Saving King

by Edison McDaniels, MD

In all of American history, surely one of the most atrocious acts of gun violence took place on the evening of April 4, 1968. No less a personage than George Wallace, the avowed segregationist, called the shot that rang out at 6:01 pm in Memphis, Tennessee “a senseless, regrettable act.” President Lyndon Johnson canceled an important trip to Hawaii — he had been scheduled to meet with his military commanders about strategy in Vietnam — upon learning of King’s death.

Over 100 American cities erupted into rioting on the news of what this single gunshot accomplished.

We are speaking, of course, of the bullet that stilled the greatest voice in the American civil rights movement, the Rev. Dr. Martin Luther King, Jr.

These facts are well known and not in dispute: King was shot at 6:01 pm and was pronounced dead at 7:05 pm at St. Joseph’s Hospital after a failed attempt at open cardiac massage. He was 39 years old.

According to King biographer Taylor Branch (At Canaan’s Edge: America in the King Years, 1965–68), King was standing on the balcony outside room 306 on the second floor of the Lorraine Motel when Jesse Jackson hollered up to him: “Doc, you remember Ben Branch?” King replied “Oh yes, he’s my man.” King then said, “Ben, make sure you play ‘Precious Lord, Take My Hand,’ in the meeting tonight. Play it real pretty.”

Ben Branch replied “Okay, Doc, I will.”

There was no reply. King had spoken his last words, and in the words of biographer Taylor Branch, time on the balcony had turned lethal and King’s sojourn on earth went blank.

But did it? Did it do so immediately? Was King doomed the moment that bullet crashed through him? Is there any action that might have saved his life as he lay supine on that balcony. Bleeding profusely from a wound to his right jaw and neck? He wasn’t pronounced dead for 64 minutes. Was he, in fact, alive during that time? Was there ever a chance he could have been saved by the relatively crude trauma care of 1968? And how about today? If King was shot in 2013, might he survive?

The state of the art in trauma care in 1968 was primitive by today’s standards. There was little or no pre-hospital care, little or no recognition of the importance of the golden hour, no concept of the trauma center or a community-wide trauma system, no specialized training in trauma life support, and no surgical subspecialty in traumatology.

Today, care of the injured begins at the scene of an accident, with pre-hospital personnel trained in the care of injured patients. These are paramedics and EMT personnel. They are well versed in how to identify and treat the things that kill folks in the first minutes after an accident, whether it be a fall, a motor crash, or a gunshot wound. These things include clearing an obstructed airway of blood, teeth, dirt, vomit, etc. In some cases this might even mean performing a surgical airway — an emergent trach — incising the front of the neck down to the trachea and inserting a tube. This dramatic move bypasses the mouth, tongue, and throat (as well as anything obstructing those areas) and is often life-saving.

First responders, as they are called, know how to control bleeding fast and efficiently. Some years ago, as a medical student, I was involved in the care of a six year-old girl who had lacerated an artery in her arm in a car accident. This little girl died of exsanguination — she bled to death for lack of somebody at the scene who know enough first aid to apply direct pressure to her wound, her only injury. First responders recognize this danger and act.

First responders aren’t only reactionary however, they are proactive. They start IV’s and begin administering fluids at the earliest opportunity. It is now well recognized that blood volume is as important — in some very acute situations more important — than oxygen carrying capacity. The practical result of this is that if a person is bleeding (internally or externally), giving them any fluid by vein is better than waiting for blood or blood products to become available. Maintaining blood volume is an important aspect of trauma care in general, and during the golden hour specifically.

First responders also administer medications and relay their findings as to a patient’s status (injuries, vital signs, etc) so that the trauma center is ready when the patient arrives.

***

The time is the 4th of April 1968, a cool Spring evening close on six pm. The place is a predominantly black neighborhood on the south edge of downtown Memphis, Tennessee. An area of run-down homes and low incomes. At 450 Mulberry Street there sits a small, modestly upscale boarding establishment, the Lorraine Motel. It is two stories and there is a pool, installed by the motel’s long time owner, Mr. Walter Bailey. The motel is popular among black musicians who frequent the nearby Stax Records. Over the years these have included Ray Charles, Lionel Hampton, Aretha Franklin, Ethel Waters, and Otis Redding before his death the year before.

Across the street and beyond a small brushy knoll is a two-story brick rooming house. 422 Main Street. On the second floor of this shoddy establishment, at the window of a small bathroom, a man named James Earl Ray waits with a 30.06 rifle. Ray has a clear view of the Lorraine Motel, of room 306 on the second floor.

