Malcolm Gladwell
Malcolm Gladwell is co-founder of Pushkin Industries and host of the hit podcast Revisionist History. He is a journalist, a speaker, and the author of several New York Times bestsellers including The Tipping…
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Robert Kennedy was killed by an assassin’s bullet in 1968, ending his presidential run. Had he been shot today, would he have lived? A what-if story about homicides and medical care and the moral consequences of a world where trauma surgeons have gotten really, really good at what they do.
Malcolm Gladwell
Midnight, June 5th, 1968.
Robert F. Kennedy is running for the Democratic presidential nomination. He's just been declared the winner of the California primary. He's now the front-runner. The White House is in his sights.
Robert F Kennedy
I want to express my gratitude to my dog, Freckles, who's been maligned. I don't care what they say about me, but when they start to attack my dog... I'm not doing this in the order of importance, but I also want to thank my wife, Ethel.
Recording
Yay! All right! Ethel! Come forward. Come forward. Hey, Ethel, come say something.
Robert F Kennedy
Her patience during this whole effort, it's fantastic. Fantastic. Thank you very much. Freckles has gone home to bed. He thought very early that we were going to win, so he retired.
Malcolm Gladwell
You can hear the supporters packing the room, despite the hour and the sweltering heat.
Recording
Okay. Hey, hey. Wait, wait a second. Hey! I want to hear really loud: Who's going to be the next President of the United States?
RFK! RFK! RFK! RFK! RFK!
Hey, here's the man. Listen to him.
Malcolm Gladwell
He leaves the stage out to the kitchen, pauses to shake the hand of a busboy. And, out of nowhere, a young man emerges holding a .22 caliber revolver. Eight shots. Boom, boom, boom, boom, boom, boom, boom, boom.
It's chaos. You can hear it, can't you? There's a photograph of this moment. Kennedy sprawled on the ground. The busboy crouched by his side. His face turned to the camera. A picture of anguish.
Recording
What happened?
I don't know. I can't explain.
What happened? Do you know?
Somebody said he'd been shot.
I'm not... Keep me plugged in. Keep me plugged in.
Please stay back. Please stay back. Everybody else, just please stay back. Just the doctor. Come right here.
Let's roll some videotape on this out here, friends.
Please.
Would a doctor come right here? A doctor. We need a doctor, right here, to the microphone, please. Immediately.
Malcolm Gladwell
My name is Malcolm Gladwell. You're listening to Revisionist History, my podcast about things overlooked and misunderstood. This episode is part four of our investigation of the messed up way Americans talk about guns.
The Supreme Court just issued one of the most important gun rights cases in its history and devoted pages to the 14th century, the 17th century, the 18th century, the 19th century, the Civil War, Reconstruction, the Constitutional Convention, and an obscure disputatious merchant from Bristol.
But nothing about the present day.
As if the crisis of gun violence on our streets is beside the point. We get our ideas about guns from a television Western written by screenwriters from Hollywood whose understanding of the American frontier is a hundred percent backwards. It's all a little weird.
And in this episode, I want to offer an explanation for how things got so weird. What I think gets missed, that is, except by the people who treat gunshots for a living.
Oh, I see. Okay. Okay. So let's walk through what happens. Sirhan Sirhan comes up to Kennedy backstage at the Ambassador Hotel and fires eight shots from a .22 caliber revolver, three of which hit Senator Kennedy. Right?
Jordan Komisarow
That's our understanding, yes.
Malcolm Gladwell
Jordan Komisarow, trauma surgeon at Duke University.
So where do those bullets go?
Jordan Komisarow
So the bullet that struck him in the head hit right behind his right ear. Sort of, if you feel everyone has a little bit of a bony prominence, so roughly around there. And the other two struck him in the axilla and they think the chest, although it would seem that from the accounts of the thoracic surgeons as they relayed them, those were of minimal consequence.
Malcolm Gladwell
Yeah, it's really the headshot that we're concerned with.
Jordan Komisarow
Yes.
Malcolm Gladwell
And in your experience, have you ever, we'll come back to this, but I'm just curious whether you've ever treated an analogous gunshot wound to the head.
