Historic Trauma

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Historic Trauma: The Enduring
Health of Ronald W. Reagan
A look back at how he survived
significant traumatic injuries
and health issues.
Cynthia Blank-Reid, RN, MSN, CEN
Trauma Clinical Nurse Specialist
Temple University Hospital
Philadelphia, PA
Presidential Characteristics
Ronald Wilson Reagan
• 40th President (1981-89)
• Born: Feb. 6, 1911 in
Tampico, IL
• Died: June 5, 2004
Beverly Hills, CA
• Oldest individual to be
elected President (70 yrs)
• Governor of CA (196775)
• Radio announcer,
television and movie actor
Presidential Life Expectancies
• Earlier presidents lived
longer than their expected life
expectancy. They lived in to
their 70s and 80s. (Avg 74)
• Tendency toward premature
death has become more
prominent in the past century
(avg loss is 7-16 years)
• Supreme Court Justices live
longer than their
counterparts in the
Legislative or Executive
branches of government
• Public service vs. self
service
• War hero
• Attorneys
• From Virginia, Ohio or
Massachusetts
• Strong female in their
life (mother or wife)
• Poor or rich
Common Presidential
Conditions
• Medical
• Cardiovascular
– Coronary artery disease
– Hypertension
• Gastrointestinal
– Stomach issues
– Diarrhea, constipation or
irritable bowel syndrome
• Stress
• Fatigue
• Weight Gain/Loss
• Injuries
• Orthopedics
– Extremity fxs
from falls
• Gunshot wounds
U.S. Presidents Who Have Had
Assassination Attempts
• Abraham Lincoln
(April 13, 1865)
• James A. Garfield
(July 2, 1881)
• William McKinley
(Sept. 6, 1901)
• Theodore Roosevelt
(Oct. 14, 1912)
• Harry S. Truman
(Nov. 1, 1950)
• John F. Kennedy
(Nov. 22, 1963)
• Gerald R. Ford
(Sept. 5 & 22, 1975)
• Ronald W. Reagan
(March 30, 1981)
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U.S. Presidents Who Have Died
From Illness While In Office
• William H. Harrison
9th President, died
30 days after
inauguration of
pneumonia
• Zachary Taylor;
12th President, died
from CV and CAD
Republicans Liked Him
• Warren G. Harding;
28th President, died
from CV and CAD
• Franklin Roosevelt;
31st President, died
from CV Hem
The Democrats Liked Him
• One of the worst
mistakes anyone can
ever make is to bet
against Americans.
– Ronald Reagan
Reagan’s Early Years
• Spent most of his early
life in Dixon, IL
• His father was a shoe
salesman and the family
moved a lot.
• Had an older brother Neil.
• Nickname of “Dutch”
given to him by his father
due to “looking like a fat
little Dutchman” and his
“Dutch boy haircut”
Early Years
• Graduated from Dixon
High School where he had
interests in sports, acting
and storytelling.
• Attended Eureka College
where he was involved in
campus politics, sports
and theater. He was on
the football team, captain
of the swim team, student
body president and in a
fraternity
College Years
• Graduated in 1932
from Eureka College
with a Bachelor’s
Degree in economics
and sociology.
• Became a radio
announcer in Iowa and
in 1937 moved to LA
to be an actor.
2
Personal Life
• Made several films
including Dark
Victory, Knute
Rockne, All
American, Kings Row,
Bedtime for Bonzo,
The Killers.
• Spokesman for GE
theater
Personal Life
• Married Nancy Davis
in 1952
• Had two children:
– Patricia Davis born
1952
– Ronald P. Reagan born
1958
Political Life
• Won 1980 Presidential
election
• As he was giving his
inaugural address – 52
US hostages who had
been held by Iran for
444 days were set free.
• Married to actress Jane
Wyman from 1940-1949
when they divorced.
