
Speaker 1: of warnings and bells, and you're strapped in like a
32:29
Speaker 1: baby and protected by a dozen airbags, and you feel
32:32
Speaker 1: so safe that you have that extra drink and drive
32:35
Speaker 1: a little faster and answer all your texts while you're
32:37
Speaker 1: driving down the freeway. So you end up being worse
32:40
Speaker 1: off than before. That's moral hazard. If someone else is
32:45
Speaker 1: doing the work of taking care of us and lowering
32:47
Speaker 1: our risk, we have the freedom to behave like idiots.
32:53
Speaker 1: I said at the beginning of this series that I
32:55
Speaker 1: wanted to explain why the way we talk about guns
32:58
Speaker 1: is so messed up, Why the Supreme Court makes such
33:02
Speaker 1: ridiculous rulings, Why gun control advocates push ideas that are
33:07
Speaker 1: so beside the point. And I think a big part
33:12
Speaker 1: of the answer is moral hazard. Moral hazard is indifference.
33:17
Speaker 1: It is the freedom purchased by other people's hard work.
33:21
Speaker 1: Doctors have become so skilled, have taken the problem of
33:24
Speaker 1: treating the wounded so seriously, have deployed every inch of
33:28
Speaker 1: their ingenuity in trying to keep the wounded alive. But
33:31
Speaker 1: the rest of us are free to fiddle while Rome burns.
33:54
Speaker 1: So you've got the CT scan. So now you know,
33:57
Speaker 1: you know, you know where the bullet is, and you
33:59
Speaker 1: know the extent of the damage, and presumably in your
34:02
Speaker 1: mind is just imagine you're the physician here. You're formulating
34:07
Speaker 1: as you look at these things a strategy for what
34:09
Speaker 1: you want to do next.
34:10
Speaker 6: Yeah, So for an injury in this location, I would
34:14
Speaker 6: want a what's called a ct angiogram, which is a
34:19
Speaker 6: picture of the blood vessels that supply and then drain
34:23
Speaker 6: the brain, which can be done, you know, within about
34:27
Speaker 6: takes an extra sort of five minutes or less. Again,
34:30
Speaker 6: this was not available at the time that the senator
34:32
Speaker 6: was injured.
34:33
Speaker 1: Kennedy's brain is flooded in blood. But today COMMISERA would
34:38
Speaker 1: have a sense of where the damage is and he
34:41
Speaker 1: would call for help.
34:43
Speaker 6: So if I'm the surgeon, that's taking care of the senator,
34:46
Speaker 6: and there is evidence that blood is coming out of
34:49
Speaker 6: a very large blood vessel, then I am calling one
34:52
Speaker 6: of my colleagues who specializes in in vascular neurosurgery to
34:56
Speaker 6: tell me to meet in the operating room and potentially
34:59
Speaker 6: taking the senator to an operating room that has the
35:02
Speaker 6: capability for us to opulate operate simultaneously. So while I'm
35:06
Speaker 6: working directly on his head, removing the skull, taking out
35:10
Speaker 6: any blood clot that I can, making space for swelling,
35:14
Speaker 6: which is largely the purpose of the surgery. Stop the bleeding,
35:17
Speaker 6: make room for the brain to swell, get control of
35:21
Speaker 6: any infection that's going to occur by removing dead tissue.
35:26
Speaker 6: Then at the same time, my partner could be accessing
35:30
Speaker 6: the blood vessels through either the wrist or the groin,
35:33
Speaker 6: kind of like how a heart catheterization takes place, except
35:36
Speaker 6: you don't stop with the heart. You go up to
35:38
Speaker 6: the brain to try and either block off extensive bleeding
35:42
Speaker 6: if you can't salvage the blood vessels, or salvage the
35:45
Speaker 6: blood vessels from the inside out.
35:48
Speaker 1: So keep going. So you've got You've brought in this
35:51
Speaker 1: this specialist to deal with the blood vessel while you
35:54
Speaker 1: are removing parts of the skull and dead tissue. Yep,
35:58
Speaker 1: what happens next.
36:00
Speaker 6: Now, since they make mention to operating at the upper
36:04
Speaker 6: part of the brain, a bit the occipital lobe that
36:07
Speaker 6: they reference, which makes us conclude that the bullet trajectory
36:11
Speaker 6: somewhat passed upward from the cerebellum upward into the occipital lobe.
36:17
Speaker 6: There it raises the possibility of removing a large part
36:20
Speaker 6: of the skull up top, which they did not do.
36:26
Speaker 6: And likely part of the reason that they did not
36:27
Speaker 6: do that is it really hadn't become more of a
36:31
Speaker 6: standard at the time because the data just didn't exist
36:34
Speaker 6: that it was helpful.
36:36
Speaker 1: They didn't use a microscope in nineteen sixty eight, Commis
36:39
Speaker 1: arrow would which would give not only magnification but illumination.
36:43
Speaker 1: They're operating in a very confined space. Back then, the
36:47
Speaker 1: standard of care was to locate and remove every single
36:50
Speaker 1: bit of debris you could find. We don't do that anymore.
36:54
Speaker 1: It does more harm than good. And then maybe the
36:56
Speaker 1: biggest issue of all, After a brain is injured, it
36:59
Speaker 1: begins to swell, and it's the swelling that poses the
37:03
Speaker 1: greatest risk to the patient. Today we know far more
37:06
Speaker 1: about how to reduce that swelling.