Jordan Komisarow
Yes.
Malcolm Gladwell
You have.
Jordan Komisarow
Yes.
Malcolm Gladwell
When a bullet strikes you behind the ear, what happens?
Jordan Komisarow
Largely, these are mostly fatal injuries.
Malcolm Gladwell
By the next morning, Kennedy was dead. I want you to imagine what would happen if Kennedy were shot today.
One of the iron laws of medicine is that the more you treat a condition, the better you get at curing it. Practice makes perfect. You develop your skills; you start to anticipate anomalies and variations; you're more motivated to try new ideas, introduce new techniques, develop new technologies. And nowhere is that iron law more in evidence in the United States than when it comes to the treatment of gunshot wounds. If you're an American trauma surgeon, you get a lot of practice.
World War I. World War II. Korea. Vietnam. Iraq One. Iraq Two. Afghanistan. Every generation of trauma surgeon got a war of their own, the best kind of crash course. Then they come home to the other war, the one on the streets. This is an area of genuine American expertise.
I was curious about this. So I went to see a man named Edward Cornwell III.
Edward Cornwell III
I got to Hopkins in 1998 as the chief of trauma, and my experience had been nine years at LA County Hospital, which was among the busiest trauma centers in the country, five as a surgical resident.
Malcolm Gladwell
I asked around, and everyone told me that if you ever got shot, Eddie Cornwell was your best hope for coming out in one piece. Mid-sixties. Fit. A little hint of patrician about him. He grew up in Washington, DC. Trained at USC Medical School. And worked there in the 90s. South Central, in the middle of the crack epidemic. He opened the Trauma Center at Johns Hopkins University in 1998. Other American cities had seen a decline in the murder rate by that point, but not Baltimore.
Edward Cornwell III
We have a protected conference that takes place, every department of surgery does; so-called morbidity and mortality conference. We talk about every patient that died or had a complication in the prior week. And I showed a table where we have five consecutive days on our trauma service, where every single day a 20-year-old died. Gunshot to the chest, dead on arrival; gunshot to the chest, dead on arrival; stab wound to the chest, ER thoracotomy. You didn't have time to go to the operating room, literally opened the chest in the emergency department, declared dead. Five different surgeons, including myself; one day, a whole basketball team of 20-year-olds, essentially dead in the emergency department; prompting us to identify that we had this dramatic increase in the brazen nature of gunshot wounds, more to the head or the chest or both.
Malcolm Gladwell
Then Cornwell came home to DC, once known as the murder capital of the United States, to head the trauma center at Howard.
Edward Cornwell III
It's interesting. I did my residency at LA County Hospital, this huge 18-story structure. I had a 15-floor elevator ride from the ER to the operating room at LA County. And I was glad for it sometimes, because I'm thinking, "Should I go on the right chest? Should I go on the left chest? Should I go on his abdomen?"
Then I get to Hopkins, I had a seven-floor elevator ride, shorter timeframe. While I'm here, I have two-floor elevator rides. So the more expert I was, the shorter the elevator ride. I was glad I had a 15-floor elevator ride. By the time I get to Hopkins, I had seen it all, so I didn't need a 15. Seven floors is fine, and I had two floors here.
Malcolm Gladwell
South Central. East Baltimore. Central Washington. I mean...
I spent a morning with him at the hospital with a colleague, an ex-army surgeon named Mallory Williams. It was a Tuesday. He'd worked the weekend and operated on two kids –19 and 20 – who'd been in a gun battle.
Edward Cornwell III
I take the 19-year-old to the operating room. He's clearly tender. He clearly has evidence of contamination. You go to the operating room, spend three-and-a-half hours doing the things that I mentioned; the liver, the stomach, small intestine, the colon, the rectal.
Mallory Williams
But let's tease that out, please.
Edward Cornwell III
Well, let me just say one last thing about him, because it's like wild, wild West. In retrospect, it becomes obvious to me that one bullet enters here and goes through his stomach, his liver, his large intestine and goes out here. Another bullet enters in his upper gluteus, buttocks, and goes across the abdomen and hits a small intestinal injuries, bounced off the pelvic. That bullet is deformed and lodged in his abdominal wall.