It is one minute after six in the evening and, in the time it takes a bullet to fly the length of the knoll, everything changes.

Martin Luther King, 39 years old, has already survived one assassination attempt. Ten years earlier, on September 20th, 1958, a deranged black woman with the bewitched name of Izola Curr plunged a steel letter opener into his chest — his sternum actually — while he was holding a book signing at a Harlem bookstore. Three hours of emergency surgery at Harlem Hospital saved his life. The blade missed his aorta by a hair’s breath.

He will not be nearly so lucky this time.

“Doc, you remember Ben Branch?” Jesse Jackson asks from his position on the pavement below the balcony. He is standing with several other men, including Ben Branch, James Bevel, Chauncey Eskridge, Hosea Williams, Andrew Young, and Solomon Jones, Jr.

King turns and steps around a maid’s cart, moves along the balcony to the exposed corner outside room 306. In the office, the hotel owner’s wife Lorene, who doubles as the switchboard operator, steps outside to peek at the party of men, perhaps wanting a glimpse of the famous Dr. King.

Up on the balcony, Minister Billy Kyles takes a few steps down the stairs. King stands at the rail and replies to Jackson. “Oh yes, he’s my man,” he shouts downward, “Ben, make sure you play Precious Lord, Take My Hand, in the meeting tonight. Play it real pretty.” The Rev. Ralph Abernathy smiles and steps back into his room to get some cologne.

Ben Branch hollers up, “Okay, Doc, I will.”

The hard, acute sound of a car backfiring on the road — only not — comes unbidden on the night air. Up on the balcony, King collapses on the instant, falling to the deck with a heavy thud. Outside the office, Lorene Bailey gasps, slaps the side of her head with her hand, and looks generally like a stricken woman. She has of a sudden developed a mad tick, her neck flinching to one side repeatedly and pulling her head with it, her eyes blinking in a rapid, almost grotesque fashion. She does not scream.

Abernathy runs out of his room to find a large pool of blood spreading around King’s head and shoulders. He bends to his stricken friend, uncertain at first what to do. He takes King’s head in his hands, noting the gaping tear along the right side of King’s lower face.

“Martin,” he says, “it’s all right. Don’t worry. This is Ralph.” Then again, “this is Ralph.”

King is still, without any sense of recognition about him. His jaw lolls at an angle hard to look at.

Abernathy extends his own neck, works his own jaw. His eyes are wide, telling, already creased with tears. Kyles is there beside him, the two say nothing to each other but much is apparent nonetheless. Kyles runs to the room to call an ambulance.

In the motel office, the switchboard lights up and the phone line buzzes, but there is nobody to answer it. Lorene Bailey has not stepped back inside. She continues to stand outside the office door, leaning against the jamb, still slapping herself. She has begun to mumble incoherently. She will never answer the switchboard.

Jackson, the others close behind, scrambles up the stairs. Collectively, they come to rest standing over King’s motionless body, Abernathy still crouched beside him, blood on his hands. They look up, almost as one, all seeming to have the same idea at the same moment. Where did the shot come from? The gathered men begin to point in the direction of the rooming house across the street.

Kyles, unable to get through on the motel phone, gives up after a minute or two and returns to the balcony. The puddle of blood around and under King is growing.

King himself is still not moving. Jackson takes his hand and feels for a pulse at King’s wrist, convinces himself he can feel one, convinces himself King is still alive and there is still hope.

At this moment, an undercover Memphis police officer, Marrell McCollough, arrives. He grabs a cleaning rag as he passes the maid’s cart and is the first to make a serious attempt to stop the bleeding. Another police officer finally calls for an ambulance.

Perhaps ninety seconds have passed since the sniper’s bullet felled the Reverend.

***

It will be another fifteen minutes, perhaps twenty, before Dr. King arrives at the nearest hospital and doctors can begin resuscitative efforts. In the interval, nobody thinks to assist with his breathing. Nobody can see the cyanosis — the blueness of oxygen deprivation — in his dark skin.

When he arrives at St. Joseph’s Hospital, valuable time is lost assessing King’s condition. The doctors have not been in touch with the first responders during the prehospital phase — indeed, these first responders have done little more than scoop and run, offering no actual first aid — and so when King comes through St. Joseph’s doors, no one is prepared.

