SPEAKER_10: Pushkin.
SPEAKER_08: Welcome.
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SPEAKER_13: From Pushkin Industries and Ruby Studio at iHeartMedia, Incubation is a new show about humanity's struggle against the world's tiniest villains, viruses. I'm Jacob Goldstein, and on this show, you'll hear how viruses attack us, how we fight back, and what we've learned in the course of those fights. Listen to Incubation on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.
SPEAKER_10: And all 12 episodes of Paul McCartney's new podcast, McCartney, a Life in Lyrics. That's just the September lineup. Sign up now on our Apple Show page or at pushkin.fm slash plus. 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.
SPEAKER_03: I want to express my gratitude to my dog, Freckles, who's been maligned.
SPEAKER_04: I don't care what they say about me, but when they start to attack my dog.
SPEAKER_04: And I'm not doing this in the order of importance, but I also want to thank my wife, Ethel.
SPEAKER_04: Come forward, come forward. And her patience during this whole effort is fantastic. Thank you very much.
SPEAKER_03: Freckles has gone home to bed. He thought very early that we were going to win, so he retired.
SPEAKER_10: You can hear the supporters packing the room, despite the hour and the sweltering heat.
SPEAKER_04: Hey, hey, hey, I want to hear really loud. Who's going to be the next president of the United States? R.F.K.! Hey, here's a man. Listen to him.
SPEAKER_10: 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.
SPEAKER_04: What happened? I don't know. What happened? Nobody said he'd been shot. I'm not. TV plugged in. TV plugged in.
SPEAKER_04: Please stay back. Please stay back. Everybody else, just please stay back. Would a doctor come right here? Let's roll some videotape on this out here, please.
SPEAKER_04: Would a doctor come right here? A doctor, will you hear a doctor right here in the microphone? Please, immediately.
SPEAKER_10: 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 100% backwards. It's all a little weird. And in this episode, I want to offer an explanation for how things got so weird. One 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? That's our understanding, yes. Jordan Comisero, trauma surgeon at Duke University. So where do those bullets go? So the bullet that struck him in the head hit right behind his right ear,
SPEAKER_09: sort of if you feel everyone has like 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. Yeah. It's really the head shot that we're concerned with.
SPEAKER_10: Yes. And have you, in your experience, have you ever, we'll come back to this, but I'm just curious whether you ever treated an analogous gunshot wound to the head. Yes. You have? Yes. When a bullet strikes you behind the ear, what happens?
SPEAKER_09: Largely, these are mostly fatal injuries.
SPEAKER_10: 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 I, Iraq II, 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 Cornwall III. I got to Hopkins in 1998 as the chief of trauma.
SPEAKER_12: And my experience had been nine years at L.A. County Hospital, which was among the busiest trauma centers in the country. Five as a surgical resident. I asked around, and everyone told me that if you ever got shot, Eddie Cornwall was your best hope for coming out in one piece.
SPEAKER_10: Mid-60s fit, a little hint of patrician about him. He grew up in Washington, D.C., 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.
SPEAKER_12: 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 that 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 rooms. Literally opened their 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 have this dramatic increase in the brazen nature of gunshot wounds. More to the head or the chest or both.
SPEAKER_10: Then Cornwall came home to DC, once known as the murder capital of the United States, to head the trauma center at Howard.
SPEAKER_12: It's interesting. I did my residency at L.A. County Hospital. This huge 18-story structure. I had a 15-floor elevator ride from the ER to the operating room in L.A. County. And I was glad for it sometimes, because I'd think, 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 time frame. I'm here, I have two-floor elevator rides. 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-floor. Seven floors is fine. I had two floors here.
SPEAKER_10: South Central, East Baltimore, Central Washington. I mean. I spent a morning with him at the hospital with a colleague of his, 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. I take the 19-year-old to the operating room. He's clearly tender. He clearly has evidence of contamination.
SPEAKER_12: You go to the operating room, spend three and a half hours doing the things that I mentioned, the liver, the stomach, the small intestine, the colon, the rectum. But let's tease that out. 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 some small intestinal injuries, bounces off the pelvic. That bullet is deformed and lodges his abdominal wall.
SPEAKER_10: 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.
SPEAKER_12: 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 the remote locations in the hospital from each other. 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.
SPEAKER_10: From a medical standpoint, what would you looking forward, what is the hypothetically, if I gave you a wish, you could solve one problem in your field?
SPEAKER_10: Reduce gun deaths?
SPEAKER_12: No, no, no. I mean, what's in your, yeah, that would reduce gun deaths. So what, 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?
SPEAKER_12: My trick wouldn't be medical. Yeah, it's not medical. It would also be social. For me, it would be two parents in every home. Yeah, yeah. That almost sounds, today, to say that today, it sounds pied and scaled. You might be in jail if you say something on that. In saying that, you think we have progressed as far as, you think we've done most, we've got most of the low hanging fruit in terms of how to save somebody once they arrive?