Malcolm Gladwell
But while he's treating the 19-year-old, he's worrying about the 20-year-old. Because there must be something going on between the two of them, right? And now the two of them are in the same hospital.
Edward Cornwell III
I made sure that the other kid doesn't go to the ICU where we typically put these patients, because I don't want the two families down there in our ICU. So we have them in remote locations in the hospital from each other.
Malcolm Gladwell
Do that for 40 years and learn from all the other trauma surgeons around the country who are doing the same thing, and you get good.
What from a medical standpoint, what would you, looking forward, what is the hypothetically, if I gave you a wish, I said you could solve one problem in your field that would-
Edward Cornwell III
I would reduce gun deaths.
Malcolm Gladwell
No, no, no. Yeah, that would reduce gun deaths. So medically speaking, what is one medical trick that I could give you that would have the biggest impact on how many people die from a gunshot wound.
Edward Cornwell III
My trick wouldn't be medical.
Mallory Williams
Yeah, it's not medical.
Edward Cornwell III
It would be all social...
Mallory Williams
It's social.
Edward Cornwell III
For me, it would be two parents in every home. That almost sounds, today, to say that today it sounds...
Mallory Williams
Yeah, yeah. You might be put in jail, if you said something...
Malcolm Gladwell
In saying that, you think we've got most of the low-hanging fruit, in terms of how to save somebody once they arrive.
Edward Cornwell III
Yeah, I've got some slides I'll show you there, but I don't think we have another peak in my lifetime. So once you get to 95%, the fruit is high up on the tree. Right?
Mallory Williams
Yeah.
Malcolm Gladwell
That's how good trauma surgeons are now. They're looking for solutions outside the hospital.
Now, think about the implications of that in a place like Washington, DC. In the last 30 years, the number of homicides in Washington in a typical year has been cut in half. People look at that statistic and say, "Oh, the city's gotten a lot safer." But isn't some part of that decline simply that Eddie Cornwell and Mallory Williams and all the other trauma surgeons of Washington, DC are now saving lives that were once lost?
A city's murder rate is not a measure of the number of people victimized by potentially lethal violence. No. It's a measure of the number of people victimized by potentially lethal violence minus how good a job doctors do at saving that person's life once they get to the hospital.
So how important is the second half of that equation? Do people like Eddie Cornwell move the needle on homicide rights a lot or just a little?
Which is why when I got back from DC I called up Jordan Komisarow, trauma surgeon at Duke University, to talk about the assassination of Robert Kennedy. Because it seemed like looking at Kennedy's injuries through the lens of the present day would be a good way to try and answer this question.
There is a long tradition among trauma surgeons of speculating about which famous shooting of a political figure would've turned out differently given today's medical know-how. If you flip through trauma surgery journals, you can find all kinds of examples. By the way, you can't play this game if you're a trauma surgeon in Canada, because they've never had any of their leaders assassinated. Or England. Because they've had just one. France had one president stabbed to death in 1894, and in 1932, President Paul Doumer was gunned down by a Russian anarchist. Germany. Not really. No one major, unless you want to count the killing of the foreign minister in 1922.
But in the United States, you can play this game for days. You've got Abraham Lincoln in 1865. Shot to the head from a .44 Derringer pistol. Does he live today? A couple of years ago, a group of neurosurgeons at Brigham and Women's Hospital in Boston reexamined his autopsy records and concluded, probably not. It was the worst kind of head injury. What about James Garfield, 20th President of the United States? Shot twice. the second bullet, hit him in the back, missing the spinal cord and embedding itself behind his pancreas. He's rushed to the hospital. It's a minor injury, but they get obsessed with taking out the bullet and that contaminates the wound. He's shot in June. He dies in September because of a sepsis infection. He survives today, easy. William McKinley is next. September 6th, 1901. Shot twice in the abdomen. He lives today. JFK? No, he's dead on arrival at the hospital.
