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Lecture convened & chaired by Dr Rex Valentine
Professor Patrick Kelly
Chairman of Dept of Neurosurgery
New York University & Medical School
23 November 2005
I reported for duty at the Naval Support Activity Station Hospital in DaNang, on 25 August 1968. The heat in the Vietnamese summer and the dust were oppressive. The quarters for new arrivals were not air-conditioned. We slept soaked in our own sweat. Just about every unattended surface was soon covered in a fine brown dust.
The Station Hospital was mostly a collection of Quonset huts – half cylinder buildings – easily and cheaply erected and vacated. A Special Forces base and a Marine Air Group were situated between the hospital and the South China Sea to the east. To the west of the hospital was a Vietnamese Village that on some nights hosted Viet Cong insurgents. It was the biggest combat hospital in Vietnam, with 1000 beds and the largest blood bank in the world. The most prominent feature was the helicopter-landing pad, in front, with easy access to two triage areas. Casualties were moved from helicopters to one of these two areas depending on the seriousness of the injury.
I joined the Department of Surgery as a GMO (General Medical Officer). The Department had 4 fully trained general surgeons; including a career Navy Surgeon, Commander Vernon Fitchett, Chairman of the Department. The others included a volunteer, Lieutenant Commander Irwin Hirsh, from Argentina, who hoped to gain American citizenship by his service, and two others drafted out of their practices. The rest of us were GMOs. In August 1968, I was also the NG (New Guy). The NG was assigned to triage, a grim introduction to the harsh realities of war.
The vast majority of casualties arrived by helicopter. Sometimes we got a radio message in advance. Sometimes we only heard them coming. This meant that we always had to be ready, 24 hours a day, for choppers that would just suddenly ‘drop in’ with seriously wounded. At the sound of the approaching helicopter, the corpsman and ‘stretcher bearers’ would line up at the fence behind the helicopter pad, hiding their faces from the dust stirred up by the rotors as the sound of the chopper grew louder and louder. They communicated by hand signals as the racket became so loud that even shouts to one another were no longer audible. Most of them were just kids 18 or 19 years old. Corpsmen had a 4-month basic medical training course at the Great Lakes or San Diego Naval Hospitals. The stretcher-bearers had no such training. They were pulled out of duty assignments on ships and stateside bases; most would have been no use in other assignments and, as such, mirrored the litter bearers of wars past. Nonetheless, many stretcher-bearers learned tasks that only the corpsmen had been trained to do in the past.
Together, we - the corpsmen, the stretcher-bearers and the New Guys -waited in the dust and the noise for the choppers to land. We never knew what we'd find, but the helicopter type gave us a rough idea of the worst-case scenario of the number of casualties we’d receive. A UH 34 could unload up to 7 casualties, a CH 46: 14 to 16 wounded and the CH-53s could dump off as many as 60 severely wounded men. We dreaded the Marine UH 34’s the most – they usually came from a hot zone- an on-going firefight- and carried the most critically injured men.
Casualties were carried from chopper to triage areas on canvas-covered stretchers. Blood, and mud could easily be hosed off the canvas covering with water. They would dry quickly in the sun and be ready for the next group of casualties in minutes. Each stretcher was placed upon two simple wooden sawhorses in the triage areas. There the stretcher became the examination table and sometimes an operating table.
The triage areas were Spartan; one was in a Quonset hut, the other was an open area under a corrugated steel roof. Rails, about seven feet off the cement floor, ran the outer length of the space. To these were attached bottles of intravenous fluids, each with connecting tubing. Wooden saw horses were neatly stacked up along the sides of the space and would be positioned at the head and foot of each stretcher as casualties were brought in from the choppers. Multiple double underwater seal and suction bottles were kept at most of the stations. These would be attached to chest tubes. Gas powered tourniquets, blood pressure cuffs, battle dressings, intravenous supplies, laryngoscopes, endotracheal tubes, chest tubes; tracheostomy sets and rudimentary surgical instrument pack sets were in ready abundance.
Triage is the most brutal place I have ever encountered in my life. I'll never forget my first patient: a young man who was a little too late in tossing a grenade. The explosion blew off his left hand, both legs and peppered the rest of his body with metal fragments. As he lay dazed on the stretcher in triage he would raise his head up to look at the place where his left hand had been. All that remained, however, were an exposed radius and ulna protruding from the mangled flesh of his forearm. Suddenly, the unreality of the sight became real and he'd pass out as his head dropped back to the stretcher.
