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Chapter 10

Table of Contents

Chapter 10

EPILOGUE

GENERAL THOUGHTS ON THE MANAGEMENT OF ORTHOPEDIC CASUALTIES

Colonel William E. Burkhalter, MC, USA (Ret.)

LESSONS LEARNED AND UNLEARNED

In the Vietnam War, perhaps as in no other conflict, wound exploration, debridement, and avoidance of primary closure became the uniform approach to wound management. As a result, the infection rate was low and cases of gas gangrene few. Staffing the first hospitals deployed to Vietnam by Regular Army officers with some experience or training in the management of combat casualties was a major factor in eliminating any need to relearn, once again, forgotten lessons from previous wars concerning wound debridement and the necessity for leaving wounds open to drain.

Debridement as an operative procedure was not easily learned, however. The surgeon had to have the courage to make the liberal longitudinal incisions and the wide excisions of the fascia necessary to expose muscular compartments as well as an intimate knowledge of anatomy so that he would not damage undamaged structures. Although his lack of experience in wound debridement might have resulted in a less than optimally debrided wound, delayed primary closure allowed surgeons to reexamine and redebride the wound in a few days, thus avoiding the problems of frank sepsis with secondary tissue loss.

An integral part of appropriate debridement is fasciotomy or fasciectomy. Fasciotomy may involve the investing fascia of the foot, leg, thigh, forearm, or intrinsic muscles of the hand. It allows exposure of muscle compartments with their subsequent decompression. The injuries resulting from certain high-velocity missiles required extensive exploration and decompression of all muscle compartments to protect the muscles and adjacent nerves from increased compartmental pressure and relative ischemia. Similar elevated compartment pressures might follow venous injury, especially injury to the popliteal vein, or a delay in vascular repairs proximal to the compartment, or crush injuries of the extremity. Fasciotomy in these cases was in some instances limb-saving.

The need for careful debridement was not eliminated by the antibiotics universally used after wounding in Vietnam. Penicillin, alone or in combination with streptomycin or chloramphenicol, was the usual agent. It was administered, usually intravenously, for three to five days in uncomplicated cases or for as long as several weeks in more complicated ones. Our concern about managing gram-positive organisms


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may have caused some of our difficulty with gram-negative infections in offshore hospitals. The use of penicillin alone in orthopedic casualties without gastrointestinal soilage seemed to avoid those superinfection gram-negative problems; it protected against clostridia and beta-hemolytic streptococcal infection. As the war progressed, the initial antibiotic treatments seemed useful, but we learned that repeated cultures should be used in deciding which specific antibiotics to use. Prolonged treatment, however, was unnecessary and frequently the source of problems.

As the war proceeded, the emphasis shifted from concern about type and duration of antibiotic to concern about individual wound management and the adequacy of individual debridements. In spite of the use of antibiotics, attempts to use delayed primary wound closure in all wounds in Vietnam produced some disastrous results. Delayed primary closure had been emphasized during World War II and the Korean War, when it was commonly used in extremity wounds, including those injuries with associated fractures and joint injuries. But wounds created by the high-velocity missiles fired in Vietnam often resulted in considerable tissue disruption. The temporary and permanent cavity phenomenon in the limb was well known, and debridement of damaged tissue created a larger permanent cavity within the extremity. In the femoral shaft fracture, skeletal traction maintained the dead space in the thigh. Under these circumstances, wound closure and minimal drainage created the milieu for wound breakdown. Attempts at delayed primary closure in high-velocity wounds of the thigh were fraught with an extremely high complication rate. Attempts to perform delayed primary closure on injuries of the leg with associated fracture of the tibia also resulted in wound breakdown. The skin of the anterior aspect of the leg tolerates tension poorly. With minimal skin loss and swelling secondary to fracture, tension closures were common. The skin responded with necrosis and subsequent sepsis. Relaxing incisions were also associated with considerable skin breakdown and subsequent tissue loss.

As a result, surgeons managing patients in the offshore hospitals and in CONUS (continental United States) became disenchanted with the technique of delayed primary closure in high-velocity wounds of the extremity. They realized that, even though several operative procedures had been performed to ensure adequate debridement, wound closure was not a mandatory next step. When wounds were encased in air-occlusive dressings and both drainage and antibiotics were recognized as necessary components of therapy, closure became an elective procedure that could be performed when and if the surgeon concluded that it was indicated, rather than at any specific time.

