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ACCESS TO CARE
THE SOLDIER AND HIS WOUND IN VIETNAM
Colonel John A. Feagin, Jr., MC, USA (Ret.)
The soldier cannot be separated from his wound. Nor could the soldier and his wound be separated from the milieu of the Republicof Vietnam, where medical officers caring for the combat casualty met both expected and unexpected difficulties. All those responsible for the wounded faced the challenges that resulted when the world of modern medicine, modern methods of evacuation, and modern weaponry encountered the paddies, jungles, and microorganisms of an ancient and tropical land. This chapter reflects specifically those experiences shared by Army surgeons at the 85th Evacuation Hospitalbetween 1966 and 1968.
The Republic of Vietnam is a country halfway around the globe from the continental United States (CONUS) between the latitudes of 9 to 16 degrees north of the equator. The terrain, ranging from rice paddies to beautiful narrow valleys, presented geographic and climatic conditions that complicated the work of the surgeon. Heat and humidity were factors. Endemic conditions of filth and disease frequently intruded upon basic care of injuries. Soldiers were wounded along waterways where human and animal excreta were common. Fevers of unknown origin invaded the health of our troops. Even postoperative fevers demanded a malaria smear for differential diagnosis.
A majority of casualties resulted from patrol actions, search and destroy missions, and helicopter assault missions that took place in areas inaccessible to land based motorized vehicles. The medical service system in Vietnam worked well, for the incoming casualties as well as for timely evacuation. From the orthopedist’s view, the helicopter made many things possible (fig.1). Since many missions took place in daylight, the casualty was usually received within the “golden” six-hour period after injury, often within less than thirty minutes. He had been well bandaged and splinted, the ride had been smooth, and preliminary diagnoses might well have been radioed ahead. If an overload had developed, the flight plan might have been changed and patient diverted to another facility with equal capability, usually within easy flight radius. Marines sometimes appeared unannounced, however, since they often did not have meshing communications.
The hospital was well prepared to receive the casualty, beginning with the helipad, which was as much a part of the facility as the surgical suite. The receiving area where the patient was resuscitated had intravenous hangers and litter racks. Radiological facilities were comparable to departments in CONUS, and surgical suites were well equipped. Gas machines with nitrous oxide, oxygen, and halothane were standard. Jet lavage, which might have been beneficial, was not consistently avail-
able, but irrigation during debridement was copious. The facilities had good floor drainage, and the postoperative area, although unsophisticated, was adequate. Respiratory ventilation units were not standard and usually were not available; if a light simple, reliable unit had been developed, it would have proven valuable. Air conditioning, desirable because of the heat and humidity, was usually available in the surgical suites and postoperative areas. Patients who could leave the recovery area were sent to nursing units that consisted of forty-bed quonset huts with concrete floors.
Evacuation after definitive surgical treatment took place after an average four-day stay in the postoperative unit, nursing unit, or both, although the holding policy at our evacuation hospital was thirty days. The fixed wing flights that usually handled evacuation took off from an immediately adjacent field and were closely coordinated with two departures per week for Clark Field, the U.S. Air Force base in the Philippines, Liaison with the Air Force was excellent, and the facilities and surgical expertise available at Clark inspired confidence. Evacuation was discouraged if the casualty was febrile, in undue pain, clinically unstable, or unable to tolerate the decrease in pO2 that would occur in flight. Sometimes attendants were sent with the casualty if tubes were to be managed or if liaison with Clark was appropriate. Patients were reevaluated, treated, and then flown on to Japan or CONUS for further convalescence.
Most hospitals were at the Table of Organization and Equipment (TO&E) strength, and the nursing staff of both recovery room and wards was excellent. Orthopedic surgeons generally felt, however, that their specialty was inadequately represented
in relation to the number and type of combat-wounded soldiers and that the TO&E was out of date. The supporting staff of specialists, nurses, and enlisted technicians was usually well qualified and dedicated to the mission. Teams became close-knit as confidence and loyalties grew. Stateside surgical standards were our standards. The draftees, whether physicians or enlisted, earned the respect of all.
The medical service and the quality and extent of care given in the battle area in Vietnam received the unstinting praise of Maj. Gen. Spurgeon Neel, the command surgeon (1973, 57). Outstanding initial care, rapid evacuation, well-established forward hospitals, readily available whole blood, current surgical techniques, and top-notch medical management minimized contamination and morbidity of potentially lethal wounds (Neel, 1973, 49)
CARE OF THE WOUNDED SOLDIER
The American soldier was reasonably well conditioned and acclimated for the tasks in Vietnam. The intermittent nature of the combat and his frequent resorts to the Post Exchange and A-rations probably helped maintain his nutritional status. Nevertheless, he was chronically dehydrated. Renal colic, even among young soldiers, was a common manifestation of the dehydration. Diarrhea was the scourge of all. Fevers of unknown origin were common, but the “sick” soldier was rarely committed to combat. Thus the typical wounded soldier was a healthy young American with approximately 17 percent body fat and reasonable cardiovascular fitness, heat acclimated, and 10 percent dehydrated.