Edward Cornwell III
But go to 1980. Ronald Reagan, a 69-year-old man with a gunshot wound to the left chest. He doesn't survive in 1900. He doesn't survive in 1920. He might've survived in 1940. There's blood transfusion. He needed blood. And 1960. But certainly, a 69-year-old with a gunshot wound to the chest for the first 100-plus years of our history would largely be fatal.
Malcolm Gladwell
If Ronald Reagan had died of his wounds the way Lincoln, McKinley, and Garfield did, the world would've been very different. He's shot in March 1981. He's just two months into one of the most consequential presidencies in American history. Does the Berlin Wall fall in 1989 without Reagan in office? Maybe, but maybe not. History is shaped not just by assassin's bullets, but also by the ability of doctors to treat the damage done by assassin's bullets. It's the Robert Kennedy case, though, that caught my eye.
I wanted, just to start, how did you come to be interested in revisiting the assassination of Robert Kennedy?
Jordan Komisarow
I was walking through the hallway one day, came across Ted Pappas, who's one of our general surgeons, and he had done a series of historical works.
He said, "Have you ever heard about Robert Kennedy?"
Which seemed like kind of an odd question I would think have heard about Robert Kennedy.
And he said, "Well, I think I may have gotten ahold of some of the original documents related to his assassination. Would you be interested in combing through them with me?"
Malcolm Gladwell
So Komisarow sits down with his colleagues and goes through what Pappas has found. Autopsy reports. Testimony from the surgeons who treated Kennedy. And they reconstruct the case.
So walk me through what happens to him after he's shot.
Jordan Komisarow
Yeah, so I've always sort of envisioned this chaotic scene where his limited security and his chief of staff went and saw sought the assistance of the available physicians.
Malcolm Gladwell
He's lying on the ground in the kitchen of the Ambassador Hotel. Today, there would be Secret Service protection, contingency plans. An ambulance on call. There was nothing like that in 1968. For bodyguards, Kennedy has two celebrity athletes. The football player, Rosey Grier, and the Olympic Gold Medal Decathlete, Rafer Johnson. No one is prepared for this kind of emergency.
Jordan Komisarow
And then this is sort of where the senator then gets unlucky, and where a lot of victims get unlucky is, he's taken to sort of the closest hospital, but not necessarily the facility that's best equipped to care for someone who had been shot in the head.
Malcolm Gladwell
Kennedy gets taken to Central Receiving Hospital on Sixth Street, just west of downtown. They stabilize him there, but they don't have a neurosurgeon. So he has to be transported to Good Samaritan Hospita. Just off Wilshire.
And what did that mistake cost him? How much time?
Jordan Komisarow
I calculated in the paper. Let me double check. So he got to the operating room of Good Samaritan two-and-a-half hours after the shooting.
Malcolm Gladwell
Two-and-a-half hours in your world, two-and-a-half hours is a long time.
Jordan Komisarow
Is a very long time.
Malcolm Gladwell
Yeah. So he gets to Good Samaritan, and what happens?
Jordan Komisarow
So they finish stabilizing him, they inspect for his other wounds, and then they decide pretty quickly to take him to surgery. They wound up removing roughly about a five centimeter, two-and-a-half inch piece of bone surrounding where he was shot in the back of the head, right behind the ear and debride, which was the standard of the day. Everything that looked abnormal along the bullet track. Tried to remove fragments of his skull. And then brought him back to the intensive care unit where they tried to cool him, which was a sort of common practice at the time, to reduce swelling in the brain. They gave him medications. Specifically steroids and something called mannitol, which is a diuretic. Both of those are aimed at reducing swelling of the brain; one of which, mannitol, is still very commonly used today. Dexamethasone is no longer used for this type of injury based upon data from large clinical trials that occurred long after this, of course.
Malcolm Gladwell
He was in a coma. He never came out of it. He was pronounced dead at 1:44 AM the next morning.
So now let's redo this, but it's 2023. There's no delay today, right? Today, if you're shot in the Ambassador Hotel in LA today, where do you go? Where's the nearest trauma center?
Jordan Komisarow
I believe the closest Level I trauma center is probably USC. But yes, you would go straight to a Level I trauma center.