The sight upset me. Commander Vern Fitchett, the chief of surgery at NSA DaNang and the triage officer of the day recognized the despair in my face. He offered a word of condolence: ‘Well, PJ,’ he said, ‘War's not pretty. Now get your ass in gear.’
Throughout the day more helicopters landed with severely wounded and mangled men. The stretcher-bearers unloaded the choppers and dropped the litters on the sawhorses. Many of the men were screaming in pain and/or anguish over losing one or more body parts. Some were in hypovolemic shock from blood loss. Others were gasping their last breath in the terminal stages of shock or a tension pneumothorax from a sucking chest wound. The sickening smell made up of a mixture of sweat, dried blood, bowel content and mud quickly permeated the metal Quonset hut in the heat of the day.
Across the aisle a young marine was sitting gasping for air with a tension pneumothorax and sucking chest wound. Vern shouted to me – pointing to the man: ‘Get a chest tube in that one - quick.’
‘Chest tube?’ A corpsman jumped in front of me and quickly placed a large bore chest tube while I was dithering.
Starting an intravenous is difficult on a man in shock. I found this out as I fiddled with trying to find a vein in a man who’d lost both legs from a booby trap.
‘Do a cut-down,’ Vern yelled as the man started gasping for air in the last stages of shock.
Vern butted me aside. He grabbed the scalpel from my hand, slashed the man's upper thigh. In seconds he found the vein.
‘Okay, now put that Goddamn tube in there,’ Vern said as he held open the incision of the vein. The tube was connected to one of the hanging bottles of Ringer's.
Vern was off, slamming a chest tube into another man.
Corpsmen scurried about. They cut off bloody fatigues and body armor. They started IVs and did subclavian sticks. They placed chest tubes and applied tourniquets.
Triage duty was port and starboard: 24 hours on, 24 hours off. I do not remember being tired that first day-the adrenalin wouldn’t have allowed me to sleep if I’d wanted to.
More choppers; more casualties. I tried to move faster. But not fast enough. A load of severely wounded men was dumped on us this time. Vern had his hands full. Two young men, both of who had bilateral traumatic amputations of their legs from booby traps, both in profound shock, arrested as I fumbled with cut-downs. They couldn't be resuscitated. I was just too damn slow.
As I looked into their dead faces I saw that they were just kids .I could see them walking across the Quad on some college campus. They would never have that opportunity again. I felt my inexperience had contributed to their deaths. I have never felt so useless in my life.
Vern looked over at me but said nothing. He glanced towards one of the corpsman. ‘Bag ‘em,’ he said and then turned his attention to another one of the casualties.
A feeling of uselessness motivates you to do better and to try harder. I learned from my colleagues. I learned from corpsmen. Inexperience teaches you humility. You're willing to learn from anybody.
We had to quickly hone our clinical skills. ComputerTomography or MRI scanning was not available then. We really didn’t need them. It became clear to me that trauma- even wartime trauma- was not very complicated. High velocity bullets went in here and out there. Metal fragments from artillery, rockets or booby traps may not penetrate in a thru and thru fashion but they could do a lot of damage. Legs, arms could get blown away. But what mattered here were the basics that any medic could recite: Airway, Breathing, Circulation and stop the bleeding.
Once the patient was stabilized, he was carried out of the triage area to the X-ray unit where the extent of the injuries could be better defined.
Booby traps, artillery and mortars peppered every conceivable place in the body. Real war is not like the movies; men don’t simply get shot and suddenly die. They hang on for a while. Few have those lucid Hollywood moments to say the dramatic heroic last words to their comrades.
We could never relax when working on triage. One never knew when a firefight somewhere would result in more casualties. Wounded men could be back to the base hospital in minutes thanks to the choppers and the bravery of their pilots. Medical evacuation (MedEvac) helicopters were frequently called to extract wounded men from the middle of a firefight. Casualty extraction was far more dangerous than simply dropping off troops.