When the soldier was wounded, corpsmen on site rendered the first treatment; splinting limbs, bandaging other injured parts, and starting intravenous fluid infusion and transfusion of O-positive blood. Fourteen percent of the blood transfused in Vietnam was given at forward aid stations (Heaton et al, 1966). Corpsmen also summoned “Dust Off,” the code name for medical evacuation throughout the command (fig.2) Morphine was not as necessary as it had been in previous conflicts, probably because of the smooth and rapid evacuation. Field tags described the care at the initial treatment site. Splinting devices, such as wireladder splints or air splints, were adequate when combined with traditional field dressings. The MAST pressure suit was sometimes available but seldom used. Frequently, the patient was taken to a definitive surgical facility, bypassing the battalion surgeon. Triage did not assume the importance it had in past conflicts because of limited engagements, the prompt availability of the helicopter, the efficiency of the medical regulating officer, and the communications accessible to him.
Resuscitation was empiric and swift. Ringers lactate, 2000 cc., with four ampoules of sodium bicarbonate, and 10 million units of penicillin were routine while type-specific blood was prepared. An indwelling urinary catheter was inserted. Within twenty-four hours after arrival at the definitive treatment facility, the wounded soldier received tetanus boosters and two to four units of type-specific blood. Intracatheter needles were inserted for prompt restoration of fluid through two or three portals. The patient usually had a systolic blood pressure of 100-mm. Hg and a pulse less than 100 beats per minute. After the patient had had roentgenograms in the radiology department, he was moved to the operating room. Following the debridement and other surgical pro-
cedures necessary to care for his wounds, he remained in the recovery area, where the vital signs were carefully monitored and replacement fluid therapy was continued. Critically wounded patients usually had indwelling urinary catheters. Monitoring the output volume helped to determine the adequacy of fluid replacement and to steer resuscitative efforts. The air conditioning of the surgical and postoperative suites helped minimize further fluid loss of the already dehydrated soldiers and undoubtedly contributed to decreasing morbidity and mortality rates. After he reached a stable condition, the patient was transferred to one of the hospital’s nursing units.
Surgeons caring for the soldier immediately after wounding had to be alert to his metabolic status, which reflected a complex process still not completely understood though better appreciated because of the studies of the United States Army Surgical Research Team (Heisterkamp 1970). This research, a testimony to the Surgeon General’s concern and insight, has stood the test of time, and the principles that evolved from it are now applied by surgeons in every major trauma center. Those portions of the report that proved particularly valuable to the orthopedic surgeons in Vietnam in the management of the wounded soldier are summarized under such topics as treating respiratory insufficiency, arterial hypoxemia after wounding, blood volumes, serum enzymes in combat casualties, and hypoxemia during convalescence.
Respiratory insufficiency in combat casualties and, subsequently, severe pulmonary disease were present in 95 percent of casualties who were resuscitated but subsequently died. Lung weight was the single most objective indication of pulmonary dis-
ease in the casualty at autopsy. Although fat studies were not performed routinely, fat embolism was recorded in only four of 100 autopsy reports. The incidence of severe pulmonary disease as found in combat casualties at autopsy has not changed in twenty-five years. Most patients died with “wet lung.” Data support the suggestion that the lung represents a particularly vulnerable target organ for a variety of pathologic stimuli. Pulmonary edema can be rapid and pernicious. (Heisterkamp 1970, 26-35.)
Thirty percent of all wounded soldiers and 17 percent of those with wounds in the extremities were hypoxemic (pO2 less than 80-mm. Hg) on admission. Oxygen, administered by mask, was beneficial. Failure of tissue oxygenation was a central feature of the shock syndrome in combat casualties. Yet cyanosis was never detected in the anemic, vascularly constricted, often muddy casualty. Shock and acidosis aggravated arterial hypoxemia and facilitated fat embolism. Microembolic phenomena were suspect (Heisterkamp 1970, 36-59).
During induction of anesthesia, patients in hemorrhagic shock exhibited biphasic shifts in serum sodium concentrations. Using succinylcholine during induction of anesthesia to the combat casualty in hemorrhagic shock may be lethal. The significantly wounded soldier already has a red blood cell deficit that leads to a decrease in red blood cell mass and red blood cell survival (Heisterkamp 1970, 159-98).
The effects of massive transfusion in the acutely wounded soldier were observed closely. In the wounded, platelets are rapidly decreased. Operative bleeding, in significant loss of volume, was not encountered. Prolonged shock rather than transfusion, per se, seemed to trigger disseminated intravascular coagulopathy (DIC). Most patients who died had coagulopathies. Episodic, nonlethal DIC probably occurs during recovery from severe trauma and shock as reflected by abnormalities of prothrombin and partial thromboplastin time in thrombocytopenia and fibrinolysis (Heisterkamp 1970, 111-48).