Malcolm Gladwell
A Level I trauma center is a recent invention; a high-tech, on-demand medical unit attached to a traditional hospital, with every kind of specialist on call 24 hours a day.
And you would get there, I mean today-
Jordan Komisarow
Rather rapidly.
Malcolm Gladwell
So he arrives at a Level I trauma center, let's just say for the sake of argument it's 15 minutes. So the difference between two-and-a-half hours and 15 minutes in your world is-
Jordan Komisarow
Might as well be a year.
Malcolm Gladwell
Yeah. Yeah. And when he gets there, he's treated very differently.
Jordan Komisarow
So at Duke, the neurosurgery team that's in the hospital, which is for us always a resident and potentially always a faculty member, the rest of the trauma team would be paged ahead of time and waiting for the patient when they arrived in the resuscitation bay.
Malcolm Gladwell
Kennedy got an x-ray once he arrived, a one-dimensional image that made it hard for the surgeons to know exactly where his bullet was. Today, he'd get an immediate CT scan in 3-D, an extraordinarily detailed image.
Jordan Komisarow
In most trauma centers, including Duke, there is a CT scanner that is about 10 feet from where the patient's first arrive, so there's very little delay.
Malcolm Gladwell
You finish the CT scan. How many minutes in are you from the moment the patient has arrived at the hospital?
Jordan Komisarow
Unless the patient was so unstable in terms of their blood pressure or heart rate that required additional stabilization, this should be occurring within 10 or 15 minutes.
Malcolm Gladwell
Yeah. Komisarow began to talk through the difference between how a brain injury like Kennedy's was treated in 1968 versus today. He gave me close to an hour of technical description, step-by-step.
So in '68, given standard of care and the extent of his injuries, he has zero chance of survival.
Jordan Komisarow
About as close to zero as you can get.
Malcolm Gladwell
Yeah. What's his percent survival chance today? He's not dying at 2:45 the next morning under this protocol.
Jordan Komisarow
I think it is far less likely he is dying at 2:45 the next morning.
Malcolm Gladwell
And listening to you describe the differences between '68 and the present day, it sounds like night and day. You have the same intention today as they did in '68. Reduce the swelling in the brain, stop the bleeding. But the ways in which you're going about doing that are-
Jordan Komisarow
Markedly different.
Malcolm Gladwell
... totally, markedly different.
How do I describe the leap that's been made between then and now? What's it like? Is it like, I've driven in a car from 1968. It doesn't seem like it belongs to a different paradigm than a car today.
Jordan Komisarow
It's the difference between a bicycle and electric car.
Malcolm Gladwell
Oh. Okay. Yeah, that makes a lot of sense. Oh, that's huge.
So what does Komisarow's what-if on the Kennedy assassination tell us? That medicine's contribution to falling homicide rates is a very big deal. Bicycles to electric cars.
Here's a back of the envelope calculation on how big this effect is. A group from the University of Massachusetts in 2002, estimated improvements in trauma care probably lowered the death rate from serious injury about 2.5 to 4% a year. So if nothing else changes, if there's still just as many would be murderers walking around, that's how much your murder rate is going to fall every year on its own.
Let me quote to you from their conclusion
"Compared to 1960, the year our analysis begins, we estimate that without these developments in medical technology there would've been between 45,000 and 70,000 homicides annually the past five years, instead of an actual 15,000 to 20,000."
Those estimates are insane. If doctors hadn't upped their game, the number of Americans being murdered every year in the United States might be as much as three or four times higher than it is now.
Here's another example.
It's from the trauma center at the University of Tennessee Medical Center in Memphis, a city with a pretty serious homicide problem. The Memphis trauma staff looked at every gunshot wound their hospital had treated from the mid 1990s to 2015.
And what they found is that every way you look at it, gun violence in Memphis got worse in that period. The number of gunshot wounds they saw increased. In fact, the number went up 59% just between 2010 and 2015.
The severity of the wounds they saw got worse. The number of people being wheeled in with multiple gunshot wounds more than tripled. In absolutely every sense, the patients coming into that hospital in those years showed that Memphis was becoming a dramatically more dangerous place.
