CHAPTER III
Care of the Wounded*
Excellence of Medical Care
Factors in Low Morbidity and Mortality
The excellence of care of the wounded in Vietnam was the result of acombination of factors: rapid evacuation of the casualty, ready availability ofwhole blood, well-established forward hospitals, advanced surgical techniques,and improved medical management.
From the standpoint of methods used to wound-mines, high-velocity missiles,and boobytraps-as well as the locale in which many were injured-in paddyfields or along waterways where human and animal excreta were common-Vietnamwas quite a "dirty" war. Yet helicopters were able to evacuate mostcasualties to medical facilities before a serious wound could become worse.There were practically no conditions under which the injured was denied timelyevacuation; weather, terrain, time of day, enemy contact, all were surmounted bythe capabilities of the air ambulances and the skill of their crews.
The use of whole blood, occasionally even before the arrival of an airambulance, contributed to the low mortality rate in Vietnam by better preparingthe wounded for evacuation. Blood packaged in styrofoam containers whichpermitted storage for 48 to 72 hours in the field could be placed in theforward area in anticipation of casualties. This was a marked increase in theutilization of whole blood, since virtually none was used at the division levelin World War II. Stocks of blood, drawn from PACOM (Pacific Command) in theearly years and later
*This chapter, involved with statistical analysis of WorldWar II, Korea, and Vietnam as indices of the quality of care of the wounded, issubject to all the handicaps of comparison. Reporting procedures have changedover the last 25 years, and the most recent reports included more individualsthrough the increased scope and efficiency of the data collecting system;moreover, some information gathered for Vietnam had no true counterpart in theprevious conflicts. Yet another problem is semantics: "hospitals" isdifferent from "all medical treatment facilities," which presents thedanger of "comparing" what is actually two different populations.Concern with these problems is highly justified, and any reader must viewcomparisons merely as illustration of trends, not as absolute fact. While thefigures will change as more complete information becomes available, the basicfact which they illuminate will not-thecare of the wounded in Vietnam has been superior to that given in combatanywhere at anytime.
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largely from CONUS (continental United States), were always sufficient.
The relative stability of forward hospitals in Vietnam made possible the useof sophisticated equipment. Air conditioning to counter the extreme heat, dust,and humidity allowed better control of the environment of the wounded before,during, and after surgery, and was necessary for the proper functioning of thehighly sensitive equipment. Commenting on hospital apparatus, the USARVneurosurgical consultant, Lieutenant Colonel Robert C. Leaver, MC, stated,"The traditional equipment seen in neurosurgical centers throughout theUnited States is available, i.e., respirators, Stryker frames, and hypothermiaunits. Other than the physical deficiencies of a hospital in a combat area,there is little that would distinguish our neurosurgical wards from those inhospitals in America."
Surgical technique as practiced in Vietnam was certainly as advanced as thestate of the art in general, and perhaps more so in the realm of trauma.Contrary to traditional procedure, surgeons in Vietnam rediscovered that wounds(except cranial and facial, and some hand injuries) responded better to adelayed closure which permitted necessary drainage. Management of severe liverinjury was a real therapeutic challenge since massive transfusion, control ofrelatively inaccessible bleeding, and removal of large portions of liversubstance were often required. Surgeons performed complex operations daily androutinely in all hospitals, not just selected ones in the rear. Vascularsurgery, sporadic in Korea, was commonplace in Vietnam, and surgeons became soadept that not only thoracic but also general and orthopedic surgeons routinelyperformed repairs.
The high level of skill was maintained despite the turnover of medicalofficers. Since surgeons arriving in Vietnam were not adequately prepared bytheir background in civil trauma to treat combat casualties, they were attachedto experienced teams for orientation and learned technique in the operatingroom.
Improved medical management of the casualty contributed to the quality care.Surgery itself had become a part of the continuing process of resuscitation anda weapon in the struggle against shock. The team approach, in which surgeons ofa variety of specialties operated together, also proved highly effective; a"team" for head injuries, for example, included a neurosurgeon,ophthalmologist, oral surgeon, otolaryngologist, and plastic surgeon. If thecasualty had multiple injuries, more than one surgical team operatedsimultaneously.
Survival Statistics
Between January 1965 and December 1970, 133,447 wounded were admitted tomedical treatment facilities in Vietnam; 97,659 of these were admitted tohospitals. The hospital mortality rate for this period was 2.6
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percent, compared to 4.5 percent in World War II and 2.5 percent in Korea.The very slight increase in hospital mortality in Vietnam over that in Korea wasa result of rapid helicopter evacuation which brought into the hospital mortallywounded patients who, with earlier, slower means of evacuation, would have dieden route and would have been recorded as KIA (killed in action). Assuming thatmost of those patients who died within the first 24 hours in hospitals belong inthis class, the rate would be much closer to 1 percent. Actually, it is furthertestimony to the high quality of medical care provided in Vietnam where eventhough mortally wounded casualties arrived at Army hospitals, the mortality ratewas only marginally greater than in Korea.
Perhaps a better index of the effectiveness of medical treatment was theratio of deaths to deaths plus surviving wounded (or "deaths as a percentof hits"). For World War II, it was 29.3 percent; Korea, 26.3 percent; andVietnam, 19.0 percent. The ratio of KIA to WIA (wounded in action) was asfollows: World War II, 1:3.1; Korea, 1:4.1; Vietnam, l:5.6.
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Patient Care Indices
Since the task of the combat physician is to salvage as much limb or functionas possible, and the goal of the Medical Department is the salvage of lives, itis proper that the accomplishments of the Medical Department mission in Vietnambe measured in terms of lives recovered rather than numbers lost.