Serum enzymes, lactic dehydrogenase (LDH) and serum glutamic oxalacetic transaminase (SGOT) levels were elevated in more than 9 percent of the combat casualties at twenty-four hours. Blast injuries of the foot and abdomen were associated with increased LDH activity; blood transfusions increase SGOT levels. Serum glutamic pyruvic transaminase (SGPT) is a direct indicator of cellular necrosis and rises late. Enzyme elevations suggested that the degree of tissue damage, metabolic alterations, or both were greater than may been obvious at the wound site. The SGOT level may be the most sensitive measure of soft tissue trauma (Sleeman et al. 1969; Heisterkamp 1970,1-8).
Oxygen tension was significantly lower in the recovery room period and recovery of oxygen tension was often delayed until the fourth postoperative day. Nasal oxygen favorably affected the degree and duration of hypoxemia. Central venous pressure was often normal despite acute pulmonary edema. Posttraumatic pulmonary edema appears to be a disease of multiple etiologies. Factors of prolonged shock, massive transfusion, blast injury, and fracture seem to play major roles in this pathogenesis (Heisterkamp 1970, 49-96).
Although we tried to estimate convalescence time, we could not generalize about the average period that would be needed because of the many complications that could occur following wounding and because of the many types of wounds. A patient who had had a laparotomy might be ready for duty in forty-five to sixty
days, while one with a gunshot wound that had fractured the femur usually required more than one year of convalescence and rehabilitation.
Rehabilitation was an important part of the wounded soldier’s convalescence. He benefited both physically and psychologically from the efforts of the physical therapists who entered the combat zone in 1967. They provided invaluable assistance to the orthopedic surgeon by improving the supervision of the patients’ isometric exercises, efforts to increase the early range of motion of the joints, pulmonary ventilation, and early ambulation of some amputees. Postoperative goals could be established and implemented before the patient was evacuated.
The proposal made in late 1967 that patients be evacuated directly from Vietnam to hospitals in CONUS for convalescence and rehabilitation was subsequently discouraged because the casualties arrived too fatigued and too dehydrated from the strenuous and lengthy fight. The break at Clark AFB proved effective for rest and reevaluation. Approximately 20 percent of the casualties going through Clark were given further surgical therapy because of fever, pain, or suspicion of wound complication before being sent to hospitals in Japan or CONUS.
CARE OF THE SOLDIER’S WOUND
Although the circumstances under which they worked were quite different from those of military surgeons or earlier conflicts, surgeons treating wounds in Vietnam owed much to their predecessors. Debridement in the modern sense was first used in the late eighteenth century by Pierre Joseph Desaul, who taught the technique to his students, among them Napoleon’s great surgeon, Jean Dominique Larrey. In the late nineteenth century, Louis X. E. L. Ollier introduced immobilization of the limb in a plaster cast in the belief that absolute rest was conducive to healing. During World War I, American surgeon H. Winnett Orr introduced immobilization of the limb as part of the treatment program for extremities afflicted withosteomyelitis. The Orr method was not simply immobilization in the correct position and then infrequent dressings with a Vaseline pack, but included all the essentials of surgical care, including adequate primary drainage, protection of wound against secondary infection, and good patient care (Trueta 1943, 31-33, 37).
Just before the outbreak of World War II, J. Trueta (l943, 39-42) modified Orr’s fundamental principles. “If, therefore...the protection of the wound by plaster cast can arrest an infection already in progress,” Trueta commented, “surely it must have even a better chance of success if applied before the infective process has begun.” He reduced the amount of gauze used for drainage, discarded Orr’s use of Vaseline, and eventually substituted a very fine mesh gauze. When he published an account of his work in 1938, he noted, “When surgeons have a good knowledge of all he details of the technique and when the organization is such that they can deal with a steady stream of cases instead of sudden overwhelming numbers, results should be as consistently good as is possible within the limitations of human endeavor.” Trueta’s book is a definitive work and essential reading for the student of trauma surgery, but trauma surgeons should also b e acquainted with the contents of the Surgeon General’s volumes on the history of orthopedic surgery in World War II (1956, 1957, and 1962) and the NATO Emergency War Surgery Handbook (1975).
In the Vietnam conflict, however, high-velocity missiles produced greater tissue destruction than any weapon used in this or other wars. (Rich et al.1967). The time-honored formula used to calculate kinetic energy, MV2/2, does not completely reflect the massive additional damage that might be done by bullets that yaw or disintegrate. Further, the formula does not reflect the effect of cavitation and secondary missiles (shattered bone) or the possibility of fractures and neurovascular injuries in bodily areas not in direct contact with the wounding agent. The wound caused by the high-velocity missile acquires explosive characteristics in itself because the kinetic energy of the wounding agent exceeds the elastic limits of the tissues (fig.3).