Largely because of Dehne’s teaching that function aids wound healing and fracture union, early functional use of the limb in the wounded patient was emphasized. It was not to be delayed because of wound closure, reconstructive procedures, or prolonged debility of parts or of the whole patient. Anything technical that compromised early functional recovery was believed to be unimportant and a deterrent to total patient rehabilitation. This was exemplified in the management of the open tibia fracture with the walking cast and of open comminuted fractures of the femoral shaft with the cast brace. The lower extremity amputee was ambulated with an open stump in a temporary plaster socket with foot extension. Wound healing by secondary intention was accepted in the upper and lower extremities, including the hand, so long as early functional use could be instituted to the injured part. This emphasis on functional recovery in the care of the femoral shaft fracture, for instance, reduced the patient’s time at full bed rest from months to a few weeks.


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COMMUNICATION AND CONSULTANTS

Orthopedic surgery in wartime deals with large numbers of casualties who, by the nature of their injuries, require weeks or months of continuing care and rehabilitation. The interchange of information between the initial treating physician in Vietnam and the receiving physicians in CONUS was vital for optimal care. But orthopedics, as a subunit under surgery in the U.S. Army administrative system, had no way of direct information exchange among orthopedic elements in Vietnam, the offshore hospitals, and CONUS. Although orthopedic surgeons in the United States were constantly trying to get information to surgeons in the Republic of Vietnam about problem areas, and orthopedic surgeons in Vietnam were interested in the follow-up treatment and progress of the patients, communication of this information was difficult.

The information and recommendations generated during the Vietnam War by five surgical conferences on management of battle casualties held at various sites in the Pacific also circulated very slowly. These conferences were attended by physicians from Pacific Command, Vietnam, and CONUS, from all three services, but few of their conclusions about the initial and early management of battle-wounded patients affected the treating physicians in Vietnam, probably because of the lack of a full-time, traveling orthopedic consultant with the authority to effect administrative or professional changes in the Republic of Vietnam. During their entire year in the country, many orthopedic surgeons never saw another orthopedist, except the ones with whom they were assigned.

We strongly recommend that in future conflicts, full-time traveling orthopedic consultants be available at all echelons with autonomous authority for administrative changes. Having orthopedic consultants in the forward area, offshore, and in CONUS would allow ready exchange of information and better assessment of management options. To have a consultant whose primary interests and training are in fields other than orthopedics to act as an orthopedic consultant is counterproductive, dangerous, and not conducive to the free flow of information or interchange of ideas.

CONTINUITY OF CARE AND REHABILITATION

Since in wartime a single patient may be treated by different physicians before arriving at a definitive treating hospital, chronological medical information about what has transpired during the transfer is important. But if you mention medical records and their administration to any combat physician who served in Vietnam, his discomfort index immediately goes up. In many instances, lack of an adequate clinical record made patient management a severe problem. The medical record for the patient repeatedly transferred from one facility to another usually contained considerable administrative data repeated over and over but very little medical information. We believe that some type of electronic cassette recorder should be placed into the evacuation system on which comments can be made and from which the information can be retrieved about what has happened previously to the patient. The cassette, designated for medical information only, would have no erasure button. It could easily accompany the patient like a dog tag around his neck, making the information constantly available along the evacuation chain. By using the cassette, the


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status of a peripheral nerve injury at the time of debridement in Vietnam, for example, could be immediately available to the physician treating the patient in CONUS. Standardization of playback capability is needed. Such a system would certainly result in a more complete medical record and eliminate poor penmanship as a factor.

Once a patient reached the definitive hospital in CONUS, the question arose as to whether this was really the definitive hospital for him. Was this hospital responsible for his long-term rehabilitation, both physical and psychological? Was this hospital capable of managing all his needs until discharge from the service or return to duty? These questions were but some of those related to the administrative aspects of the patients’ injuries that concerned all orthopedic surgeons treating long-term, severely injured patients. Throughout the entire war, the problem of hospital responsibility was never resolved.

Two types of Army units and the Veterans Administration system were in the group of definitive hospitals that cared for the wounded who faced long hospitalization. The military system had a Class I or station hospital and Class II or general or teaching hospital. The Veterans Administration also had hospitals throughout the country that varied considerably in their individual capabilities. In the administration of the evacuation system, orthopedic patients were initially sent to a military hospital close to their home. This could be a Class I or Class II hospital with an orthopedic service and a physical therapist.

Col. Raymond Bagg has pointed out that patients who have no chance of returning to active duty should be rapidly separated from the service. He advocated that this separation be accomplished as soon as possible because of the financial loss to the patient. For instance, a PFC U.S.M.C. with a bilateral above-knee amputation would not be capable of being returned to duty. In this case total CONUS hospitalization could amount to six to seven months. Veterans Administration compensation would amount to $638 per month during the Vietnam War, while active duty pay during the same time would be $180 per month. This pay differential amounts to about $3,092 for over six months of hospitalization.