Dr. King is being bagged, though it is not clear any air is getting through his swollen airway and into his lungs. He is not breathing on his own and his blood pressure is beyond measure. Still, the EKG traces a jagged, rhythmic line on the CRT screen. His pulse is faint but present at the groin, lost altogether in his extremities, which feel cool to the touch. He has lost perhaps half his blood volume and is well into the dead zone of acute hemorrhagic shock.

The doctors and nurses — there are no EMTs, no paramedics, nobody dedicated to the study of trauma — struggle to find a vein. They can’t get IV access with the vessels collapsed. One of the docs cuts down on King’s swollen, distorted anterior neck, opening his trachea and passing a tube into his lungs to deliver oxygen. Still others cutdown over his left ankle and in the crease of his left elbow in their desperate quest to find a vessel. It has been perhaps thirty minutes. Time — and life — are slipping away.

The EKG tracing continues to show a heartbeat, but no pulse is palpable at the groin or anywhere else. This is complete circulatory collapse, a lethal land where the heart beats but there is nothing in the pipes to fill it and so nothing to pump forward. The cutdowns have found there mark however, and now saline and universal donor blood begin to pour into the cannulated veins — the pipes begin to fill.

Except that now King’s heart has become an ineffective quivering mass of muscle, unable to deliver on its promise. Those gathered at his bedside decide upon a final, desperate gambit. A surgeon picks up a knife and incises over the left side of the chest, just under the nipple and parallel to the ribs. It is a long incision, opening half of King’s chest along the top of a rib from his breastbone to his left side.

In one fell swoop, the knife cuts through skin, muscle, and sinew to expose the papery lung, which bellows up and down into the incision with the pace of the ventilation. There is little bleeding because there is little blood present to bleed. The surgeon reaches in with both hands, grasping the ribs above and below the wound, and yaws the hole wide with all his might until there is a palpable — and audible — ‘pop’ as the ribs fracture out of the way. This is not a time for subtlety.

The exposure thus gained, the surgeon now reaches heartwise with one hand and wraps the hollow, collapsed muscle with his fingers. He begins to squeeze, closing his fingers fistlike, then opening them again in a rhythmic dance, encouraging the heart to fill and empty, fill and empty…

This futility continues for twenty or so very long minutes before King is pronounced dead at 7:05 pm, sixty-four minutes after being shot.

That is how it was in 1968.

***

In February 1976, an orthopedic surgeon, Dr. Jim Styner, crashed his small plane in a rural Nebraska cornfield. He sustained serious injuries, his wife was killed instantly, and three of his four children sustained critical injuries. The subsequent care he and his family received at the first hospital was inadequate and, in the doctor’s words, worse than he was able to deliver at the site of the crash itself. There had to be a better way.

Out of this grew the modern trauma system used throughout the United States today. The system recognizes the importance of the golden hour, the significance of pre-hospital care, and the concept of a trauma system wherein injured patients are taken not to the nearest hospital, but to the nearest trauma center.

Dr. Styner’s experience led directly to the development of the ATLS certification, which is largely required today by anyone involved in trauma care. ATLS means Advanced Trauma Life Support, and it teaches a standardized method of trauma care and evaluation in which the most life threatening items are addressed first. It has very likely saved over a million lives.

In addition to all of this, there are now surgeons who specialize in trauma surgery (incidentally, the first civilian trauma surgeon in the US may have been Dr. George E. Goodfellow, who performed the first modern exploratory laparotomy (belly surgery) for a gunshot wound on July 13, 1881, in Tombstone, Arizona of all places — this was just 11 days after President Garfield was shot in the belly, dying months later of his wounds, or perhaps of the treatment he received for those wounds). These are the folks who man the trauma centers 24/7, and along with the nurses, technicians, and paramedical personnel, they make the system work.

None of this was in place in Memphis in April 1968.

King was shot with a .30 caliber rifle. The single bullet struck him in the right side of his jaw, just behind and below the corner of his mouth. His jaw was fractured. The bullet appears to have had a downward trajectory, passing into his neck, where both the right external jugular vein and vertebral artery were severed. The bullet transected his spinal cord at the C7/T1 level and came to rest in the muscles over his left scapula (shoulder blade), just under the skin about three inches off the midline. It did not pass through his chest, lungs, or the heart. There was apparently considerable damage to his throat (pharynx) and to the soft tissues on the right side of his lower face and neck.

King was under surveillance by both the Memphis police and the FBI at the time of his assassination, and the assassination was in fact witnessed by the police. The first person to him was a police undercover agent, who used a cleaning cart towel to staunch the “profuse” bleeding.