Troops were healthy, jumped out quickly and the chopper could be on its way. MedEvac choppers, on the other hand, had to sit in the Landing Zone (LZ) while wounded men either hobbled aboard or were carried to the LZ and loaded onto the chopper on stretchers. Meanwhile enemy gunners were trying to put one more American helicopter and its pilots out of commission. Bullets are whizzing by and the mortar rounds start popping around the craft as the enemy mortar men start getting their range. It was always incredible to me that these helicopter crews could go back to these hot LZs after they dropped off a load of casualties on us. Perhaps it is in our nature to minimize the risk our own lives when we can save others.
There is nothing like a military Triage area in wartime. Nothing in the civilian world runs as efficiently or as well, no hospital emergency room - no ‘trauma center’.
I’ve always been slightly amused at how amateurish these ‘state of the art’ civilian operations truly are in comparison to a military triage unit. In countless wars efficient systems for handling large numbers of casualties have evolved by a process of natural selection: Poor systems meant dead men. By the time of Vietnam, casualty handling was so good that over 90% of the casualties were able to reach most base hospitals alive, and survived.
The military medical system is a team effort. Simple wound debridements were done by corpsmen. They got to be very good at what they did. So did I –after a while. After working in wartime triage, there is very little in a civilian practice that can rattle you. Status Epilepticus or an epidural clot are nothing compared with the bilateral amputee with multiple fragment wounds and massive blood loss, or the casualty with pericardial tamponade whose chest must be opened in Triage to get his heart going again.
The injuries in Vietnam usually involved multiple organ systems. After stabilization in Triage, we'd determine from physical examinations and radiographs what surgical disciplines were required for each patient. They would be taken to a pre-op area where the patient's name and the surgical procedures required were listed on a white board by the triage officer. He also set priorities based on the severity of each patient’s injuries. Then the appropriate surgeon and an anesthesiologist would be sent for.
The Operating Rooms
After a cursory examination of the patient and x-ray films in the pre-op area the patient would then be taken to the Operating Room. Patients could be in the operating room within 20 minutes of their arrival at the station hospital and sometimes even faster. We had ready access to the largest blood bank in the world at that time and it was located within 30 yards of most of the operating rooms. Fresh blood, occasionally necessary for its clotting factors, was readily available from 3000 healthy US Marines stationed across the road from the hospital. Marines were always eager to volunteer to help a comrade.
The operating rooms were in temporary pre-fabricated buildings. They were as well equipped as any in the States, and ready for anything. This was an important lesson to me, which would also be useful for present day hospital administrators. Great surgery can be done in humble surroundings. It's not the real estate. It's the people!
The Operating Room team could assemble in a matter of minutes and the operating room could also turn over for the next case also in minutes. This now makes me wonder about OR turnover times of up to 2 hours at civilian academic medical centers (including my own).
We did our part and our colleagues did theirs. We learned to trust and respect our colleagues in other surgical disciplines. There were no ‘turf wars’. The only priority was what was best for the patient. A single patient might need orthopedic, general surgical, ophthalmologic, vascular, and plastic and neurosurgical procedures. Usually, all of these were carried out on the same patient simultaneously.
We didn't waste time in surgery. We had to work fast for two reasons: First to minimize blood loss. Patients with traumatic amputations multiple fragment wounds could require 30-40 units of transfused blood; some required as many as 80-90 units. And second, we never knew when the operating room would be needed for the next group of casualties.
The most life-threatening injuries were dealt with first; we quickly learned the urgent situations that may be encountered by colleagues in other disciplines, so that we could set priorities on which procedure was done first. Less serious procedures were done after life-threatening situations had been dealt with. We helped each other out, when necessary. A general surgeon might go to the foot of the table to help his orthopedic colleague.
Corpsman acted as scrub nurses and sometimes, first assistants. They were just kids and sometimes they acted like kids. But in spite of their youth, they were military professionals and performed in an outstanding fashion when required. Anesthesia was administered by fully trained anesthesiologists as well as by dentists who had been given specialty training at a Naval hospital and by nurse anesthetists.
We worked 7 days a week, 12 hours per day. We then had first call every other or every third day. When we were busy call didn't mean anything. There was no such thing as the Bell commission in Vietnam. During periods of heavy military activity – The Tet Offensive of 1969, for example, the pace could be brutal. I remember once operating through the day, then all night and the next day. I fell asleep in a hamper of soiled linen and slept for 8 hours. Then operated the next day. When the work came in - we did it there and then, there was no choice.