Multiple wounds were more common in Vietnam than in previous conflicts because of the high velocity of lightweight rounds, the rapid fire at close range, and the extensive use of mines and booby traps. These wounds were dirtier than in any previous conflict; a tremendous amount of dirt, debris, and secondary missiles were hurled into the wound during the prolonged cavitation phase. Massive contamination challenged the surgeon to choose between radical excision of potentially salvageable tissue and a more conservative approach that might leave a source of infection (Neel 1973).
The effectiveness of medical treatment for the wounded can be determined from the ratio of deaths to deaths plus surviving wounded. For World War II, the ratio was 29.3 percent; for Korea, 26.3 percent; and for Vietnam, 19 percent. The ratio of killed in action to wounded in action was 1 to 3.1 in World War II; 1 to 4.1 in Korea; and 1 to 5.6 in Vietnam. Sixty-five percent of wounds in Vietnam were caused by fragments, but 51 percent of the deaths were caused by small arms as compared with only 32 percent in World War II and Korea. More than 54 percent of the wounds sustained by soldiers in Army of the Republic of Vietnam were ex-
tremity wounds. Approximately 42 percent of Americans wounded in Vietnam returned to duty (Neel 1973, 51-52).
Among wounds encountered by orthopedists in Vietnam were those that were self-inflicted, usually involving the second toe of the left foot. Because of the close range, in these instances, M16 wounds were perforating but not particularly devastating, probably because the bullet had not begun to yaw and entrance and exit wounds were quite equal. Approximately 50 percent of these soldiers could be returned to duty in the theater after appropriate debridement and delayed primary closure. Orthopedist saw only occasional self-inflicted hand wounds. Since these were more severe than the foot wounds, the patient was usually evacuated.
Regardless of how the wound was inflicted, surgery was usually carried out by or under the direction of specialists. Many new lessons had to be learned and old lessons relearned because of the high-velocity missiles. We learned to visualize each wound as a compartment and to appreciate that each of the structures within the compartment had a different tolerance or compliance and a different response to the wounding agent. Skin has a high degree of elasticity and a generous blood supply. Fascia served only to construct. Bone shatters like fine china, and yet nerves and arteries accept the shock reasonably well. Occasionally, though, an intact vascular or neural tube disguises intimal or fascicular damage within its confines. Decompression and drainage in high-velocity wounds can be obtained only when incisions are carefully planned and encompass almost the length of the involved segment. No better guideline for debridement exists than the poem of Sir James Learmonth: “Of the edge of the skin/take a piece very thin/the tighter the fascia/the more you should slash’er/of muscle much more/till you see fresh gore/ and bundles contract/at the last impact/leave intact the bone/except bits quite alone.”
In primary wound care, the debridement procedure augmented with intravenous antibiotics and copious lavage was effective. We gave special attention to opening the fascia and the compartment of the upper and lower extremities when they were penetrated by high-velocity missiles. Amputation was not done in stylized fashion but rather was performed to retain the maximum amount of skin and length. Vascular injuries with associated fractures were best handled by a team. Fasciotomy was always accomplished if the disruption of the flow was greater than six hours. Tourniquets were always in place and were used for the hand and foot but were seldom used for the leg or thigh. Tissues were not shifted during the initial surgery. Kirschner wires were sometimes used as spacers during the primary debridement. Because of increased cavitation from the high-velocity missiles, more extensive compartment decompression relief was needed. This was particularly true in the upper extremities where the lacertus fibrosis and carpal tunnel bound their respective segments. In the lower extremity, the fascia required incision. After surgery, bulky air occlusive dressings were applied to decrease the chances of secondary contamination and gram-negative septicemia. Sugar tong splints were occasionally used in preference to circular bandages. At the 85th Evacuation Hospital, the cast table was an outdated World War II model, but a crude spica could be applied when one had assistance.
Physical therapy was initiated before evacuation to promote well-being, retain joint motion when feasible, and/or alleviate psychological stress. Skin traction on amputee stumps was routine. A self-contained system was used for air evacuation.
If we suspected that debridement had not been adequate or that infection had developed, we promptly performed another debridement procedure. Patients with temperatures greater than 100.5 degrees F(38.2 degrees C) were not evacuated but were returned to surgery. A compromised compartment or area of undue tissue tension usually explained the fever or pain.
Secondary wound care, which included the management of wound closure, wound breakdown, wound infection, stabilization of long bone defects, and similar problems, was not ordinarily handled in Vietnam. Although reexploration for surgical complications indicated by fever, pain, excessive drainage, or vascular compromise was encouraged whenever and wherever they appeared, most secondary wound care took place after the patient was evacuated to the 106th General Hospital, in Yokohama, Japan; the U.S. Air Force Hospital at Clark AFB; Tripler Army Medical Center in Hawaii; or CONUS.
