The Trach Incision -

[Robert Prudhomme]

I thought you'd never ask! LOL

Deviation of the trachea to the left (or the right) is the result of a respiratory emergency known as a "tension pneumothorax", more commonly referred to as a collapsed lung. As is typical of a lung injury, the lung is no longer able to fill and expand with each inspiration (indrawn breath), due to a tear or perforation of the lung tissue itself. However, instead of expanding the lung, air will travel through the lung and fill the pleural cavity the lung occupies. Often, air will enter this cavity but will be unable to return to the trachea when the patient exhales, due to the collapsed lung acting as a check valve. With each breath, the pressure and volume of air in the pleural cavity grows, until pressure begins to be exerted on the heart, superior and inferior vena cavae (large veins), pulmonary veins and arteries and the opposite unaffected lung; severely impairing the function of all these things. The problem is made worse by positive pressure ventilation, such as was administered to JFK with a respirator, once the tracheostomy was in place. 

One of the external signs of a tension pneumothorax is a trachea visibly deviated away from the side the tension pneumothorax is on.

As I said, this is a medical emergency and, if left untreated, has a very good chance of killing a patient.

JFK's back wound was much lower than what was reported in the autopsy, and the bullet entered the top of JFK's right lung. The 1/4 inch bullet hole through the flesh of JFK's back either sealed itself, or was sealed when JFK was laid on the gurney in Trauma Room One. Once this entrance wound was sealed, and positive pressure ventilation begun, a tension pneumothorax in the right lung was inevitale; explaining two very important points.

1. Dr. Carrico's observation of diminished breath sounds, especially in the right lung, when he listened to JFK's breathing with a stethoscope; following intubation of JFK with an endotracheal tube.

2. Dr. Perry's request that a chest tube be inserted into JFK's right lung and that this tube be connected to underwater drainage; the standard method for relieving a tension pneumothorax.

Edited November 18, 2016 by Robert Prudhomme

[Robert Prudhomme]

I thought you'd never ask! LOL

Deviation to the left (or the right) is the result of a respiratory emergency known as a "tension pneumothorax", more commonly referred to as a collapsed lung. As is typical of a lung injury, the lung is no longer able to fill and expand with each inspiration (indrawn breath), due to a tear or perforation of the lung tissue itself. However, instead of expanding the lung, air will travel through the lung and fill the pleural cavity the lung occupies. Often, air will enter this cavity but will be unable to return to the trachea when the patient exhales, due to the collapsed lung acting as a check valve. With each breath, the pressure and volume of air in the pleural cavity grows, until pressure begins to be exerted on the heart, superior and inferior vena cavae (large veins), pulmonary veins and arteries and the opposite unaffected lung; severely impairing the function of all these things. The problem is made worse by positive pressure ventilation, suc as was administered to JFK with a respirator, once the tracheostomy was in place. 

One of the external signs of a tension pneumothorax is a trachea visibly deviated away from the side the tension pneumothorax is on.

As I said, this is a medical emergency and, if left untreated, has a very good chance of killing a patient.

JFK's back wound was much lower than what was reported in the autopsy, and the bullet entered the top of JFK's right lung. The 1/4 inch bullet hole through the flesh of JFK's back either sealed itself, or was sealed when JFK was laid on the gurney in Trauma Room One. Once this entrance wound was sealed, and positive pressure ventilation begun, a tension pneumothorax in the right lung was inevitale; explaining two very important points.

1. Dr. Carrico's observation of diminished breath sounds, especially in the right lung, when he listened to JFK's breathing with a stethoscope; following intubation of JFK with an endotracheal tube.

2. Dr. Perry's request that a chest tube be inserted into JFK's right lung and that this tube be connected to underwater drainage; the standard method for relieving a tension pneumothorax.

 

 

 

Wow, sure killed that thread quick.

[Micah Mileto]

It's just that from hearing Perry's testimony about cutting the strap muscles, and knowing that a trach incision is a different thing from the incision in the neck, and also considering the metal trach tube that was inserted in and out of the throat, this issue could just be a bunch of baloney. Especially since Crenshaw's reliability is in question.