But what happened to the mortality rate of gunshot victims coming into that hospital during that period? It went down. It dropped by a third. The trauma doctors at the University of Tennessee Medical Center are so good that they made the increase in bloodshed on the streets of Memphis all but invisible.
So what does the homicide rate in Memphis tell us about the level of violence in Memphis? Nothing. That's implication number one. We probably should stop using homicide rates as a measure of how safe and healthy a community is.
Natalie Hipple
Homicides are what get all the attention. Right? They get all the attention from the media. They get all the attention from the response. The mayor might show up on the scene, or the whole prosecutor might show up on the scene.
Malcolm Gladwell
That's Natalie Hipple, a criminologist at Indiana University.
Natalie Hipple
They tape off the whole scene and not every nonfatal shooting gets that kind of response. So those are the numbers that people are sensitive to, but I don't know that it means much.
Malcolm Gladwell
A few years ago, Hipple and a group of other criminologists argued that we should shelve the homicide statistic in favor of a measure of what they call bullet-to-skin contact.
That is just a measure of how many bullets have hit people in a given community over the previous year. Which makes more sense, right? Because now we've corrected for the bias caused by doctors saving so many more lives.
The problem is that that bullet-to-skin number doesn't exist. No one pulls that statistic out. The police lump all those cases in the general category of aggravated assault, mixed in with punches and shoves.
Natalie Hipple
They don't have a definition for a nonfatal shooting. There's no way to pull those data out of those sets.
Malcolm Gladwell
Wait. Stop there. You're telling me that we are the most wealthiest and most sophisticated country in the world that is simultaneously in the grip of a prolonged chronic outbreak of gun violence...
Natalie Hipple
Mm-hmm.
Malcolm Gladwell
We have no hard, useful numbers on the total number of shootings?
Natalie Hipple
Nope. Not that the federal government maintains. As soon as you drop down to aggravated assaults, they're really, really messy. And so no, we don't.
Malcolm Gladwell
What Hipple had to do was go through all the old aggravated assault records compiled by the Indianapolis Police Department and pull out the gunshot wounds by hand.
Natalie Hipple
The first thing we did was pull all the aggravated assaults. And they report to the FBI. So they pulled all those case numbers and we started reading. I mean, literally in the bucket, out of the bucket, in the bucket, out of the bucket. And then-
Malcolm Gladwell
This is thousands and thousands?
Natalie Hipple
Thousands, yeah.
Malcolm Gladwell
How many people were engaged in this project?
Natalie Hipple
Gosh. Well, I mean, we had a full-time-
Malcolm Gladwell
How many graduate students lives did you ruin in this project?
Natalie Hipple
Well, each of us had our own. I mean, there wasn't a lot of funding.
Malcolm Gladwell
For newer cases, she got the police to help her out. Indiana has a reporting requirement.
Natalie Hipple
If you show up at the emergency department and you're stabbed or you're shot or you're really badly bludgeoned or something, the medical facility is required to report that to the police.
Malcolm Gladwell
So every day the police would send her the list of reports they'd gotten from the trauma center the night before.
Natalie Hipple
The procedure was: detective goes to the scene, figures out what's going on, and then writes up what they know about the incident right then, and there that goes out. So that's usually within 24 hours. But I got on that email list, so then I'm forwarding them to my research assistant. The two of us are reading every single one.
Malcolm Gladwell
How many are you getting a day?
Natalie Hipple
Oh, my email right now, hundreds.
Malcolm Gladwell
Wait, you're getting hundreds of-
Natalie Hipple
My police department email's off the hook.
Malcolm Gladwell
So this is all the bullet-to-skin reports from the city of Indianapolis.
Natalie Hipple
Mm-hmm, yeah. And Indianapolis is the 17th largest city in the country. They run about 800,000 people, give or take. So you can only imagine what this must look like in Chicago or New York.
Malcolm Gladwell
What she's finding is what you'd expect she'd find. Indianapolis is just like Memphis. The curve for bullet-to-skin contact is going one way, and the curve for homicides is going another.