Little has been written on secondary wound management, perhaps because of an assumption that surgeons have little trouble knowing when and how to proceed. Such, however, is not the case. Certainly, delayed primary closure is one of the most valuable methods of wound care. Indication for closure, ideally accomplished within seven days after injury, is a clean appearance of the wound. But the fact that high-velocity missiles caused larger defects and potential “dead spaces” complicated the surgeon’s decisions. Thus the adequately debrided wound overlying a fracture frequently presented a challenge to the surgeon performing the delayed primary closure. Many of the wounds sustained in Vietnam could not simply be closed by reapproximation of skin edges. Tension was too great, and underlying “dead space” offered a favorable milieu for bacterial growth. Every conceivable type of suture and plastic technique was applied to the problem: near-far or far-near sutures, subcuticular sutures, adhesive bandages, relaxing incisions, muscle slides, and grafts of all natures were tried. None was universally successful. Too often the volume deficit was too large to be overcome. The solution to this problem was found in the techniques of Trueta, who recommended “adequate debridement, augmented by plaster retention of the tissues, and await the passage of time. Bacteria flora is self-adjusting, granulation tissue abounds, and wound contracture “miraculously’ closes the deficit” (1943-35).
Implicit in the guidelines of the NATO Handbook (1958) is a common understanding of the criteria of a “clean appearance of the wound.” This determination must be based on studies of bacteriologic findings so that decisions can be made on a more scientific basis. Periodically, such studies have been done (Marshall et al. 1976), but Trueta (1943-54) seems to have been the first serious student of wound flora in battle casualties. Certainly, he was the first surgeon to study the effect of occlusive plaster in-depth.
In the early years of the conflict in Vietnam, surgeons initiated delayed primary closure with relish and fervor. Ultimately however, most orthopedic surgeons came to the realization that not all wounds over fractures could be closed. The breakdown rate over fractured femurs, for example, was in excess of 50 percent. The breakdown seemed to be based more on the size of the deficit than on the wound flora, although gram-negative contamination must be suspect because broad-spectrum antibiotics encouraged overgrowth of these organisms. As a result, surgeons came to place greater reliance on either the occlusive dressing technique for the lower leg or grafting for the leg, hand, forearm, and arm. The mesh graft made its
appearance during the Vietnam conflict, gaining immediate acceptance and popularity. Thus, a broader therapeutic range seemed acceptable to the surgeon of the Vietnam era. Primary wound drainage was usually obtained by an incision of adequate length and the accompanying fasciotomy. Counter incisions were not usually recommended. Suction drainage was frequently used beneath the flap of the wound closed by delayed primary suture and seemed effective (Trueta 1943, 35). Penrose drains were again condemned either for primarily or secondarily closed extremity wounds (CINCPAC-1 1967). Packing wounds with gauze often interfered with free drainage and was therefore also discouraged.
WOUND INFECTION AND ANTIBIOTICS
To prevent impending wound infection as well as treat it when it was already established, antibiotic therapy was an important supportive measure. Although much has been published about antibiotics in the civilian literature, such is not the case in military literature. Penicillin arrived without much of a literary stir in World War II. Senior surgeons apparently realized that the quality of wound care, not the antibiotics, would determine the end result. Only Hampton (1957) seemed to develop new therapeutic regimens based on the protection of antibiotic coverage. He also advocated delayed primary internal fixation of fractures, but the experience is still not conclusive on this technique. We really do not know whether antibiotics will allow early reparative fracture surgery.
Before the spring of 1944, sulfanilamide drugs were used by our forces in the care of war wounds. In mid-1944, when penicillin became available generally, it was used in an effort to provide a wider margin of safety for the aggressive surgical procedure (Hampton, 1957). Blood replacement and antibiotic therapy were considered merely adjunctive measures to protect living tissue against invasive infection (Hampton 1957). In the European Theater of Operations, American soldiers were provided with sulfanilamide pills and sulfa crystals in their first aid kits almost until the end of the war. They were instructed to take the pills as soon as they were wounded and to sprinkle the crystals into the wounds. It was also rather a general policy to spread sulfa crystals into the wound at surgical closure. Both of these practices were eventually abandoned (Cleveland 1956).
Sulfanilamide and penicillin helped broaden the scope of surgery, but surgeons using them emphasized their protective rather than their prophylactic or curative aspects. Unfortunately, antibiotics gave surgeons a feeling of confidence in delayed primary closure of wounds (Cleveland 1956). Cleveland reported that in World War II, osteomyelitis subsequent to open long bone fractures occurred in 5.4 percent of 2,152 wounds in the European theater. There is no proof, however, that the incidence of serious wound infections in his series was substantially reduced by the use of either sulfonamide or penicillin. The remarkable freedom from infection that was enjoyed during World War II should be attributed chiefly to adequate debridement plus the liberal use of whole blood to replace blood rather than to the use of new agents (Cleveland 1956).