King was apparently immediately unresponsive, or at least unconscious. One report says he had a pulse after he was shot. There is no report of him regaining consciousness, nor are there any reports of him moving or writhing around. There was considerable blood apparently.

The fractured jaw would not have been fatal, though it would have bled significantly. He could have had airway issues however, with blood and teeth in his throat, as well as blast injury to the soft tissues. A bullet causes a wave of cavitation around it, stretching and tearing tissue. This is an instantaneous wave, which dissipates immediately but the damage is done. There is no evidence anyone did anything to improve King’s airway, which suggests he might have been deprived of oxygen very quickly.

His external jugular vein was severed by the bullet. This is not an especially large vessel and would not likely have accounted for much of the blood. An injury to the external jugular, despite what the movies try to suggest, is generally not fatal.

***

Unfortunately, injury to the vertebral artery may very well be fatal. There are three reasons for this. First, this is a major artery which can and frequently does bleed profusely when injured. Not always however. It certainly can clot or spasm shut.

Blood loss, however, is not the biggest problem when the vertebral artery is injured with penetrating trauma such as a gunshot. This artery is very well protected, not only deep inside the neck but largely encased in bone as well. It is also close to the spinal cord and thus it’s injury implies a very serious injury in which the spinal cord is also at risk. More on this in a moment.

The third problem with the vertebral artery is that it may be the sole or major blood supply to the all important brainstem, the area of the brain which controls blood pressure, heart rate, respiratory response, etc. These are the so-called vegetative functions, that is, the basic functions that support human life. This part of the brain was the first to develop evolutionarily speaking, because without it no life can exist. Significant injury to the brainstem is not compatible with any reasonable life experience — and generally not compatible with life at all.

Most people have two vertebral arteries, one left and one right, although one or the other is often dominant (larger). The paired arteries ascend in the neck and converge at the skull base to form the single basilar artery, which actually feeds the brainstem. Damage to one vertebral artery is generally not fatal in a 39 year old, although in an older person it could be (if they have bad atherosclerosis with occlusion of one artery). Damage to a single dominant vertebral artery could also be fatal if the the nondominant artery is too small to take over. King appears to have had normal cerebral blood vessel anatomy on autopsy, so this would not have been an issue. His undamaged left vertebral artery should have been sufficient to supply his brainstem.

It is unlikely King received any significant pre-hospital care. The autopsy shows that great efforts were made to resuscitate King once he arrived at the hospital. Cutdowns were undertaken in his left arm and left ankle, probably in an effort to gain access to his collapsed blood vessels. Placing an IV in an individual with very low blood volume from profuse bleeding can be quite challenging. An old method, though still used today, is to incise over the blood vessel and visualize it directly while cannulating it. A more reliable method today, proven time and again in Iraq and Afghanistan, is to place an intraosseous line — sticking a large needle through the skin and into the bone marrow of the upper arm, the sternum, or the tibia. This is fast and does not require an advanced knowledge of anatomy. And once the bone marrow is accessed, it acts like a superhighway to the venous system. While this method was known in 1968 and was probably used in Vietnam, it was not apparently used on King.

An emergency tracheostomy was done, though likely only after a prolonged period of airway compromise. Prolonged because we do know there was a delay in calling the ambulance. In what must be viewed as an almost cosmic coincidence, the motel’s switchboard operator (and namesake, the owner’s wife Lorene) had stepped away from her station to observe Dr. King. Apparently, she witnessed the assassination, but we will never know what she saw for sure. The event must have traumatized her in the extreme, for she began to mutter incoherently and quickly became useless. She was taken to the hospital herself, and died five days after Dr. King. She had suffered either a heart attack, or, more likely given her incoherent babbling, an intracranial hemorrhage. There were two casualties at the Lorraine Motel that day.

The ambulance was apparently dispatched by the police surveillance unit after a delay brought on by the confusion of the situation. Meanwhile, King was likely not breathing (as I shall show in a moment), or at least not breathing in any effective manner. The first order of business in ATLS is airway protection and there is a reason for this. With just 3–8 minutes of airway compromise, brain damage is likely and the odds of recovery — even survival — diminish appreciably. Time does not stand still in the moments after a major trauma.

***

So King was shot through the right jaw and neck and lay bleeding profusely on the second floor balcony of the Lorraine Motel. He was not moving and appeared to be unconscious to all observers. Some thought he was dead already, though this is unlikely since dead men do not bleed (bleeding requires a beating heart to push blood out; that’s actually the definition of bleeding). A police officer tried to staunch the bleeding with a towel. Could anyone have done better? And would it have made a difference?