But the whole thing is absurd, right?
In the hospitals of Indianapolis, the trauma surgeons have marshaled the very finest of 21st century technology and spent millions upon millions of dollars to save every last life they can. But does the city know whether gun violence is going up or down? Sure, but only because Natalie Hipple and her graduate students are going through their emails every morning.
One last question. I don't mean this in a disparaging way. The way you describe your work sounds insanely depressing.
Natalie Hipple
Thank you for acknowledging that. It is depressing. I've started checking in on grad students. When I hire them, I'm like, "This is not something that you have over coffee and donuts and do your work. It's going to change your mood."
Malcolm Gladwell
Which brings us to the second implication of the homicide equation, which is that maybe these two things, how good the doctors are and how lackadaisical the rest of society's response to the problem has been, are connected.
Economists love to talk about moral hazard. I'm sure you've heard that phrase. Its formal definition is: The lack of incentive to guard against risk where one is protected from its consequences.
Someone lives in a flood zone, you subsidize their flood insurance. So what happens when their home is washed away? They rebuild it in exactly the same place. Why should they give up their beautiful views of the ocean if someone else is picking up the tab? That's moral hazard.
Or, here's another example. The rate of people dying in car accidents fell dramatically for years, which makes sense. Cars got a lot safer, more people wore their seatbelts. But recently, the death toll has started to climb again.
And why? Maybe it's because your car is filled with all kinds of warnings and bells, and you're strapped in like a baby and protected by a dozen airbags. And you feel so safe that you have that extra drink and drive a little faster and answer all your texts while you're driving down the freeway. So you end up being worse off than before.
That's moral hazard. If someone else is doing the work of taking care of us and lowering our risk, we have the freedom to behave like idiots.
I said at the beginning of this series that I wanted to explain why the way we talk about guns is so messed up. Why the Supreme Court makes such ridiculous rulings. Why gun control advocates push ideas that are so beside the point. And I think a big part of the answer is moral hazard.
Moral hazard is indifference.
It is the freedom purchased by other people's hard work. Doctors have become so skilled, have taken the problem of treating the wounded so seriously, have deployed every inch of their ingenuity in trying to keep the wounded alive, but the rest of us are free to fiddle while Rome burns.
So you've got the CT scan so now you know where the bullet is and the extent of the damage. Presumably in your mind, I just imagine you're the physician here, you're formulating as you look at these things, a strategy for what you want to do next.
Jordan Komisarow
Yeah. So for an injury in this location, I would want a what's called a CT angiogram, which is a picture of the blood vessels that supply and then drain the brain, which can be done within about, takes an extra sort of five minutes or less. Again, this was not available at the time that the senator was injured.
Malcolm Gladwell
Kennedy's brain is flooded in blood, but today Komisarow would have a sense of where the damage is and he would call for help.
Jordan Komisarow
So if I'm the surgeon that's taking care of the senator and there is evidence that blood is coming out of a very large blood vessel, then I'm calling one of my colleagues who specializes in vascular neurosurgery to tell me, to meet in the operating room, and potentially taking the senator to an operating room that has the capability for us to operate simultaneously.
So while I'm working directly on his head, removing the skull, taking out any blood clot that I can, making space for swelling, which is largely the purpose of the surgery. Stop the bleeding. Make room for the brain to swell. Get control of any infection that's going to occur by removing dead tissue.
Then at the same time, my partner could be accessing the blood vessels through either the wrist or the groin. Kind of like how a heart catheterization takes place, except you don't stop at the heart, you go up to the brain to try and either block off extensive bleeding, if you can't salvage the blood vessels, or salvage the blood vessels from the inside out.
Malcolm Gladwell
Keep going. So you've, you've brought in this specialist to deal with the blood vessel while you are removing parts of the skull and dead tissue. What happens next?
Jordan Komisarow
Now, since they make mention to operating at the upper part of the brain a bit, the occipital lobe that they referenced, which makes us conclude that the bullet trajectory somewhat passed upward from the cerebellum upward into the occipital lobe. It raises the possibility of removing a large part of the skull up top, which they did not do. And likely part of the reason that they did not do that is it really hadn't become more of a standard at the time because the data just didn't exist that it was helpful.