During the Korean War, a broad spectrum of antibiotics was available, but no new techniques were introduced or policies established. Battle casualties in Korea
suffered less wound infection than casualties in previous wars. Clostridial organisms were present in approximately 46 percent of wounds at the time of debridement. The beneficial and protective affects of antibiotics in minimizing Clostridial infection (Art et al. 1956) suggested that antibiotic therapy might influence both aerobic and anachronic flora.
Records to substantiate all observations on orthopedic wound infection in the Vietnam War do not exist, since few longitudinal studies have been conducted that could accurately document them. The incidence of chronic osteomyelitis following the Vietnam conflict is not known, but two reliable articles (Brown and Urban 1969; Foreland and Metz 1976) reflect successful spontaneous closure of infected long bone nonunion by debridement, ambulation, and weight bearing plaster augmented by posterior bone graft. Nonunion and chronic osteomyelitis concerned us, but such problems were usually resolved between eighteen and twenty-four months following wounding (Brown and Urban 1969).
The experience gained with leaving joint and hand wounds open reduced infection to an all time low in anatomic areas where it had historically been common and disastrous. The classic article by Burkhalter et al. (1968) indicated an infection rate of 2.2 percent. A long-term report on open joint wounds does not exist, although Davis (1970) stated his optimism about the prognosis of the patients. Infection was inevitable in hip joint wounds associated with intra-abdominal wounds. A team approach was lifesaving. Drainage of the joint must be accompanied by appropriate general surgical care of the visceral injury that also had drainage and diversion (CINCPAC-1 1967). These potentially lethal wounds must be recognized early.
Wound infection in amputation stumps has been well documented (Keblish et al. 1970). Stumps were often edematous and infected, and by the time they were examined after the patients were evacuated from Vietnam, their skin edges had retracted. Skin traction had been frequently ignored, interrupted, or ineffectively applied en route. At Valley Forge General Hospital, Pennsylvania, the orthopedic team initiated a dynamic program of early ambulation in spite of open stump wounds.
By the time of the Vietnam War, orthopedic surgeons recognized that none of the antibiotics were substitutes for adequate surgery. They were the beneficiaries of World War II and Korean experiences as well as of the guidelines stated in the NATO Emergency War Surgery Handbook (1958). The handbook noted that “antibiotic therapy is an important supportive measure which is employed for the prevention of impending infection or the treatment of established infection, but its role is limited in these objectives. It is not a primary therapeutic measure.” Topical antibiotics had not grown in favor since their dispensation in World War II, except when used for burns,. An in-depth study by Noyes et al. (1967) reflected the historical perspective as well as a clinical trial of Sulfamylon. They reported that neither the qualitative nor the quantitative bacterial flora of patients treated with Sulfamylon changed when compared with the flora of untreated wounds. Furthermore, none of the antimicrobial regimens tested prevented proliferation of Pseudomonas species.
Little mention was made of antibiotics in discussions of military surgical practices of the U.S. Army, Vietnam (USARV). After a consultant visit to Japan and Southeast Asia in November 1966, Col. Robert M. Hall, MC, Orthopedic Consultant in the USARV Surgeon, failed to mention antibiotics or to make specific recommendations for their use (Hall 1966). Moreover, command guidance was limited concern-
ing the use of new broad-spectrum antibiotics, the selection of appropriate agents to counter gram-negative overgrowth and resistant strains, and the adverse effects, such as nephrotoxicity and ototoxicity, inducted by antibiotics. Heaton et al. (1966), such as nephrotoxicity and ototoxicity, induced by antibiotics. Heaton et al. (1966), however, commented on the use of antibiotics in joint wounds, noting that “antibiotic protection is mandatory as pyarthrosis is a great danger in these large avascular tissues.”
No orthopedic recommendations about antibiotics were made at the first Commander in Chief, Pacific (CINCPAC), Surgical Conference (20-25 May 1967). The consensus of the attendees was that joint wounds must be covered by antibiotics, although in the fresh, well-debrided extremity wound, antibiotics were not indicated. The conference coordinator did, however, recommend comparing various antibiotic regimens in addition to the penicillin-streptomycin combinations, indicating a change from the old penicillin-streptomycin regimen, particularly with heavier coverage against gram-negative organisms. (Art et al. 1956).
By the time of the fourth CINCPAC Surgical Conference (16-19 February 1970), we were already aware that antibiotics such as kanamycin, neomycin, streptomycin, and polymixin B caused respiratory depression or apnea in our patients when used as lavage in body cavities. Toxic complications, associated with antibiotics had been brought to our attention by Col. T. J. Whelan, MC, (1968) in a letter circulated from Tripler Army Medical Center to the Vietnam theater in 1968.