Two things might have made an immediate difference. First, and at the very least, King needed a surgical airway at the scene, something likely not available in 1968 Memphis, where there were no paramedics. All of the bystanders, including the police officer, appear to have been overwhelmed by the profuse bleeding and, perhaps, by the enormity of the personage laid on the balcony before them. Being overwhelmed by profuse bleeding is common in untrained personnel, and one of the hallmarks of a trauma professional is NOT being overwhelmed in such a situation. You go back to the basics. The basics here suggested ensuring an airway, while at the same time controlling the profuse bleeding.

The bleeding. Stopping the bleeding would have been difficult, maybe even impossible. But it possibly could have been slowed by direct pressure and slowing it might have been all that was necessary — if someone had been present to place a large bore IV, preferably two, or, even better, an intraosseous line. Recall that in the acute situation, maintaining blood volume (more properly this would be intravascular volume) is more important than maintaining blood itself. Giving King several liters of saline through an IV or IO line would have supported his blood pressure and prevented circulatory collapse, which would have allowed the doctors at St. Joseph’s Hospital to concentrate on his true injuries — rather than opening his chest to perform open cardiac massage, an act of desperation that rarely works (probably less than 1% of the time).

By the time King arrived at the hospital, he was likely in complete circulatory collapse, including something called electromechanical dissociation, in which the heart beats but there is nothing filling the vessels and so the pumping is ineffective. Sort of like a hydraulic pump after a pipe has ruptured and the lines are empty. You can run a pump like that forever, but it won’t do any good. Well, the human heart won’t run forever in that situation, though it will keep up for awhile, especially in an otherwise healthy 39 year-old. Had he been sixty or sixty-five, with advanced coronary disease, he might have had a heart attack and his heart might have stopped before he got to the hospital. But as it was, it was likely still beating — albeit ineffectively — when he got to the hospital.

That’s why the doctors on duty decided to ‘crack his chest’ as it’s called. It was a last ditch effort to squeeze out whatever was present in his vessels, while at the same time they performed the cutdowns to try to reinfuse some kind of blood volume, probably either saline or O positive blood transfusions. It was, however, a case of too little too late. By then, Dr. King was already dead, at least from a brain and neurologic perspective. He could not have survived without help in the field from the very first.

But what if he’d had that help? What if someone had been present to do a surgical airway and to control the bleeding? Could he have survived then? Could he have recovered to sermonize another day?

Unfortunately, no.

***

Dr. King’s injuries, according to the autopsy, included a complete transection of his spinal cord at C7/T1. In additional to the bullet transecting the right vertebral artery, a structure very close to the spinal canal as noted above, the bullet also transected his spinal cord. The result: he was immediately paralyzed below the neck. At best, he might have been able to move his upper arms, though this was not mentioned in any of the witness statements.

And this paralysis would have been permanent.

More to the point, however, the acute transection of the spinal cord at C7/T1 would have made spontaneous breathing difficult, though not impossible. Lots of people suffer such an injury and are able to breathe unaided. What made the difference in King’s case?

Breathing relies on two sets of muscles, and two intact sets of nerves to move those muscles. One set of muscles, the intercostals, are stretched between the ribs. The nerves to them come directly off of the spinal cord at various levels between T1 and T12 or L1. All of these nerves are rendered immediately useless when the cord is injured in the cervical (neck) region.

The second set of muscles of breathing is really one muscle: the diaphragm. The diaphragm is innervated by the phrenic nerve, which arises from the mid-cervical region C3-C5. Hence, an injury above C3 (such as in the case of actor Christopher Reeves) results in complete inability to breath on one’s own and the need for a respirator. These patients need artificial respiration immediately at the time of injury or they do not survive. This is the usual cause of death in high cervical cord injury.

Thus, patients injured at C5 or below are able to breath on their own usually. Patients injured above C5 are not.

Dr. King was injured at C7/T1, shouldn’t he have been able to breathe on his own?

Not so fast. Recall the phrenic nerve innervates the diaphragm. The phrenic nerve arises at C3-C5, then passes through the soft tissue of the neck, into the chest, and eventually reaches the diaphragm. The nerve is, or course, vulnerable to injury anywhere along this path.

In Dr. King’s case, his cord was transected at C7/T1, knocking out all of the intercostals, which meant he had to rely completely on the paired phrenic nerves, one left and one right.