• Had three children
-Maureen (1941-2001)
-Michael born 1945
(adopted)
- Christine (Sept 26,
1947; lived 1 day)
Political Life
• Was originally a Democrat
• Became involved in the Board
of Directors of the Screen
Actors Guild in 1941 and
became president in 1947
• Became a member of the
Republican Party in 1962
• Ran for Gov of CA and won in
1966 and 1970
• Defeated in run for Republican
Presidential nomination in 1968
and 1976
The Day He Almost Died
• March 30, 1981-Wash
D.C. Hilton giving speech
when just before 2:30 PM,
John Hinckley, Jr. using a
“Saturday night special”
fired several rounds.
• Several police and SS
were wounded but James
Brady was most critical.
• Had been in office only 69
days.
3
Ronald W. Reagan
March 30, 1981
• The bullet struck the
limousine and flattened to
the size and shape of a
coin and then entered
Reagan’s body under the
left arm.
• Originally they did not
think that he was hit but
then blood came from
Reagan’s mouth.
Ronald W. Reagan
March 30, 1981
• Americans saw what
really happens for the
first time in a
Presidential
assassination.
• Wounded people were
left lying in the street.
Ronald W. Reagan
April 1981
• Had his chest tube
pulled, and went home
on April 11, 1981.
• He had been in the
hospital for 12 days.
Ronald W. Reagan
March 30, 1981
• Rushed to George
Washington Hospital
Center where he was
collapsing and saying
he couldn’t breathe.
• Chest tube inserted.
Ronald Reagan
March 30, 1981
• X-ray showed bullet
entered left armpit, struck
the 7th rib, and burrowed
three inches into the left
lung. Was less than an
inch from his heart.
Within 3 hours he was in
surgery. Had bleed out
30% of his blood volume.
He is 70 years old.
Hearing Aids
• Early in his presidency,
Reagan started wearing
hearing aids
• First in his right ear and
later in his left ear
• Went public with
information in 1983
• Small audio-amplified
hearing sales had a boost
in sales after he
announced it.
4
Polyp Surgery – 1985
Skin Cancer
• July 13, 1985 – had
surgery at Bethesda Naval
Hospital to remove
cancerous polyps from his
colon.
• Relinquished presidential
power to VP Bush for 8
hours.
• He was the first president
to use delegation of
power.
Challenger – Jan 28, 1986
• “The future doesn’t
belong to the fainthearted;
it belongs to the
brave….we will never
forget them, nor the last
time we saw them, this
morning, as they prepared
for their journey and
waved goodbye and
slipped the surly bonds of
Earth to touch the face of
God.”
After The Presidency
• July 4, 1989 while
visiting friends in
Mexico, he was
thrown from a horse
and was unconscious.
• Weeks later (Sept), he
was diagnosed with a
chronic SDH which
was removed at Mayo
Clinic.
• August 1985 – had
skin cancer cells
removed from his nose
• Oct 1985 -had
additional skin cancer
cells removed from his
nose.
Life at the White House
• Jan 1987 – had
surgery for an
enlarged prostrate
• July 1987 – had third
cancer operation on
his nose
Subdural Hematoma
• Focal brain injury
• Beneath the dura resulting from
acceleration, deceleration, or combination
forces
• More common than epidural hematomas
5
Subdural Hematoma
Causes
• Usually venous in
origin; tearing of the
bridging veins
• Also from injuries to
tissue or vessels of
cerebral cortex
• Direct injury to brain
tissue
Subdural Hematoma
Signs and Symptoms (onset varies)
• Steady decline in level of consciousness
• Hemiparesis or hemiplegia on opposite side
of hematoma
• Unilateral fixed and dilated pupil on same
side as hematoma
Part of the Message
He Read on His Diagnosis
“I have recently been told that I am one of the
millions of Americans who will be afflicted with
Alzheimer’s Disease….at the moment I feel just
fine. I intend to live the remainder of the years
God gives me on this earth doing the things I have
always done….I now begin the journey what will
lead me into the sunset of my life. I know that for
Americans there will always be a bright dawn
ahead. Thank you, my friends. May God always
bless you.”
Subdural Hematoma
• Onset may be acute (within 48 hours) or
chronic.