After Vietnam, bleeding in Neurosurgery has never bothered me. Bleeding from an aneurysm, a vascular tumor or meningioma and its management is relatively straight forward (clip the aneurysm, resect the tumor and the bleeding stops). I've seen much worse. Bleeding from a fractured liver is very difficult to stop.
Like Triage, however, wartime trauma surgery is basic. There are general principles: stop the bleeding, clear out the bowel content, remove badly injured tissue, repair bowel and blood vessels, stabilize fractures by external fixation, amputate unsalvageable limbs. The surgery was straightforward, but the postoperative care could be complicated.
Septic shock, blood transfusion reactions, hypovolemic acidosis, fluid and electrolyte problems, renal failure were challenges usually handled by general medical officers. In addition, infections in men with multiple injuries, many open wounds, in a hot humid climate were horrendous: Infections such as Staphylococcus, pseudomonas osteomyelitis and gas gangrene, were relatively common.
In the Intensive Care Unit as in the Operating Room, consultants were always available, appeared and did their jobs. In spite of the fact that many of the physicians were draftees, all took their jobs very seriously. In addition, most of these physicians were in their thirties, just out of their residencies. In Vietnam they learned a great deal about the practical management of very sick patients. However, the patients had benefit of the cumulative knowledge of physicians from many different training programs. It was always impressive to see how, as many as 8 physicians could suddenly gather at the bedside of a critically ill patient, discuss his care and decide upon a management plan decisively and without argument.
The Intensive Care Unit was large and well run. The wards, which were in Quonset huts, were clean, well staffed and equipped. Corpsmen, who were enlisted men, did a great deal of the patient care. Registered nurses, who were officers, supervised them.
Navy nurses boosted morale. There seemed to be nothing better for a wounded marine coming out of anesthesia than to see the face of an American woman. And these nurses prided themselves on bedside nursing. They were not ‘administrators’. They took great care of patients as they worked alongside the corpsmen.
In contrast to the doctors, many of whom had been drafted and ordered to Vietnam, Navy nurses were all volunteers. In fact, Vietnam was the most requested duty assignment within the Navy Nursing Corps during the war. The Navy Nursing Corps’ proud tradition traces its roots to the ‘Lady with the Lamp’- Florence Nightingale and to Clara Barton who tended the Union troops in the Civil War and founded the American Red Cross. Navy Nurses shared our work. They also shared the risk.
Mortar & Rocket Attacks
Beyond the watchtowers of the Station Hospital’s perimeter fence was a small Vietnamese village. It was well hidden by trees and brush. The village was located just to the west of the hospital compound. Many small villages in Vietnam were well patrolled by US and ARVN (Army of The Republic of Vietnam) troops during the day. The night, however, belonged to the Viet Cong. The village next to us was no exception.
To the east of the hospital was Marine Air Group, MAG-16 and CH 53 Gunships were based here. They were attractive targets for the enemy. At night the Viet Cong would come into the small village to the west of us and from there would lob mortar rounds or fire rockets over the hospital to hit MAG –16s. Sometimes, the rounds fell short and landed on the hospital or in the grounds. We’d hear the sirens and the explosions through the night. Some staff went to the bunkers. A few used to sleep in flak jackets under their bunks. Most of us, however, would simply roll over and try to sleep through the noise. In the morning, on our way to breakfast, we'd find the damage.
If they could Vietnamese civilian employees would patch the holes in the roof and clean up the mess. Sometimes the mortars would hurt or kill someone. We never discussed this; the subject was better left alone. A feeling of invincibility and the belief that it was always someone else who could get killed or wounded helped a great deal. After a while we usually regarded the rocket and mortar attacks as an inconvenience that interfered with our sleep and nothing more.
I recall a time when a colleague and I were drinking one night with some of the nurses on the patio of their residence when mortar rounds started landing around us. The nurses took it in their stride. We all huddled together under one of the picnic tables. We continued to drink, told stories and the nurses giggled as mortar shells popped around us. Years later, a truck backfiring would remind me of this night in a ‘flashback’ - not of terror but a curiously pleasant and nostalgic memory of how close I felt to the people with whom I worked.