But the right side of his neck was heavily damaged by both the bullet itself — and the blast injury, that is, the concussive wave from the energy of the bullet. It is entirely possible, if not likely, the right phrenic nerve was anatomically or physiologically severed as well. In such a situation, he had only the left hemidiaphragm working — only the left chest to breath with.

He must have lost something like 80% of his breathing capacity in the instant the bullet struck. Nobody could have survived that without artificial respiration, and so one has to conclude Dr. King was indeed doomed from the moment the bullet found its mark.

To have had any chance to survive, Dr. King would have needed not just a surgical airway, but artificial respiration as well. In addition, he needed his bleeding slowed if not halted, while at the same time placement of an immediate and reliable large bore IV access, preferably an intraosseous line.

If he had had all of these things, he might have survived long enough to get to a competent trauma center, but probably not long thereafter. It is very unlikely all of this could have been accomplished — even today — without some extended period of hypoxia (oxygen deprivation), resulting in brain damage and stroke. It is possible that since Dr. King was rendered immediately unconscious by all witness accounts, he very quickly lost adequate blood flood to his brainstem. Most patients will faint with just a 10–12 second interruption of blood flow to the brainstem.

In addition to all of the above, Dr. King’s spinal cord injury, a complete transection at C7/T1, rendered him immediately paralyzed below the neck.

One must conclude that his particular injury pattern was severe and not survivable in 1968. Even today, his case would offer great challenges. It is possible — with timely emergent care and under the best possible conditions — that he would survive the initial injury long enough to make it to the ICU, though whether or not he would ever wake up is questionable.

In the words of the Edwin Smith Papyrus, that most ancient and wise medical and surgical treatise, this was an injury not to be treated. Under the best of circumstances, even today, it was not compatible with any quality of dignified human life.

Dr. King was indeed doomed from the moment the bullet found its mark.

***

Here’s how it would be today.

It is one minute after six in the evening.

“Doc, you remember Ben Branch?” Jesse Jackson asks from his position on the pavement below the balcony. He is standing with several other men near the car intended to take them to dinner.

King turns and steps around a maid’s cart, moves along the balcony to the exposed corner outside room 306. In the office, the motel owner’s wife Lorene, who doubles as the switchboard operator, steps outside to peek at the party of men, perhaps wanting a glimpse of the famous Dr. King.

Up on the balcony, Minister Billy Kyles takes a few steps down the stairs. King stands at the rail and replies to Jackson. “Oh yes, he’s my man,” he shouts down, “Ben, make sure you play Precious Lord, Take My Hand, in the meeting tonight. Play it real pretty.” The Rev. Ralph Abernathy steps back into his room to get some cologne.

Ben Branch hollers up, “Okay, Doc, I will.”

When the shot pierces the evening, Minister Billy Kyles pauses and turns on the stairs. He thinks at first thought a car has backfired on the road. But up on the balcony, King collapses to the deck. Outside the motel office, Lorene Bailey gasps, slaps the side of her head with her hand, and looks generally like a stricken woman. She has of a sudden developed an acute tick, her neck flinching repeatedly and her eyes blinking in a rapid, almost mad fashion. She does not scream.

At the sound of the shot, Abernathy fears the worst and runs out of his room to find a large pool of blood spreading around King’s head. Abernathy grabs a towel from the maid’s cart and bends to his stricken friend, trying desperately to staunch the flow of blood. He takes King’s head in his hands, noting the gaping tear along the right side of King’s jaw. “Martin,” he says, “it’s all right. Don’t worry. This is Ralph.” Then again, “this is Ralph.” King is still, without any sense of recognition about him. Abernathy holds pressure on the wound.

The Reverend Abernathy looks up, eyes wide, misty, and telling. Kyles is there beside him, the two say nothing to each other but much is apparent nonetheless. Kyles runs to the room to call an ambulance. He presses 9 and then 911 and it gets picked up immediately. He doesn’t even have to give an address. The system is dynamic and the address of the motel, 450 Mulberry Street, pops up on the operator’s computer screen without prompting. Paramedics are dispatched immediately and arrive within five minutes.

In the interval, a Memphis undercover police officer arrives on scene and attempts to administer mouth to mouth resuscitation.

Lorene Bailey has not stepped back inside the motel office. She continues to stand outside the office door, leaning against the jamb, still slapping herself. She has begun to mumble incoherently. She will never step inside the motel office again and will die within several days of the intracerebral hemorrhage that is even now seeping into her brain. This odd coincidence is perhaps a result of what she has witnessed this evening, or perhaps it was just her time.