 

Obviously the autopsy doctors at least strongly considered the possibility that the throat wound was a bullet hole, and stuck probes through and into it, but the 6.5 cm wound with widely gaping irregular edges could be the real consequence from the Parkland incisions.

Edited November 29, 2016 by Micah Mileto
baloney not balogna.

[Robert Prudhomme]

You really don't have a clue what you are talking about. Not even close.

[Micah Mileto]

14 minutes ago, Robert Prudhomme said:

You really don't have a clue what you are talking about. Not even close.

When Perry et. al say that the trach incision was 2-3 centimeters, they're not talking about the whole incision over the neck, correct?

[Robert Prudhomme]

How did Dr. Perry know there was bruising to the apex of the right pleura? Was this not known about until the lungs were removed from JFK's chest at the autopsy?

Edited November 30, 2016 by Robert Prudhomme

[Robert Prudhomme]

Micah

This is taken from Dr. Perry's testimony to the ARRB. 

" MR. GUNN: could you describe about how big the tracheostomy wound was that you cut?
DR. PERRY: I've been asked this a lot. Of course, some of them said it was too big for a surgeon but my reply to that was that it was big enough.
There are only two medical emergencies, airway & bleeding. Everything else can wait. This just couldn't wait, and I had no idea how big it was. I made it big enough. At that time we used old metal flange tracheotomy tubes and quite large [sic] with a cuff on them. And when I made the incision through the wound , I made it big enough that I could look to either side of the trachea. There was blood in the trachea through the end - when I looked through the pharyngoscope and attempted to put in the tracheal tube with blood inside the trachea.
There was hair [sic = "air"] in the mediastinum, and I didn't know whether I was going to encounter carotid arteries or whatever. But the path of the bullet clearly put those vessels at risk as well as the trachea, so I made the wound big enough to do that.
How big it was, I don't know. I'm sure Dr. Humes measured it to see when they got there. When he found out it was a tracheostomy, he measured. But since I made the transverse incision, went right through it, I made it big enough to control an underlying bleeding blood vessel if necessary and big enough to do a trach.
How big it was, who knows. Ron might know, but I don't know. Big enough.
DR. JONES: I was busy putting in the left chest tube and doing a cut down on the left arm and I was not paying a lot of attention to that.
DR. PERRY: We were all -
DR. JONES: I thought it was about an average size incision. I didn't see anything abnormally large or abnormal length of the incision.
DR. PERRY: It was bigger than I would make for an elective situation. In a patient that's not in extremis where you're doing an elective tracheostomy you make a nice tiny skin line incision in order to minimize the subsequent scarring. In an emergency situation, you make an incision adequate to accomplish the job, and in this case it was going to take more. After I'd made the incision, Dr. McClelland arrived and his hands came in to help me with the tracheostomy, but I'd made the incision at that time but Bob may recall how big it was because he held the retractors for it. It was big enough for me to control the trachea, and if necessary, to do a little more."

From Wikipedia:

" In humans, the trachea passes ventrally to the esophagus, dorsally to the ascending aortic arch, but the left main bronchus from the trachea, passes ventrally to the descending aortic arch. The human trachea has an inner diameter of about 25 millimetres (1 in) and a length of about 10 to 16 centimetres (4 to 6 in). "

As the interior diameter of the trachea is 25 mm (2.5 cm), and Dr. Perry stated to the ARRB that he made the transverse neck incision long enough to give him a good view of the areas on either side of the trachea, in order to assess damage, and as the trachea was discovered to be not where it was expected to be but, rather, deviated to the left, I am beginning to believe a 2-3 cm. transverse incision in the skin of JFK's neck would not have been long enough to give him the control of the trachea and surrounding tissue he described. The tracheostomy tube used on JFK was described as being made from metal. Below is a photo of a typical metal tracheostomy tube from that era.

If the man's fingers in this photo are similar in size to mine, I would estimate this metal tube to be approximately 2 cm. in diameter; possibly smaller. Perhaps the 2-3 cm. incision was really a vertical incision in the trachea itself, large enough to accommodate a 2 cm. tracheostomy tube.