SPEAKER_10: Yeah, I got some slides I'll show you there, but I don't think we have another peak in my lifetime.
SPEAKER_12: So once you get to 95%, there aren't any, the fruit is high up on the tree, right? That's how good trauma surgeons are now. They're looking for solutions outside the hospital.
SPEAKER_10: Now, think about the implications of that in a place like Washington, D.C. 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, D.C. 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 rates a lot or just a little? Which is why when I got back from D.C., I called up Jordan Commissaro, 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. One of the biggest crossroads in my career was when I was in my late 20s. I'd been living in Washington, D.C. for 10 years and knew I wanted to do something different, go somewhere new. But I didn't know where. I had this idea that maybe I wanted to go to Germany, kind of start over. But I didn't talk to anyone about it. The biggest decision of my life to that point. And I just assumed I could handle it all by myself, which is crazy, right? Just with a major decision in your life, career or relationships or anything, having someone smart and thoughtful to talk to makes a world of difference. That's why therapy is so important. If you're thinking of starting therapy, give BetterHelp a try. It's entirely online, designed to be convenient, flexible and suited to your schedule. Just fill out a brief questionnaire to get matched with a licensed therapist and switch therapists anytime for no additional charge. Let therapy be your map with BetterHelp. Visit BetterHelp.com slash Gladwell today to get 10 percent off your first month. That's BetterHelp. H-E-L-P dot com slash Gladwell. People are excited about what A.I. will do for them. At IBM, we're excited about what A.I. will do for business. Your business.
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SPEAKER_10: Do you know that right now, as you listen to this, there's an astronaut named Frank Rubio in some tiny spacecraft way, way up there in space? He left for the International Space Station in September of last year, thought he was going for six months. And then once he was up there, NASA called him up and said, actually, Frank, we want you out there for a year. 371 days, to be exact. My question is, if you're NASA and you pull that bait and switch once, how do you recruit the next crop of astronauts? I mean, you say to your recruits, I need you to leave your family and friends and everything you know and love dearly, eat food out of a tube, but only for six months. And they're like, wait, look at Frank. That's what you told him. And he's still up there. Recruiting for astronauts, if you're NASA, is hard. If only there was some sophisticated job recruiting site capable of finding those few Americans who are perfectly happy to float around in space for an undetermined length of time. Sadly, for NASA, there's no such tool. But for the rest of us. Oh, yes, there is. ZipRecruiter. New hires cost an average forty seven hundred dollars for all of us non spaceflight companies. And with that kind of money at stake, you have to get it right. So what's the most effective way to find the right people for your roles? ZipRecruiter. See for yourself. Right now, you can try it for free at ZipRecruiter.com slash Gladwell and experience the value ZipRecruiter brings to hiring. Once you post your job, ZipRecruiter's smart technology works quickly to identify people whose skills and experience line up with exactly what you want. It's simple. ZipRecruiter helps you get hiring right. Four out of five employers who post on ZipRecruiter get a quality candidate within the first day. See for yourself. Go to this exclusive Web address to try ZipRecruiter for free before you commit ZipRecruiter.com slash Gladwell. Again, that's ZipRecruiter.com slash G L A D W E L L. ZipRecruiter. The smartest way to hire. Somewhere out there. Believe it or not, there's someone who wants Frank Rubio's job. There is a long tradition among trauma surgeons of speculating about which famous shooting of a political figure would have turned out differently given today's medical know-how.
SPEAKER_10: 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 Dumas 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.
SPEAKER_10: 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 6, 1901. Shot twice in the abdomen. He lives today. JFK? No. He's dead on arrival at the hospital. But go to 1980, Ronald Reagan, a 69-year-old man with a gunshot wound to the left chest.
SPEAKER_12: He doesn't survive in 1900. He doesn't survive in 1920. He might have survived in 1940, his blood transfusion. He needed blood in 1960. But certainly a 69-year-old gunshot wound to the chest for the first 100-plus years of our history would largely be fatal.
SPEAKER_10: If Ronald Reagan had died of his wounds, the way Lincoln, McKinley, and Garfield did, the world would have 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 assassins' bullets, but also by the ability of doctors to treat the damage done by assassins' bullets. It's the Robert Kennedy case, though, that caught my eye. I wanted to start, how did you come to be interested in revisiting the assassination of Robert Kennedy? 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.
SPEAKER_09: And he said, you know, have you ever heard about Robert Kennedy? Which seems like kind of an odd question, because everyone, I would think, had 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?
SPEAKER_10: So Commissaro 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.
SPEAKER_09: Yeah, so, you know, I've always sort of envisioned this chaotic scene where, you know, his limited security and his chief of staff went and sought the assistance of the available physicians. 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.