Jackson and the others scramble up the stairs. Collectively, they come to rest standing over King’s motionless body, Abernathy still crouched beside him. They look up, almost as one, all seeming to have the same idea at the same time. Where did the shot come from? The gathered men begin to point in the direction of the rooming house across the street.

Kyles, having gotten through to 911, returns to the balcony. The puddle of blood surrounding King is large, but not growing.

King himself is still not moving. Jackson takes King’s pulse, convinces himself he can feel one, convinces himself King is still alive and there is still hope.

The undercover Memphis police officer, Marrell McCollough, continues his efforts at mouth to mouth.

Within five minutes, Memphis paramedics arrive. Their first order of business is to assess King’s airway, control the bleeding, and take his vitals. His pulse is 140 — very fast. BP is 90 over palp, then 80 over palp on retaking. The diastolic is too low to register properly. King is diaphoretic and not breathing on his own. And there is a jagged hole in the right side of his lower face, with blood welling profusely every time the compressing towel is lifted.

“St. Joseph’s, this is squad 51,” the paramedic says into his radio.

“Go ahead 51,” the voice on the other end, that of an ER doc, says.

“We have a black male, 39 years of age, gunshot wound to right face and neck. And sir — “

“Yes?”

“Sir, it’s Dr. King.”

The voice on the other end is silent a moment, then the sound of air being taken in. “Right. You say Dr. King?”

The paramedic nods his head in the affirmative, perhaps forgetting himself in the moment, then continues talking to the radio, giving the vitals. “There’s a great deal of blood, mouth is full of debris, swollen. O2 sat is 70.” As he says these words, he elevates King’s legs, placing a pillow under them. He pulls the eyelid down, checking for cyanosis, then confirms the bluish discoloration present under the fingernails. King’s life blood is slipping away. Literally.

“I’ll have to do a criik — a surgical airway.”

The ER doc on the other end of the radio concurs. “Good luck, man.”

The paramedic drops the radio, needs two hands. His partner continues to work on the wound, removing the towel and stuffing the hole with gauze. The bleeding slows to a trickle. Progress in the battle, if not the war.

The paramedic feels the front of the neck, discerning the anatomy, feeling for the cricoid cartilage. This is difficult, feels nothing like the models he has practiced on, nothing like the necks he has felt back at the station in preparation for just such a moment. The jaw is looser than it should be, and he can feel pieces of bone moving about under the skin, like gravel he thinks. His fingers slip in the blood as he moves to the midline. Finally he determines where to cut, pauses to simultaneously take a deep breath and say a prayer, and cuts. He makes a one inch vertical incision just over and below the adam’s apple. There is bleeding, not huge, and he deepens the cut. He feels with his finger, probing ever deeper with the digit until he finds the gristly cartilage of the trachea.

He takes another deep breath — the first pulse you should take at any emergency is your own he recalls — and makes a final stab with the scalpel into King’s airway. The relief is palpable on both their parts — King’s chest rises as air flows in and the paramedic’s own breathing normalizes. He has been hyperventilating without realizing it.

All of this takes no more than two or three minutes.

With the bleeding controlled and the airway secured, he turns his attention to gaining some sort of access to King’s vasculature. A large bore IV, preferably two. If he doesn’t do it now, the man’s circulatory system may collapse altogether from unrestored blood loss. It’s now or never, but a cursory search of King’s arms and legs — his clothes have been cut away by now — fails to find a suitable vein.

There’s a weak pulse at the groin, still in the 130 range, but just now that is too unreliable. He might be able to hit the vein with a needle, or he might not. The paramedic needs a sure thing. He determines to go IO — intraosseous.

It’s a large needle, 14G, and long, about five inches. He recalls the three common spots he could use — the shin over the tibia, the sternum, or the humerus just below the shoulder. He chooses the humerus, with its bony prominence, and slams the needle home, pushing heavily to core into the bone. This generally hurts like hell, but the paramedic notes King does not move. A bad sign.

He checks King’s pupils quickly. They are 3–4 millimeters in size and constrict to light. A good sign. Dead pupils don’t react to light. King is still with them. Time to move.

He applies a cervical collar and they wrap King in a blanket to keep him warm. Once bundled, they roll.

St. Joseph’s is waiting when they arrive and Dr. King is immediately moved into the trauma bay. Several doctors, an ER doc and a trauma surgeon among them, do a quick assessment as the first responders give way to the trauma team. The nurses check the IO and establish several more large bore IV’s. This is easier now because the paramedics have given him several liters of saline during the transport over, replacing blood volume. Now they hang O negative blood as well.