37:08
Speaker 6: I've wondered if your hands her hands hand jerks up
37:10
Speaker 6: and instead of getting shot back here, the bullet comes
37:14
Speaker 6: across his occipital lobe. The senator probably has a visual
37:19
Speaker 6: field deficit, a blind spot, but quite possibly survives same thing.
37:26
Speaker 1: If the headshot was a little lower, that might not
37:29
Speaker 1: have made a difference back then, but today possibly.
37:33
Speaker 6: Yeah. So I had another patient that came to mind
37:37
Speaker 6: that actually made me think of the senator. He was
37:41
Speaker 6: a young person who had been shot not in the
37:45
Speaker 6: back lobe, but the front low so damaged part of
37:50
Speaker 6: the jaw, but more importantly, afterwards injured the crotted artery,
37:55
Speaker 6: one of the main blood supplies to the brain. You know,
37:58
Speaker 6: the two crowded arteries supply about eighty percent of your blood,
38:01
Speaker 6: and was hammrhaging extensively from that prior to when it
38:06
Speaker 6: then damaged the brain itself. And we did you know
38:11
Speaker 6: very nearly exactly what I laid out to you. One
38:14
Speaker 6: of my partners, who's a vascular neurosurgeon, working from inside
38:18
Speaker 6: the blood vessels, fed a wire to help repair this.
38:21
Speaker 6: I took off a large chunk of the patient's skull.
38:24
Speaker 6: The patient was in a coma for several weeks, was
38:28
Speaker 6: in the ICU for about for several months, but then
38:32
Speaker 6: went home and cares for himself works. I don't think
38:39
Speaker 6: I would ever sort of categorize him as perfect. But
38:43
Speaker 6: you could meet him and other than part of his
38:47
Speaker 6: scar extends in front of his hairline, the rest is
38:50
Speaker 6: hidden behind. You would not be able to sort of say, oh, yeah,
38:54
Speaker 6: you were shot in the head or you had a
38:56
Speaker 6: brain injury.
38:57
Speaker 1: Yeah. So that's another another scenario for Robert Kennedy. If
39:03
Speaker 1: the bullet had gone today, had hit him there, he
39:07
Speaker 1: could have survived.
39:09
Speaker 6: There are many scenarios where he survives.
39:15
Speaker 1: And what happens when someone survives a violent act that
39:19
Speaker 1: once upon a time would have killed them. The world
39:22
Speaker 1: changes in a million, small and large ways. Two months
39:26
Speaker 1: before Robert Kennedy was assassinated in Los Angeles, Martin Luther
39:30
Speaker 1: King was assassinated in Memphis. Single shot to the face
39:34
Speaker 1: from a Remington rifle, broke his jaw, traveled down his spine,
39:38
Speaker 1: severed his juggular vein, and lodged in his shoulder. Kennedy
39:42
Speaker 1: was in Indianapolis at the time. Addressing a crowd, and
39:45
Speaker 1: he gives his most famous speech where he tells everyone
39:48
Speaker 1: the terrible news. Remember as you listen that he was
39:52
Speaker 1: speaking off the cuff. He had no time to prepare.
39:56
Speaker 1: This was from his heart.
39:58
Speaker 3: For those of you who are black and are attempted
40:03
Speaker 3: to be filled with hatred and mistrust of the injustice
40:10
Speaker 3: of such an act against all white people, I would
40:16
Speaker 3: only say that I can also feel in my own
40:19
Speaker 3: heart the same kind of feeling. I had a member
40:24
Speaker 3: of my family killed, but he was killed by a
40:27
Speaker 3: white man. But we have to make an effort in
40:31
Speaker 3: the United States. We have to make an effort to understand,
40:37
Speaker 3: to get beyond, or go beyond, these rather difficult times.
40:42
Speaker 3: My favorite poem, my favorite poet, was Eschylus, and he
40:47
Speaker 3: once wrote, even in our sleep, pain, which cannot forget,
40:58
Speaker 3: falls drop by drop upon the heart, until in our
41:02
Speaker 3: own date despair against our will comes wisdom through the
41:08
Speaker 3: awful grace of God.
41:12
Speaker 1: We had someone who might have been president who could
41:15
Speaker 1: quote Eschylus from memory, and then Kennedy issued a challenge
41:21
Speaker 1: for the country to do something about the violence tearing
41:24
Speaker 1: us apart. But I think only the doctors were listening.
41:29
Speaker 3: What we need in the United States is not division.
41:33
Speaker 3: What we need in the United States is not hatred.
41:37
Speaker 3: What we need in the United States is not violence
41:39
Speaker 3: and lawlessness, but is love and wisdom and compassion toward
41:45
Speaker 3: one another, and a feeling of justice toward those who
41:51
Speaker 3: still suffer within our country, whether they be white or
41:55
Speaker 3: whether they be black.
42:23
Speaker 1: Our revisionist History Gun series was produced by Jacob Smith, Bend,
42:28
Speaker 1: daph Haffrey, Piara Powell, Tally Emlin, and Leemn Gistoo. We
42:33
Speaker 1: were edited by Peter Clowney and Julia Barton. Fact checking
42:37
Speaker 1: by Arthur Gomberts and Kashelle Williams. Original scoring by Luisquira,
42:42
Speaker 1: mastering by Flonn Williams. Engineering by Nina Lawrence. I'm Malcolm Gladwell.