• Patient at risk to develop a SDH
– Elderly
– Those on anticoagulants
– Chronic alcohol users
• More lethal than most other brain lesions
The Diagnosis
• August 1994 diagnosed at 83 years
with Alzheimer’s
Disease.
• Nov. 1994 announced his
diagnosis to the public
via a recorded
message
Dementia
• A disorder of consciousness
• An acquired and progressive cognitive deficit
• Affects the content, not the level of
consciousness
• Increases with age – may effect 5 -20% of
elderly over 65 yrs.
• Underlying pathology affects the cerebral
cortex and subcortical connections
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Dementia -Continued
• Considered to be a global cognitive disorder as opposed to
an acute onset of a confused state.
• On CT and MRI :
– There is enlargement of the ventricles and cerebral cortical sulci.
– As the brain ages, it atrophies and there are changes. There will always be
minor changes in neurologic function with memory and cognitive
problems which are normal as the brain ages and atrophies with age.
These changes should not be considered dementia.
– Must have accurate assessment with mental and physical workup.
• Only 10% of the dementias are reversible, but it is
necessary to determine possible causes of dementia so that
appropriate treatment may begin.
– For instance, a chronic SDH or a vitamin B 12 deficiency may be
causing a problem and once corrected, the deficit should cease.
Common Causes of Dementia:
• Alzheimer’s Disease
(most common)
• Dementia with Lewy
Bodies
• Parkinson’s
• Vascular dementia
(multi-infarct)
• Hydrocephalus
• Intracranial mass lesions
• Hypothyroid
• Pick’s Disease (frontotemporal dementia)
•
•
•
•
•
•
•
•
•
Huntingdon’s disease
Creutzfeldt-Jacob
AID’s dementia
Progressive multifocal
encephalopathy
Lymphomas, leukemia
Primary alcohol dementia
Head trauma
Vitamin B12 deficiency and
other nutritional deficiencies
Wilson’s Disease
Clock Drawing Test
• Clock drawing and handwriting are two simple tests to distinguish
the kind of dementia.
• The key to treatment is assessment and many tests are given
including the mini mental and clock drawing tests. Alzheimer's has
very distinct stages where the hands disappear entirely.
• The hallmark of ischemic vascular dementia is micrographia (tiny
writing), The patient will draw a tiny little clock and cannot make
a larger clock, and in late stages no numbers or hands and the
circle is actually a conglomeration of small lines.
• Ischemic vascular dementia pts have slowed mentation so
everything must be done slowly and make sure to give the patient
plenty of time to finish tasks.
Causes of Dementia
• Only 10% of the dementias are reversible, but
it is necessary to determine possible causes of
dementia so that appropriate treatment may
begin.
– For instance, a chronic SDH or a vitamin B 12
deficiency may be causing a problem and once
corrected, the deficit should cease.
• About 15% of patients having a pseudo dementia
caused by things such as depression or alcoholism
(Korsakoff Amnesic Syndrome).
Dementia Testing
• CT/MRI/MRA
– There is enlargement of the ventricles and cerebral cortical sulci.
– As the brain ages, it atrophies and there are changes. There will always be
minor changes in neurologic function with memory and cognitive problems
which are normal as the brain ages and atrophies with age. These changes
should not be considered dementia.
– Must have accurate assessment with mental and physical workup.
• Psychiatric/geriatric workup
• Mini mental & clock drawing is very indicative of dementia.
• Can only definitively label Alzheimer’s on autopsy, is a
cluster of symptoms
Clock Drawing Continued
• Frontal lobe dementia loses track.
• Lewy Body Dementia pts have prominent visual hallucinations as one
of their hallmarks . The clock may look hallucinatory to the patient.
You may see the clock face but the hands will be inside and outside the
circle, and the hands may be squiggly.