I am at a loss to understand how this metal tracheostomy functioned properly as, from what I have studied, the metal tracheostomy tubes did not have an inflatable cuff to lock them in place in the trachea and provide an airtight seal for positive pressure ventilation; unlike the inflatable cuff seen on a plastic tracheostomy tube.

What kept the air from escaping past the metal tracheostomy tube, with no cuff to seal the trachea off?

Edited November 30, 2016 by Robert Prudhomme

[Micah Mileto]

What's wrong with this? Why couldn't this have happened?

[Robert Prudhomme]

There is a great variety of tracheal incisions.

Considering that the trachea only has an inside diameter of 2.5 cm, and that Perry stated to Lifton he made an incision 2-3 cm. long, I would tend to think this was a vertical incision in the trachea itself he was describing.

Note, in second diagram, diameter of tracheostomy tube in relation to trachea; showing the obvious need to make a 2-3 cm. long incision in the trachea to accommodate insertion of the tracheostomy tube.

Edited November 30, 2016 by Robert Prudhomme

[Micah Mileto]

50 minutes ago, Robert Prudhomme said:

There is a great variety of tracheal incisions.

Considering that the trachea only has an inside diameter of 2.5 cm, and that Perry stated to Lifton he made an incision 2-3 cm. long, I would tend to think this was a vertical incision in the trachea itself he was describing.

Note, in second diagram, diameter of tracheostomy tube in relation to trachea; showing the obvious need to make a 2-3 cm. long incision in the trachea to accommodate insertion of the tracheostomy tube.

So.... the neck incision wasn't altered between Bethesda and the official start of the autopsy?

Edited November 30, 2016 by Micah Mileto

[Robert Prudhomme]

It's starting to look like there is a strong possibility of the incision in the skin of JFK's throat not being altered between Parkland and Bethesda although, while I strongly feel the throat incision could not have been 2-3 cm., the incision seen in the autopsy photo still seems to be too large.

Ever notice how Perry, in all of his testimonies and interviews, never actually states the dimensions of the throat incision?

Edited November 30, 2016 by Robert Prudhomme

[Sandy Larsen]

Robert,

Every time I've seen the 2 to 3 cm figure, I've gotten the impression that the doctor was referring to the incision in the skin. I don't know if that is what the doctors said or if I just assumed it. Do you know off-hand what the doctors actually said?

I just looked up tracheotomy, and the definition is the incision in the windpipe. So if the doctors said 2 to 3 cm was the length of the tracheotomy, then that settles that... 2 to 3 cm incision in the trachea.

[Robert Prudhomme]

I'm beginning to think this is the case, Sandy. All the photos I have seen so far of the metal tracheostomy tubes they were using in 1963 show these tubes to be about 2 cm. in diameter, meaning a 2-3 cm. incision in the trachea itself would be needed to allow the tube entry into the trachea. As the interior diameter of the adult male trachea is only 2.5 cm., I would wager Perry made the 2-3 cm. incision a vertical incision.

It hardly seems possible that Perry made a transverse incision in the skin outside of the trachea that, at 2-3 cm. long, could have been shorter than the outside diameter of the trachea.

Edited December 1, 2016 by Robert Prudhomme

[Robert Prudhomme]

What is never discussed is whether or not Perry truly observed the deviation of JFK's trachea to JFK's left prior to making the throat incision, or only after he was able to see the trachea up close. If he did observe the deviation leftward of the trachea prior to opening the throat, did he appreciate just how far to the left it was deviated, and how this would affect the tracheotomy procedure? It is entirely possible he made a very symmetrical throat incision, only to find he had to extend this incision to JFK's left just to get complete access to the left side of JFK's trachea.

[Sandy Larsen]

I vaguely recall someone on the forum saying that the tracheotomy incision was vertical. I replied by pointing out that the stare-of-death autopsy photo clearly shows the incision to be horizontal. IIRC the person did not defend what he'd said. If he read that somewhere, I wish he had defended it by referencing the source of that information. I'd like to see it.

For a long time many have said that the incision we see in the stare-of-death photo is significantly wider than the reported 2 to 3 cm. And only now it is being discovered that this was based on a fundamental misunderstanding the whole time?  I find that unsettling.