Malcolm Gladwell
They didn't use a microscope in 1968. Komisarow would. Which would give not only magnification but illumination. They're operating in a very confined space. Back then, the standard of care was to locate and remove every single bit of debris you could find. We don't do that anymore. It does more harm than good. And then, maybe the biggest issue of all. After a brain is injured, it begins to swell. And it's the swelling that poses the greatest risk to the patient. Today, we know far more about how to reduce that swelling.
Jordan Komisarow
I've wondered if Sirhan Sirhan's hand jerks up and instead of getting shot back here, the bullet comes across his occipital lobe. The senator probably has a visual field deficit, a blind spot, but quite possibly survives.
Malcolm Gladwell
Same thing if the headshot was a little lower. That might not have made a difference back then, but today, possibly.
Jordan Komisarow
Yeah. So I had another patient that came to mind that actually made me think of the senator.
He was a young person who had been shot, not in the back lobe, but the front lobe. So damaged part of the jaw, but more importantly afterwards, injured the carotid artery, one of the main blood supplies to the brain. The two carotid arteries supply about 80% of your blood. And was hemorrhaging extensively from that prior to when it then damaged the brain itself.
We did very nearly exactly what I laid out to you. One of my partners who's a vascular neurosurgeon working from inside the blood vessels, fed a wire to help repair this. I took off a large chunk of the patient's skull. The patient was in a coma for several weeks, was in the ICU for about several months, but then went home and cares for himself, works. I don't think I would ever categorize him as perfect, but you could meet him and other than part of his scar extends in front of his hairline, the rest is hidden behind. You would not be able to say, "Oh yeah, you were shot in the head," or, "You had a brain injury."
Malcolm Gladwell
Yeah. So that's another scenario for Robert Kennedy. If the bullet had gone today, had hit him there, he could have survived.
Jordan Komisarow
There are many scenarios where he survives.
Malcolm Gladwell
What happens when someone survives a violent act that once upon a time would've killed them? The world changes in a million small and large ways.
Two months before Robert Kennedy was assassinated in Los Angeles, Martin Luther King was assassinated in Memphis. Single shot to the face from a Remington rifle. Broke his jaw, traveled down his spine, severed his jugular vein and lodged in his shoulder. Kennedy was in Indianapolis at the time addressing a crowd, and he gives his most famous speech where he tells everyone the terrible news. Remember as you listen that he was speaking off-the-cuff. He had no time to prepare.
This was from his heart.
Robert F Kennedy
For those of you who are Black and are tempted to filled with, be filled with hatred and mistrust of the injustice of such an act against all white people, I would only say that I can also feel in my own heart the same kind of feeling. I had a member of my family killed, but he was killed by a white man. But we have to make an effort in the United States. We have to make an effort to understand, to get beyond or go beyond these rather difficult times.
My favorite poem, my favorite poet was Aeschylus, and he once wrote, "Even in our sleep, pain which cannot forget falls drop by drop upon the heart, until in our own despair against our will, comes wisdom through the awful grace of God."
Malcolm Gladwell
We had someone who might've been president who could quote Aeschylus from memory. And then, Kennedy issued a challenge for the country to do something about the violence tearing us apart, but I think only the doctors were listening.
Robert F Kennedy
What we need in the United States is not division. What we need in the United States is not hatred. What we need in the United States is not violence and lawlessness, but is love and wisdom and compassion toward one another, and a feeling of justice toward those who still suffer within our country, whether they be white or whether they be Black.
Malcolm Gladwell
Our Revisionist History Gun series was produced by Jacob Smith, Ben Naddaff-Hafrey, Kiara Powell, Tali Emlen, and Lee Mengistu. We were edited by Peter Clowney and Julia Barton. Fact checking by Arthur Gompertz and Keishel Williams. Original scoring by Luis Guerra. Mastering by Flawn Williams. Engineering by Nina Lawrence. I'm Malcolm Gladwell.
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