• These patients also may have visual-spatial skill problems early in the
disease so doing the clock draw is very difficult. They might even refer
to the drawing as “those 3 guys went outside” referring to the 3
numbers outside of the clock.*
*Dementia Screening Tools: The Clock Draw-Gail Petersen PhD
[email protected]
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CLOCK DRAWING*
OR
Mini Mental Exam
Micrographia
Alzheimer’s stage 4
Ischemic Vascular Dementianote the paucity of hands
(not able to place 2
hands)
Frontal Lobe
Dementia
Alzheimer’s stage 5
(lose both hands)
Alzheimer’s stage 6
• Next slide is a depiction of Folstein and
McHugh’s Mini Mental exam or MMSE
• Scores:
– 24-30 Normal
– 18-23 Mild dementia
– 10-17 Moderate dementia
– <10 severe dementia
Lewy Body
Dementia
Max score
5
5
What is the (year) (season) (date) (day)) (month)
Where are we: (state) (county) (town or city) (hospital)) (floor)
Alzheimer's
REGISTRATION
3
Name 3 common objects (apple, table, penny) Take 1 second to say each.
Have pt repeat after you said them. 1 pt each correct answer.
Repeat until h/she learns all 3. Count trials and record. Trials:____
ATTENTION AND CALCULATION
5
Spell “world” backwards. Score of number of letters in correct order
(D__L___R___O___W___)
RECALL
3
Ask for the 3 objects repeated above. 1 point each correct. Cannot test if
couldn’t memorize above)
LANGUAGE
2
1
3
1
1
1
Name a “pencil” and “watch” (2 points)
Repeat the following, “No ifs, ands, or buts.” (1 Point)
Follow 3 stage command: Take a paper in right hand, fold in ½ , put on floor(3 pts)
Read and obey: “Close your eyes”
(1 Point)
Write a sentence
(1 Point)
Copy the following design:
(1 point)
•
•
•
•
•
Not a disease but a collection of symptoms
Onset usually in 60’s
More common in women than men
Etiology unknown
Conclusive diagnosis done per autopsy
– Classic senile sticky debris of plaques
– Neurofibrillary tangles
*
After the Diagnosis
• Nov 1994 – public
announcement
• Remained physically
active, took walks thru
parks and on beaches,
played golf regularly
• Was forgetful with names
and dates
• 1999 – stopped going to
his office in Century City
The Bel Air Home
• January 13, 2001 – at the
age of 89, fell at home and
broke his hip.
• Repaired the next day with
a pin, plate and screws.
Daughter Maureen was a
few floors away being
treated for melanoma.
• He spent a little over a
week in the hospital and
then went home with PT.
8
90 Years Old
• August 8, 2001 –
Maureen died at age
60 from melanoma.
• Oct. 11, 2001 -turned
90. Only John Adams,
Herbert Hoover and
Gerald Ford would
reach age of 90.
25th Amendment
• Framers of the Constitution intended for an
“acting President.” In 1841, John Tyler became
“President” -no one challenged him. Precedent
was set and all others followed.
• Presidential Succession Law of 1947 provided an
order of succession (Speaker of the House of Rep,
President Pro Tempore of Senate, Sec of State,
etc)
• Added to Constitution in 1967; involves inability
to do the job, designating and returning of power .
Reagan’s Legacy
The End
• June 5, 2004 -Died at the
age of 93 years and 120
days of pneumonia
• At the time of his death,
he was the longest living
president. Gerald Ford
would die in 2006 having
lived 93 years and 165
days.
Conclusions
• Twenty-fifth amendment
transfers power to the
Vice President.
• Presidents are mortal.
• Most leave office in
poorer health.
• Modern ones and their
spouses now get health
care for life.
Questions?
• The Great
Communicator
• Reaganomics
• Ending Cold War
• Berlin War Came
Down
• Challenger Disaster
• Wanted a
constitutional
amendment requiring
a balanced budget
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References
• Dawson, Ian (2005): Medicine in the
Middle Ages. Enchanted Lion Books:
New York City.
• Mattox K, Feliciano, D, Moore EE, (eds)
Trauma (5th edit). 2004. McGraw-Hill.
References
• Mattox K, Feliciano, D, Moore EE, (eds)
Trauma (5th edit). 2004. McGraw-Hill.
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