An intern slips in a foley catheter, checking for a femoral pulse simultaneously. The urine runs as a pale yellow fluid into the bag between the injured’s legs. There is nothing to suggest any blood in it, meaning neither the kidneys nor the bladder have been injured. A quick frontal chest x-ray is obtained. The results show the lungs are fully expanded and the trach tube is appropriately located. There are no bullet fragments in the chest cavity — this is a momentary relief — but the lower neck shows a great deal of damage to the spine.

“Has he moved? Has anybody seen any movement in his extremities?” the trauma surgeon in charge hollers loud enough to be heard by everyone assembled in the trauma bay. A few nod their head ‘no’ while most remain silent.

“BP 100/60, pulse 110. Oxygen sat 89%.”

The room is a whirl of activity. The trauma surgeon points and an aide rushes off to alert CT. An ER doc quickly runs an ultrasound probe across the upper abdomen. The results are normal. The soft abdomen shows no sign of internal injury.

Attention turns to the upper chest and neck. There is much blood here, but the packing remains in place. King’s vitals have stabilized, suggesting whatever bleeding is going on is not immediately catastrophic. A respiratory therapist continues to bag him, squeezing the bellows attached to the tube disappearing into King’s throat by hand. She does this at a steady pace, perhaps twenty times a minutes, using both hands. Everybody works around her.

Less than ten minutes after he arrives, Dr. King is wheeled out of the trauma bay. The floor is awash with blood, packaging material, a pillow, discarded needle caps, and an IV bag somebody dropped in their haste. One of Dr. King’s black patent leather shoes sits on its side against the bottom of a cabinet beside the entry door.

Once in CT, the patient is carefully but efficiently transferred to the CT table, which is then advanced into the gantry. The respiratory therapist has donned a lead apron and has continued her efforts at bagging the Reverend. It is not clear if he could initiate a breath on his own and now is not the time to find out.

The doctors — a radiologist, the trauma surgeon, several surgical residents, the ER doc — a half dozen nurses and assorted other folks fill the CT control room, protected from the radiation by the lead in the walls. They watch the table slide into the gantry of the machine as the scanning starts. The first pictures are of the brain — and they are modestly reassuring. There is nothing to suggest the bullet entered the braincase, that is, nothing to suggest the bullet passed into or through the skull — or the brain.

Likewise, on these first images, taken perhaps thirty or forty minutes after Dr. King’s collapse on that balcony, there is no evidence of a stroke, no evidence the brain itself is nonviable.

But the next pictures the CT gives up are anything but comforting. They show a cervical spine befouled by violence. The bullet has torn across the right side of the neck, from above downward, from lateral to medial, from front to back. The path of the bullet seems to have been calculated to do as much damage as possible.

The right side of Dr. King’s lower jaw is blown apart. Indeed, as the scan shows, bone and teeth fill both his mouth and throat. There is a massive soft tissue gash down the right side of the neck, from jaw to the hollow of his shoulder just above his collar bone. The seventh cervical and first thoracic vertebrae are fractured, and it is apparent the bullet has passed directly through the spinal canal. From there, the bullet somehow has come to rest just superficial to the left shoulder blade, about three inches off the midline, just deep to the skin.

The surgeons glance each to the others, perhaps looking for solace, for a forgone hope. They all know. There is no way the spinal cord is not severely damaged, no way the Reverend is not paralyzed. This is bad, very bad, all the moreso because it must have happened at the moment of impact — and rendered him unable to breath.

The same question passes through every mind in the room. How long was Dr. King not breathing? How long was he without oxygen? His heart is beating now — their actions have seen to that — but to what effect? He might just as well have drowned on that balcony. With no ability to move air in and out of his lungs, the blood his heart pumped lacked oxygen. Game over, now or later.

He will linger a time in the ICU, a few hours or perhaps a few days, but in the end the combination of profound blood loss and spinal cord injury are too much. Dr. King never had a chance. Not in 1968, and not in 2013 either.

He is free at last.

Note: This is a work of creative nonfiction.

About The Author

Edison McDaniels is a practicing surgeon & wordsmith, who writes short stories, novellas, and novels when he’s not incising skin. Read more about him at www.surgeonwriter.com and look for his fine & intense works of fiction at the Amazon Kindle store.

His latest novel, Not One Among Them Whole, is available for the Kindle and as a trade paperback from Northampton House Press.

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