The fourth CINCPAC conference recommended prophylactic antibiotics and penicillin in large doses. Surgeons could use broad-spectrum antibiotics at their discretion, but they were cautioned that wound cultures and recultures should guide subsequent antibiotic use. This conference also addressed antibiotics and sepsis, noting:
Infections have been frequent sequelae of wounds throughout the history of military medicine. Adequate debridement, immunization, and antibiotics have significantly reduced the incidence of wound complications such as gangrene, tetanux and streptococcal cellulitis. However, massive infection in wounds created by weapons of modern warfare (e.g. high velocity missiles) and primitive warfare (e.g., punji sticks) remains a major problem at all levels of medical care, in-county, off-shore, and in CONUS facilities.
Among the antibiotics used in Vietnam, the most common were penicillin and streptomycin, but both were ineffective against microorganisms in more than 50 percent of the wounds of patients evacuated from Vietnam. All microorganisms cultured were sensitive to Mandelamine. The success of penicillin in vivo seemed to be dose-dependent. Our experience showed that it should be administered frequently with perhaps as much as 20 million units of penicillin, continuous intravenous drip, given for twenty-four hours (Matsumoto 1968).
The operating surgeon should have knowledge of the type or extent of wound contamination in order to select the appropriate antibiotic, but operating surgeons and the supporting laboratory rarely have time to made adequate bacteriologic determinations while they are caring for wounded patients. Such information should come from a research team. A beginning was made by the Walter Reed Army Institute of Research (WRAIR) team (Matsumoto 1968). Nevertheless, although broad-spectrum antibiotics were available late in the Vietnam conflict and antibiotics were an important adjunct in the care of Vietnam wounded, they neither mitigated nor modified the basic concepts of war surgery in the thirty-five years since their introduction.
Wound infection must be considered not only as a response of soft tissue and bone to wounding but also as a response to environment and contaminating factors introduced in the geographic area. Thus, in the management of wounds and in the selection of antibiotics, quantitative microbiology proved to be a reliable and valuable diagnostic aid that had considerable influence on surgical decisions. In patients with fewer than 105 bacteria per gram of tissue, most wounds healed without a wound infection. In those patients demonstrating greater than 105 organisms per gram of tissue, infection was usually present. A team developed a rapid quantitation technique for determining the magnitude of wound contamination that will be considered for secondary wound management in future conflicts (Marshall et al. 1976). The serious student must review the works of G.T. Rodeheaver, Ph.D. (University of Virginia, Medical Center, Charlottesville, Virginia), who has applied quantitative microbiologic determinations to civilian wounds.
Wound studies in Korea revealed a large percentage containing pathogenic aerobes and anaerobes (Lindberg 1955). In a group of 175 positive cultures from 112 wounds, 13 species of bacteria were identified (Art et al. 1956). Forty percent were contaminated by Clostridia species, which were sensitive to various antibiotics (Heggers et al. 1969). The most frequently identified bacteria were Staphylococcus aureau, Aerobacter aerogenes, Pseudomonas, and Proteus. The Surgical Research Team (Art et al.1956) pointed out that if routine antibiotics are to be used, penicillin is not the drug of choice.
The most common microorganisms found in the Vietnam combat casualties suspected of causing morbidity and mortality were Staphylococcus aureus (29.2 percent). Pseudomonas aeruginosa (18.3 percent), and Escherichia coli (17.3 percent) (Matsumoto 1968). Blood cultures from sixty-five cadavers revealed nineteen positive cultures. The most common organisms in this instance were Pseudomonas aeruginosa and Klebsiella pneumoniae. The team found no anacrobic microorganisms and concluded that the debridement in this study was adequate. Although all surgeons were concerned with gram-negative overgrowth and emergence of resistant strains, little objective data have been found to substantiate the perceived problem.
Serratia marcescens was a striking finding in blood cultures in Vietnam. Since it is an airborne organism, surgeons, aware of possible virulence, demanded frequent blood cultures and meticulous respiratory care of wounded patients on assisted ventilation. The medical surgical staffs pooled their expertise in the effort to prevent and manage sepsis induced by Serratia marcescens. It became clear to both internists and surgeons that attention to good infection control practice was of prime importance from the outset in the hospital environment at combat support facilities. This principle was even more important when these hospitals began to serve as fixed installations in support of an active combat role. Since effective bacteriologic analysis was critical to medical support of combat operations, plans to provide it had to be made early in the course of planning for the establishment of a relatively fixed hospital. Although this approach reflected the view of military internists and surgeons in Vietnam, medical officers in CONUS also employed it when caring for patients with melioidosis (Buchman et al. 1973).
