Crisis Management Leadership: AN INTERVIEW WITH BEN AARON, MD

AN INTERVIEW WITH BEN AARON, MD - THE TEAM THAT SAVED RONALD REAGAN

Washington DC March 30 1981, 2:27 pm:

On March 30 1981, 2:27 pm, John Hinckley Jr shot President Ronald Reagan, White House Press Secretary James Brady, Secret Service agent Tim McCarthy and Washington D.C. police officer Thomas Delahanty using his Röhm RG-14 .22 cal blue steel revolver loaded with six "Devastator" brand cartridges (each with small aluminum and lead azide explosive charges designed to explode on contact). Hinckley fired six shots in 1.7 seconds, first hitting Jamey Brady in the head and then officer Delahanty in the neck. As Special Agent Jerry Parr pushed President Reagan into the limousine, a fourth shot hit Secret Service agent Tim McCarthy in the abdomen. The sixth bullet ricocheted off the armored side of the limousine and hit the president.

It was initially assumed that The President was uninjured. Thinking he was uninjured, they initially planned to take the President to the White House. Until he coughed up blood, President Reagan assumed the pain in his left chest was due to rib fractures from being pushed into the limousine. Special Agent Parr thought otherwise and directed the motorcade to George Washington University Hospital. Upon arrival the President walked into the Emergency Department unassisted but immediately collapsed. At the insistence of The Physician to the President, Daniel Ruge, the ED team was instructed to treat the President as any other trauma victim. The President was in shock and the Trauma team quickly discovered a bullet entrance wound in his left axilla. Within 30 minutes, he was stabilized and transported to the Operating Room where, with the assistance of Joseph M. Giordano, Chief Thoracic Surgery Benjamin L. Aaron, performed a thoracotomy. ^Wikipedia

An interview a few weeks later revealed the anxiety control methods both surgeons utilized when they realized they were operating on the President:

Giordano: ''I looked at him and I could feel myself getting tense, which has happened to me occasionally when I do surgery. When that happens, I talk myself through it. I thought, 'O.K., calm yourself. You want this to go well. Concentrate, and do everything the way you always do it, if you expect to get good results.' But I could not divorce myself from the fact that he was the President and his wound could have been lethal.''

Aaron: “He assessed the seriousness of the President's wounds, and said he too would have had ‘heightened anxiety’ if he had not judged that Mr. Reagan's bleeding could be controlled. Although Dr. Aaron described himself as someone who ''doesn't get anxious about things,'' he acknowledged that he was ''on edge at times.'' ''When I couldn't feel that bullet, and I knew it should be there, I thought it might have embolized through the pulmonary veins, into the heart and gone someplace.'' …The bullet, it turned out, was flat. ''I just couldn't feel it in that spongy lung tissue,'' Dr. Aaron said. ''The X-ray settled me down because I realized that when I was feeling for the bullet it wasn't trapped in one place. It had room to move, and it just squirted away from my fingertips.” ''Then it was just a matter of hanging in there until I could find the blooming thing by passing a catheter along the bullet track. It took about five minutes of very concentrated tactile discrimination until I suddenly pinned it down and got it out.''

INTERVIEW WITH BEN AARON, MD:

After Jon White revealed the heroic aspects of the team saving the Presidents life I had questions of Dr. Aaron:

1. What leadership or crisis management experience /techniques did you discover worked well for you?

2. What ones did you figure out quickly you had to improve upon.

3. What preconceptions about your skill or your medical center staffs skill proved correct?

4. What ones proved false?

5. What lessons did you rehash with the residents and /or hospital staff in post scenario debriefings?

Dr. Aaron was kind to discuss this with me:

“Bear in mind that all this took place 35 years ago and that it is coming from an 83 year old brain. Also, at the time, things were moving at a fast pace during which time there was not much time for reflection or organization, or to put it another way, much of the time we were "winging it" in dealing with the complexities imposed by the unique nature of the event. “

1. Leadership or crisis management experience/techniques applied?

The care in the ER was flawless as regards urgent processing, mobilization of staff and systematic application of appropriate care. This was not an accident, but came about because of aggressive and thorough preparation and training of the ER staff and residents. In order to take care of the President, James Brady and Tim McCarthy (SS), the area had to be cleared of patients, the ensuing crowd screened and managed, and assignments quickly defined. No one consulted any manuals on procedures on techniques. The key was preparation and training, professionally applied.