Sandbags offer more protection from flying shrapnel than picnic tables. Neither the nurses nor I really considered that in a second we could be like those poor guys we took care of, day after day. This gave me insight into the feelings of combat troops who could go back into battle or the Med-Evac chopper pilots who could repeatedly return to hot Landing Zone’s day after day. One always thinks that it will be someone else that gets killed or wounded.
Even our own weapons posed risk. A significant number of our casualties were victims of ‘friendly fire’ or occasionally, some of the wounds would contain live ordinance, which had not exploded on impact. One general surgeon, who had been drafted out of his practice, risked his to own life to remove an unexploded M37 to save a man. He was ultimately awarded a much-deserved silver star for his bravery.
The Air-Evacuation Route
The primary mission of the Station Hospital was to treat wounded men so they could return to duty. If return to duty within 30 days was unlikely, the goal was to stabilize patients for return to hospitals in the Continental United States (CONUS). However, it was unlikely that many of these severely injured men would have been able to tolerate the 22-hour journey back to CONUS. Therefore, patients were admitted to, treated and re-stabilized in a network of intermediate hospitals along the way. This would break the trip up into more easily tolerated segments. Army, Navy and Air Force hospitals in Japan, the Philippines, Guam, Hawaii and the US West Coast formed what was known as the Air Evacuation System; the Air-Evac route. In CONUS, an elaborate network of well-equipped military hospitals took over the chronic care and rehabilitation of the wounded still on active duty. The Veterans Administration hospital system took over when the casualties were discharge from the military
Every morning a special bus would pull up to the back door of the Station Hospital. Patients on stretchers would be loaded onto the bus that would make the 20-minute trip to the DaNang Airport .The bus would back up to the cargo bay of a specially equipped C-141 Starlifter and the stretchers would be stacked up in the cargo compartment. The plane would take off for the Philippines, Japan or Guam. They were on their way home.
Occasionally, one of the doctors or nurses from the station hospital would accompany one or more especially critical casualties on trips to Japan or the Philippines. This would provide a 3-4 day ‘R&R’ (Rest & Recuperation) before returning on a military transport to Vietnam.
I found these brief visits out of country highly disorienting: Alone in clean hotel room in a modern city like Tokyo or Manila with no idea what to do but get into trouble; and no time to adjust to these new surroundings before having to catch the plane back to Vietnam. Surprisingly, one becomes used to living in a Quonset hut and with all that goes with it, the dust and grime, the open showers (which rarely had hot water). One misses the good things like eating with colleagues in the Officer’s Mess, commiserating with friends over drinks at the Officer’s Club and, of course, even working. Especially confusing was the one week R&R that I spent with my wife in Hawaii. After a few days, I was looking forward to returning to Vietnam, not because I wasn’t having a good time in Hawaii, but because I felt that I didn’t really belong there. I didn’t know it then, but this was a preview of what would happen four months after that when my duty assignment in Vietnam was to be over.
After a while we got to know the South Vietnamese employees who filled and stacked sandbags as well as other menial tasks about the hospital compound. Some came from the village that used to hit us with mortars at night. Some were found to be supplying intelligence on American casualties and other information to the Viet Cong. They were turned over to the Army of the Republic of Vietnam (ARVN rangers). They were probably executed on the spot; we never saw them again. But most Vietnamese non-combatants were people with strong family ties, who simply wanted to survive. During the day they were terrorized in their villages by our troops and the cruel and corrupt ARVN rangers; at night they were grilled and sometimes tortured by the Viet Cong in attempts to extract intelligence.
The Vietnamese paid a heartbreaking price during the war. Booby traps, shrapnel and napalm inflicted great suffering on women and children as well as our troops and on the enemy. A soldier missing a leg is somewhat understandable. A child missing a leg is tragic. Wounded Vietnamese didn't have helicopters to take them to their poorly equipped hospitals. They came by ox cart and sampan and it could be a 2-day journey.
Occasionally, desperate Vietnamese would bring their wounded relatives and children to our hospital. We'd stabilize them in Triage, do surgery for life-threatening emergencies, but have to transfer them to Vietnamese civilian or foreign charity hospitals: US.Operations Mission or the German hospital ship, Helgoland. We could not admit them to the Station Hospital; its mission was to care for wounded Americans. To this day I am haunted by some of the Vietnamese patients we had to refuse. One case was that of a pretty little girl wounded by an American ‘Willie Peter’ (white phosphorous) grenade. Her father had carried her for several miles to get to us, ignoring the fact that the Willie Peter was burning him also. We placed the little girl on a stretcher and soaked her in copper sulfate solution. Her father collapsed in tears.