Extra pulmonary melioidosis, a disease manifesting itself as an orthopedic problem, had received little attention until the French and then the Americans were exposed to the soil and rice paddies of Southeast Asia (Buchman et al. 1973). It was a
gram-negative infection with an extrapulmonary form. The laboratory had to be alert for Pseudomonas pseudomallei, and the surgeon had to be aware of the possibility of infection by this organism. Since 1966, at Valley Forge General Hospital, seventy-one patients have been treated for melioidosis with no fatalities. Sixteen of the patients with melioidosis as an extrapulmonary disease were the subject of a report by Bushman et al. (1973). Prolonged antibiotic therapy with tetracycline was essential.
Another unusual manifestation of bacteriologic organisms was seen in immersion foot. Combat soldiers experienced epidemics of distinctive warm-water skin injury called “paddy foot,” a variant of warm-water immersion foot. The immersion foot is caused by interaction of several factors; principally, changes brought about in the resistance of the skin to infection because of long exposure to contaminated the resistance of the skin to infection because of long exposure to contaminated water; damage to the skin generated by wearing boots and socks; presence of etiologic organisms in the water and the environment; and increased temperature of the tropical environment. Akers (1974a and 1974b) has reported on the natural history, epidemiology, and field experiments of paddy foot.
The key to dealing with immersion foot was prevention. Rest, elevation, and therapeutic use of antibiotics were essential to the treatment. The jungle boot seemed to be relatively effective in drying itself and protecting the bottom of the foot from minor penetrating blows, but it did not provide much ankle or foot support. Callosities and immersion foot sometimes required evacuation to in-county convalescent hospital facilities, but out-of-country evacuation was seldom necessary. Most soldiers returned to their units after five to seven days of treatment.
Gas gangrene and tetanus were almost nonexistent in Americans wounded in Vietnam. The rarity of clinical gangrene in these patients cannot be explained entirely on the basis of rapid evacuation, early debridement, or timely antimicrobial therapy (Noyes et al. 1967). The rarity of gas gangrene is even more surprising in view of the extensive arterial repairs that were attempted. I did not see or hear of a case of tetanus in an American casualty in Vietnam, but we routinely gave 0.5 cc. tetanus toxoid boosters to each patient admitted to the primary treatment facility. Certainly war wounds without concomitant complications of these two ill harbingers represented surgical progress. Both tetanus and gas gangrene were seen in the Viet Cong casualty, who frequently arrived moribund and tetanic. These patients were extremely toxic; pulse was usually greater than 140 per minute. Even the most heroic measures seldom saved a limb or life. Occasionally, with intensive and dedicated supportive measures, we were successful in treating a Viet Cong casualty with tetanus (Brown 1974).
Wounded soldiers constituted the principal concern of Army orthopedic surgeons in Vietnam, but Vietnamese civilians also benefitted from the presence of U.S. medical officers in their county and the assistance rendered through Medical Civic Action Program (MEDCAP) activities. Although little mention is made of specialty MEDCAP care, the reconstructive bent of the orthopedic surgeon is such that considerable specialty care took place at all levels (fig. 4). Reconstructive procedures for poliomyelitis, leprosy, congenital deformities, and civilian war wounds were undertaken, when feasible, at almost every hospital with an orthopedic sur-
geon. This type of care, which Vietnamese surgeons usually looked on as interesting but complex and impractical under the wartime circumstances, would not otherwise have been available and was gratifying to both patient and surgeon. It was regrettable that, because of limited communications, reconstructive techniques could not be shared with Vietnamese surgeons.
As a rule, continuity of MEDCAP care was nearly impossible. The most notable exception was a Qui Hoa Leprosarium, five miles from Qui Nhon, to which MEDCAP orthopedists went regularly every week from 1966 to 1971. American physicians performed surgical procedures, including limited amputation, posterior tibial tendon transfers, reconstructive had surgery, neurolysis and transfers of the ulnar and peroneal nerves (White and Feagin 1972). The regularity and dependability of such visits throughout this period resulted in a much higher than usual standard of medical care for the patients with leprosy in that beautiful valley and left a lasting mark on a small community (White and Feagin 1972).
The situation--treating the soldier wounded in Vietnam--presented many challenges to the orthopedic surgeon. The heat, the humidity, the character of the countryside, and the nature of the wounding agents all influenced care and procedures. Helicopters made rapid evacuation and prompt treatment possible regardless of terrain, and air conditioning facilitated the work of surgeons in the operating rooms of the hospitals receiving the wounded. Whole blood was readily available, and the orthopedic personnel and supporting staff rendered outstanding initial care. As a result, contamination and the morbidity of potentially lethal wounds were minimal. As General Neel pointed out in 1973, the soldier wounded in Vietnam received “a quality of care superior to that in any previously conflict” (1973,58).
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