I recall insisting, from the get-go, that everyone on my team regard the President first and foremost as a patient in trouble and to put aside any consideration of who he was or what might be swirling around beyond our perimeter of care. This kept us focused on the task at hand and help quell nervousness. You might call this the principle of putting first things first. I did not note it at the time, but have been told since that as the team leader, my calm demeanor, efficiency, decisiveness and apparent lack of nervousness did much to hold things together as this event moved along. (Jon White, MD noted that this was indeed the case- Dr. Aaron maintained a calm demeanor with no yelling and no screaming, which allowed flawless communication and the ability to resuscitate the President and rapidly transport him to the OR).

2. Consideration of changes or alterations.

One can be persuaded in such a situation that having additional professional experience at the table could be helpful and perhaps diffuse responsibility should things go wrong. I had many offers of help from fellow surgeons, but quickly put this aside in favor of a three-person team composed of me, my chief Thoracic resident and a surgical intern (just as it would be if the patient came in off the street). This seemed to me to be the simplest route to good decision making during the operation. This might be termed good management versus too many "cooks" calling the shots.

Because of the remote possibility that the bullet might have transited the dome of the left diaphragm, the ER General Surgeons strongly supported an abdominal paracentesis before opening the chest to rule out injury to the spleen, etc. I had seen no evidence of this and had reservations about taking the time to do the procedure (20 minutes or so), but as the President's condition was stable at the time, I agreed to move ahead on this even though had I found a hole in the diaphragm, I could easily have dealt with the problem through the chest. This gets down to using clinical judgment (was it safe to take the additional time) to forestall a fuss with the General Surgery group.

Putting the President, post-op, on the ICU was a management mistake, as his presence along with all of his SS entourage and visiting staff rendered the ICU unworkable. We quickly evacuated a wing of the hospital, tailored it to all the requisites and had the patient moved in 6 hours. My plan for post-op care was drastically and suddenly altered but I and my team quickly adapted to the new circumstances and moved on. Being flexible, prepared for contingencies, and able to move in different directions effectively is essential to completing the mission.

3. How ready were we?

Occasionally one hears that University medicine is "sterile", impersonal, isolates a patient from compassionate care and has poor inter-staff communication. Some of this may be true, but what University Medical centers do provide is well credentialed and experienced staff and first rate facilities. We were prepared for this challenge at every level of staff, management and resource availability and because of this, the event came off without a significant hitch. It was a team effort in every regard from beginning to end and a wonderful thing to be a part of.

4. What plans or preparations proved false?

We were not prepared for the security requirements by the SS. There was a SWAT team on the roof at all times during the eleven days he was present. When he needed good quality x-rays (there was a portable machine in his suite), the halls had to be cleared and explosive sniffing dogs preceded his visit to the x-ray floor. His food supply was carefully guarded. Bullet proof glass was installed in his room (despite the fact that he was on the 3rd floor of an interior court with a window free wall opposite). ALL entrants to the 3rd floor had to undergo a SS check, each and every time they entered. Medical folk, especially doctors, are not particularly patient people by nature, so with great restraint, and resolve, we managed to work it through to a successful conclusion. The lesson here is to practice situational awareness and be willing to accept imposed restraints, always keeping the mission as our first goal.

5. Post event debriefing.

Post mortems are standard issue for any medical event. We had many discussions after the fact, but almost all centered about things like conduct with the intrusive press (residents and especially interns, are full of false info and quite willing to share it). To relive and relieve tensions. we produced a high quality 30-minute documentary utilizing all the primary participants (doctors and nurses, etc) plus actors as the presidential party. This process brought out into the open the vital parts played by each participant and highlighted the importance of the synthesis of each performance in attaining a good outcome. On almost every count, we were satisfied with how our medical center responded to each and every challenge and this was echoed by the AMA in their commendation of our efforts.

I hope that this insight into how our medical center and all it's integrated parts dealt with a most unusual and unexpected event will help you develop a useful syntax for your book. If you have additional questions, fire them my way and I will field them as best as I can.

Sincere regards, Ben Aaron, MD

Special thanks to Dr. Jon White, Chief Surgery VAMC Washington DC for filling in the gaps.

https://en.wikipedia.org/wiki/Attempted_assassination_of_Ronald_Reagan assessed 111316

Altman LK. THE DOCTORS WORLD. New York Times. April 21, 1981

http://www.nytimes.com/1981/04/21/science/the-doctors-world.html assessed 111316

CRISIS MANAGEMENT LEADERSHIP: TRAINING TO SURVIVE THE CRITICAL MOMENT

Kenneth A. Lipshy, MD FACS