SPEAKER_10: There was nothing like that in 1968. For bodyguards, Kennedy has two celebrity athletes, the football player Rosie Greer and the Olympic gold medal decathlete, Rafer Johnson. No one is prepared for this kind of emergency. And then this is sort of where the senator then gets unlucky.
SPEAKER_09: And where a lot of victims get unlucky is he is 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.
SPEAKER_10: 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 retransported to Good Samaritan Hospital, just off Wilshire. And what did that mistake cost him how much time? I calculated in the paper. Let me double check.
SPEAKER_09: So he got to the operating room at Good Samaritan two and a half hours after the shooting. Two and a half hours in your world, two and a half hours is a long time.
SPEAKER_10: Is a very long time.
SPEAKER_10: Yeah. So he gets to Good Samaritan. Now what happens? So they finish stabilizing him. They inspect for his other wounds.
SPEAKER_09: And then they decide pretty quickly to take him to surgery. And 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, you know, Debreed, which was the standard of the day, sort of 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. He was in a coma. He never came out of it.
SPEAKER_10: He was pronounced dead at 1.44 a.m. 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 L.A. today, where do you go? Where's the nearest trauma center? I believe the closest level one trauma center is probably USC. But yes, you would go straight to a level one trauma center.
SPEAKER_09: A level one 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.
SPEAKER_10: And you would get there. I mean, today, rather rapidly today he gets to be arrives at the level one trauma center. Let's just say for the sake of argument, it's 15 minutes. Yeah. The and in your so the difference between two and a half hours and 15 minutes in your world is might as well be a year.
SPEAKER_09: Yeah. Yeah. And when he gets there, he's treated very differently.
SPEAKER_10: So at Duke, the neurosurgery team that's in the hospital, which is for us, always a resident and potentially always a faculty member.
SPEAKER_09: The rest of the trauma team would be paged ahead of time and waiting for the patient when they arrived in the resuscitation bay.
SPEAKER_10: 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 3D, an extraordinarily detailed image.
SPEAKER_09: In most trauma centers, including Duke, there is a CT scanner that is about 10 feet from where the patients first arrived. So there is very little care, very little delay. You finish the CT scan.
SPEAKER_10: You're how many how many minutes in are you from the moment the patient has arrived at the hospital?
SPEAKER_09: Unless the patient was so unstable in terms of their blood pressure, heart rate, that that required additional stabilization. That should be occurring within 10 or 15 minutes. Yeah.
SPEAKER_10: Commissaro 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. About as close to zero as you can get. Yeah. What's what's his percent survival chance today?
SPEAKER_10: He's not dying at 245 the next morning under this protocol. I think it is far less likely he is dying at 245 the next morning.
SPEAKER_09: Yeah. Listening to you describe the differences between 68 and the present day.
SPEAKER_10: It sounds like night and day. You have the same intention today as they did in 68. Reduce the swelling in the brain repair, stop the bleeding. But the ways in which you're going about doing that are markedly different. 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.
SPEAKER_09: It's the difference between a bicycle and electric car. Oh. OK. Yeah, that's that makes a lot of sense. Oh, that's huge.
SPEAKER_10: So what does Commissaro'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 lower the death rate from serious injury about 2.5 to 4 percent 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 have 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.
SPEAKER_11: Homicides 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. That's Natalie Hippel, a criminologist at Indiana University.
SPEAKER_10: They tape off the whole scene and not every non-fatal 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.
SPEAKER_11: A few years ago, Hippel 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.
SPEAKER_10: 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.
SPEAKER_11: They don't have a definition for a non-fatal shooting. There's no way to pull those data out of those sets.
SPEAKER_10: Wait, stop there. You're telling me that we are the wealthiest and most sophisticated country in the world that is simultaneously in the grip of a prolonged chronic outbreak of gun violence. We have no hard, useful numbers on the total number of shootings. 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.
SPEAKER_10: 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.
SPEAKER_11: The first thing we did was pull all the aggravated assaults. And they report to the FBI, and so they pulled all those case numbers and we started reading. I mean, literally, just in the bucket, out of the bucket, in the bucket, out of the bucket. This is thousands and thousands. How many people were engaged in this project?
SPEAKER_10: Well, I mean, we had a full-time... How many graduate students' lives did you ruin in this project?
SPEAKER_10: We had, well, each of us had our own. I mean, there wasn't a lot of funding.
SPEAKER_11: For newer cases, she got the police to help her out. Indiana has a reporting requirement.
SPEAKER_11: If you show up at the emergency department and you're stabbed or you're shot or you're really badly bludgeoned or something, they are, the medical facility is required to report that to the police.
SPEAKER_10: So every day, the police would send her the list of reports they'd gotten from the trauma center the night before.