Wounded ARVN soldiers may have had better access and facilities than civilians but medical care was not a priority. I recall having lunch at an ARVN hospital at the invitation of a South Vietnamese Army surgeon. During lunch, a helicopter with wounded landed and the casualties were moved into their triage area. I was getting anxious. However, the surgeons didn't move. They continued to enjoy their meal and conversations. Following a leisurely cup of coffee and a cigarette, we all strolled over to the triage area to see what the helicopter had brought in. There were about 12 wounded men. Four of them had apparently bled to death on their stretchers, three others had chest wounds, two of these had died, and another was gasping his last before a chest tube was inserted. My host must have seen the rage and disgust in my face. He said quietly, ‘Dr. Kelly, please let me show you something.’
We walked across a dusty dirt covered courtyard to a large prefabricated building, large enough to serve as a professional basketball stadium. We opened the door and the smell of rotting flesh, excrement and urine hit us. The building comprised only a single room and it seemed as if every square inch of the floor space was occupied with patient's beds. Many of the beds had traction rigs and the place looked like a jungle. There was almost no space in between the beds. If an attendant wanted to get to the patient in the far corner of the room, he would have had to crawl over the beds of other patients.
This, I reasoned, may explain why so many ARVN troops had amputations: it was easier to simply amputate an injured extremity and be done with it, than expend the considerable resources to allow fractures to heal. It was also more cost effective to let the critically injured ‘triage themselves out’ and die. I suddenly understood what my host was trying to tell me: wounded South Vietnamese soldiers weren't air-evacuated back to the States. They stayed there. After a while they'd simply run out of space and resources to care for them.
A complete unabridged monograph of Patrick Kelly’s talk will be available in the BRLSI Members’ Library from next year.
Summary of Discussion
Representatives of Amnesty International and United Nations were present. The speaker said that, even now, not a day goes past that he does not think of his year in Vietnam in one way or another.
The questions and discussions included the following subjects, and parallels between Vietnam and Iraq were made. The speaker said the casualties in Iraq were nothing like as high as Vietnam. But a member pointed out that they could be if the war continued.
The Vietnamese did not take care of South Vietnamese civilians. The South Vietnamese surgeons themselves were overwhelmed. The injured remained on site.
Vietnam was about containing communism.
The Survival rate for American combatants had much improved beyond WW2 due to immediate dispatch of the injured from battlefield by Helicopters. Pilots of these were very brave and remained on or close to the battlefield for 20 mins picking up casualties.
A member brought up the subject of the role of the media in Iraq.
The speaker pointed out that in Vietnam the media found American Atrocities such as the My Lai massacre more newsworthy than atrocities of the enemy. While the Viet Cong hang and disembowel their victims who gave any intelligence to Americans.
Another member stated the 2000 Americans killed in Iraq had been counted one by one, but at least 100,000 Iraqis had been killed and injured already, many of them innocent civilians.
Mr Ghazi Sabir Ali, an Iraqi, and member of the Institution said sanctions had killed 500,000 Iraqi children, and added that the Americans spend 3.5 billion dollars monthly in Iraq.
The question of oil as a motive for invading Iraq arose. The speaker agreed it was very much about oil. Again our Iraqi member pointed out that America consumes about 21million barrels daily and the rest of the world 61million bd a total of 82mbd as stated by OPEC. America now only produces 19% of its own oil.
The issue that the US originally supported Saddam Hussein was raised.
Another member suggested that sanctions should be removed and troops got out as soon as possible.
Patrick Kelly said that if civil war developed, Iraq would be divided into three clear-cut factions, Sunnis, Shiites and Kurds.
Ghazi Sabir Ali said this was not so clear-cut and many felt they were Iraqis first and Shiites second. Some pro-Iranian others Arab Shiites.
In a vote of thanks by Rodney Tye, who had spent time in the Middle East during WW2, emphasized the importance of preserving the Anglo- American alliance. He then gave a catalogue of mistaken British interference abroad including the Middle East, and then admitted that he saw himself as one of the bad guys.