Based on finances alone, certainly early separation is indicated. However, if this change from military to civilian status changes rehabilitation relationships or goals or results in administrative transfer, greater loss may result in the future. Severely injured patients need all the support we can provide since they are relatively fragile for a considerable time after a combat-related injury. Administrative changes that increase financial reward but also increase instability may be counterproductive. Indiscriminate and repeated transferring of patients with changes of physician and therapist after the vital process of rehabilitation has been instituted reduces its effectiveness. As soon as the patient’s physical condition allows, he should be sent to a specialized treatment center for definitive care.

The Army’s Class I hospitals were frequently staffed by physicians who were in military service for only two years. Most of these physicians had one year in the Republic of Vietnam and then one year in a Class I hospital, or vice versa. The presence of an orthopedic surgeon for only one year in the management of complex orthopedic injuries injected dissimilarities in training, lack of experience, and limited continuity of care into the situation. These men, although fully trained, Board-certified and Board-qualified, were caring for complicated cases in a relatively isolated system with only minimal experience.


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The Class II hospitals were adequately staffed with medical and paramedical individuals but had limited beds and holding facilities. In addition, they were unable to receive, treat, and completely rehabilitate all the orthopedic casualties from Vietnam. Thus there were frequent transfers of patients from Class I to Class II hospitals and from Class II medical centers to the Veterans Administration system in a haphazard fashion based on administrative requirements. The transfer usually occurred in the middle of the rehabilitative process and was dictated by bed requirements, transfer or discharge of medical or paramedical personnel, or the policy to get the patient as close to his home as possible. These transfers interfered with rehabilitation, introduced a new treating team to the patient, and frequently changed the rehabilitative goals.

In any decision concerning rehabilitation of orthopedic patients, occupational and physical therapists are essential. In most military hospitals the occupational therapist became an upper extremity therapist, while a physical therapist concentrated on the lower limb. These two groups were involved, daily or several times daily, in the treatment of each patient. These were the individuals who implemented and modified the early functional use of the damaged limb concept mentioned previously. The physical therapists were directly concerned with the lower extremity amputee from early ambulation in the plaster-of-Paris socket to wound closure to definitive prosthesis. In the patient with the cast brace for femoral shaft fracture gait training, muscle training and encouragement were required. The occupational therapists were concerned with training the patients in the activities of daily living, with peripheral nerve testing, and with early prosthetic training of the upper extremity amputee. In addition, they fabricated splints, tested patients, and helped patients with peripheral nerve injuries reeducate their upper extremities to perform voluntary motion effectively. Such activities were carried out not just in CONUS but in the Republic of Vietnam and in offshore hospitals as well. These innovative, interested, intelligent individuals were of immense value to both patient and physician, and disruption of the relationship they had developed with the individual patient and of the course of rehabilitation that they had started with him was harmful to his progress.

The lack of continuity and its adverse effects upon rehabilitation were a serious medical problem throughout the war in Vietnam. The role of patient rehabilitation in the recovery process requires further study and better application. To avoid the professional problems that I have mentioned, we recommend the development of the professional center concept as it existed in World War II. Because they would be staffed by medical, paramedical, and rehabilitative personnel, these professional centers could become definitive care centers in CONUS to manage patients completely from reception from overseas to definitive disposition. Whether the center is a U.S. Army hospital or a Veterans Administration hospital makes little difference. That is an administrative decision. But this approach would eliminate the indiscriminate transfer of a combat-wounded soldier from hospital to hospital and team to team, reducing his motivation and negatively affecting the entire rehabilitative process.

The dispersion of orthopedic patients throughout CONUS complicated even collecting the comprehensive data needed to study the care and rehabilitation of orthopedic patients, always difficult in wartime. When the group of orthopedic surgeons was brought together in 1972 to write this history, we knew it would be an immense undertaking, not merely because of the sheer number of words but because of our


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desire to write a history useful for orthopedic surgeons in the day-to-day practice. Our statements and conclusions had to be supported by scientific data, but, because of the difficulty of retrieving the information we needed, most of the clinical data in the chapters came from records collected by individual authors rather than from a central retrieval system. The establishment of centers for hand, peripheral nerve, amputee, and other medical problems in significant numbers would make it possible in the future to collect data and alter treatment modalities on the basis of past experience. A center concept for complex orthopedic injuries is essential if usable management options are to be learned in future wars. So long as these complex orthopedic cases are widely dispersed, clinical data retrieval will be, at best, haphazard.

This chapter has covered in a general way the practice of orthopedics during the era of the war in Vietnam. It contains lessons learned, lessons relearned, and some lessons that we believe should be forgotten. In addition, it mirrors our frustrations regarding dissemination of professional orthopedic information within the evacuation system and our immense concern for our patients and their total rehabilitation. Our recommendations to improve the system are made because of this concern and our desire to improve patient care.