SPEAKER_11: The procedure was, detective goes to the scene, figures out what's going on, and then writes up what they know about the incident that happened right then and there, and then 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. How many are you getting a day? Oh, my email right now, hundreds.
SPEAKER_11: Wait, you're getting hundreds of... My email, my police department email is off the hook. So this is all the bullet to skin reports from the city of Indianapolis.
SPEAKER_10: Yeah, and Indianapolis is the 17th largest city in the country. They run about 800,000 people, give or take.
SPEAKER_11: So you can only imagine what this must look like in Chicago or New York.
SPEAKER_10: 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 Hippel 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.
SPEAKER_11: Thank you for acknowledging that. It is depressing. I've started checking in on grad students. You know, I'm like, you're going to read all like, but when I hire them, I'm like, this is not, you know, something that you have, you know, over coffee and donuts and do your work, right? It's going to change your mood. Which brings us to the second implication of the homicide equation, which is that maybe these two things, how good the doctors are
SPEAKER_10: 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 seat belts. 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. As you know, if you listen to Revisionist History, I'm a big runner. I wake up at odd hours to watch races on different continents. I once left a really important business lunch with some completely made up excuse so I could sneak away to the bathroom and watch the 5,000 meters at some obscure Belgian track meet. Now, are any of these meets on network television? No! You have to subscribe to some obscure streaming service out of Bulgaria, which you sign up for and promptly forget about. And after doing this for 10 years, I realized I am personally bankrolling the streaming operations of the Bulgarian track and field community. And then I discovered Rocket Money. Rocket Money is a personal finance app that finds and cancels your unwanted subscriptions, monitors your spending and helps you lower your bills all in one place. Most people think they're spending $80 on their subscriptions, when in reality the number is closer to $200. When you're signed up for so many things, like streaming services you use to watch one track meet or free trials for delivery you don't use, it's so easy to lose track of what you're paying for. With Rocket Money, you can easily cancel the ones you don't want with just the press of a button. No more long hold times or annoying emails with customer service. Rocket Money does all the work for you. Stop wasting your money on things you don't use. Cancel your unwanted subscriptions and manage your money the easy way by going to rocketmoney.com slash Gladwell. That's rocketmoney.com slash Gladwell. Rocketmoney.com slash Gladwell. The one thing we can never get more of is time. Or can we?
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SPEAKER_10: So you've got the CT scan, so now you know, you know, you know where the bullet is and you know the extent of the damage. And presumably in your mind, 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. 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, you know, within about takes an extra sort of five minutes or less.
SPEAKER_09: Again, this was not available at the time that the senator was injured. Kennedy's brain is flooded in blood, but today Commissaro would have a sense of where the damage is, and he would call for help.
SPEAKER_09: 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. So keep going. So 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?
SPEAKER_09: Now, since they make mention to operating at the upper part of the brain a bit, the occipital lobe that they reference, which makes us conclude that the bullet trajectory somewhat passed upward from the cerebellum upward into the occipital lobe. You know, 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.
SPEAKER_10: They didn't use a microscope in 1968. Commissaro 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.
SPEAKER_09: 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.
SPEAKER_10: Same thing if the headshot was a little lower. That might not have made a difference back then, but today, possibly.
SPEAKER_09: 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. You know, the two carotid arteries supply about 80% of your blood and was hammering extensively from that prior to when it then damaged the brain itself. And we did, you know, 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 several months, but then went home and cares for himself, works. I don't think I would ever sort of 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 sort of say, oh, yeah, you were shot in the head or you had a brain injury. Yeah. So that's another scenario for Robert Kennedy. If the bullet had gone today, had hit him there, he could have survived.
SPEAKER_09: There are many scenarios where he survives.
SPEAKER_10: And what happens when someone survives a violent act that once upon a time would have 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.
SPEAKER_02: For those of you who are black and are tempted to 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. 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.
SPEAKER_10: We had someone who might have 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.
SPEAKER_02: 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.
SPEAKER_04: Our revisionist history gun series was produced by Jacob Smith, Ben-Daddaf Hafri, Kiara Powell, Tali Emlin and Lee Mengistu.
SPEAKER_10: We were edited by Peter Clowney and Julia Barton, fact checking by Arthur Gompertz and Cashel Williams. Original scoring by Luis Guerra. Mastering by Flon Williams. Engineering by Nina Lawrence. I'm Malcolm Gladwell.
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SPEAKER_01: Do you hear it? The clock is ticking. It's time for the new season of 60 Minutes. The CBS News Sunday Night tradition is back for its 56th season with all new big name interviews, hard-hitting investigations, and epic adventures.
SPEAKER_06: No place. No one. No story is off limits. And you'll always learn something new. It's time for 60 Minutes. New episode airs Sunday, September 24th on CBS and streaming on Paramount Plus.