The bed occupancy rate in Vietnam ran approximately 60 percent, and that inoffshore facilities about 50 percent, which allowed ample flexibility to respondto fluctuating casualty rates and remain capable of providing optimum medicalcare.
The average length of stay per case for patients in Vietnam was considerablybelow that of both earlier conflicts:
| Days |
World War II | 80 |
Korean War | 75 |
Vietnam* | 63 |
*Through July 1967.
This reduction of approximately 20 percent reflected the advances in woundmanagement and patient care.
Of the 194,716 wounded in Vietnam, (January 1965-December 1970), 61,269 (31percent) were treated and returned to duty immediately. Of those admitted totreatment facilities, the distribution was as follows:
42.1 percent returned to duty in RVN
7.6 percent returned to duty in PACOM
33.4 percent returned to duty in CONUS
2.7 percent still hospitalized, 31 December 1970
14.2 percent other dispositions (died; transferred to Veterans' Administration hospital; discharged; and so forth)
Two to three percent of the hospitalized wounded in Vietnam had significantvascular injuries, and the amputation rate for those with major arterial injurywas about 13 percent. This rate was approximately the same as that for Korea,and markedly less than the 49 percent rate for World War II. The approach wasfor maximum conservation of stump length which, in conjunction with developmentsin prosthetic manufacture, decreased morbidity and length of hospitalizationamong orthopedic patients.
Nature of Wounds
The lethality of modern weapons directly affected the work of the medicalpersonnel who attempted to undo the damage. While one must
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be wary of dubbing things "new," certainly the problems whichmedical personnel in Vietnam encountered were more complicated than before.
Mechanics of Wounding
High-velocity, lightweight rounds from M16/AK47-type weapons have greaterkinetic energy and leave larger temporary and permanent cavities and moresevere tissue damage than do low-velocity projectiles, and their easy deflectionby foliage resulted in tumbling and spinning and the generation of even largerentrance wounds. Moreover, blood vessels not in the direct path of the missilewere affected. The bullet usually disintegrated and was rarely found whole evenwhen all exit wound was absent. These rapid fire weapons increased the chancesof multiple wounding, which complicated resuscitation and treatment.
The claymore mine received its first field trials by both sides in Vietnam.The intensity of peppering and velocity of the fragments often resulted in deeppenetration in a number of sites. The extensive use of mines and boobytraps inVietnam created a serious medical problem: the proximity of the blast causedsevere local destruction, and tremendous amounts of dirt, debris, and secondarymissiles were hurled into the wound. Massive contamination challenged thesurgeon to choose between radical excision of potentially salvageable tissueand a more conservative approach which might leave a source of infection.
Causative Agents
The data on the physical agents which caused wounds and deaths reflect thenature of the combat. Much higher proportions of the casualties were caused bysmall arms fire, and by boobytraps and mines, than in Korea or World War II, andmuch lower percentages were caused by artillery and other explosive projectilefragments. This relationship generally was more pronounced among the fatalitiesthan among the wounded. (Table 6)
Statistics compiled at different times in the Vietnam conflict mirrored theshift in combat from the defensive to the offensive. In 1965, U.S. forces weremost concerned with establishing and defending their bases, and only in 1966 didthey launch operations to check the enemy offensive. By 1968, troops wereusually engaging the enemy in his defensive positions. Wounding from small armsfire decreased from 42.7 percent in June 1966 to 16 percent in June 1970, whilethe percentage from fragments (including mines and boobytraps) rose from 49.6percent in 1966 to 80 percent in 1970.
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TABLE 6.-PERCENT OF DEATHS AND WOUNDS ACCORDING TO AGENT,U.S. ARMY, IN THREE WARS: WORLD WAR II, KOREA, AND VIETNAM
| Agent | Deaths | Wounds | ||||
| World War II | Korea | Vietnam1 | World War II | Korea | Vietnam1 | |
Small arms | 32 | 33 | 51 | 20 | 27 | 16 |
Fragments | 53 | 59 | 36 | 62 | 61 | 65 |
Booby traps, mines | 3 | 4 | 11 | 4 | 4 | 15 |
Punji stakes | -- | -- | -- | -- | -- | 2 |
Other | 12 | 4 | 2 | 14 | 8 | 2 |
1January 1965-June 1970.
Source: Statistical Data on Army Troops Wounded in Vietnam, January1965-June 1970, Medical Statistics Agency, Office of the Surgeon General, U.S.Army.
Anatomical Location of Wounds
The rapid fire weapons of the enemy resulted in a significant increase overWorld War II and Korea in the percentages of multiple wounds among thedistribution of wounds by site. (Table 7)
Small arms fire caused approximately two-thirds of the wounds of the head andneck, and three-fourths of the trunk wounds; fragments accounted for theremainder. Fragments and small arms contributed fairly equally to wounds of theextremities.
The distribution of fatal wounds by location differed from that for totalwounds since some areas were much more likely to involve mortal
TABLE 7.-LOCATION OF WOUNDS IN HOSPITALIZED CASUALTIES, BYPERCENT, U.S. ARMY, IN THREE WARS: WORLD WAR II, KOREA, AND VIETNAM
Anatomical location | World War II | Korea | Vietnam1 |
Head and neck | 17 | 17 | 14 |
Thorax | 7 | 7 | 7 |
Abdomen | 8 | 7 | 5 |
Upper extremities | 25 | 30 | 18 |
Lower extremities | 40 | 37 | 36 |
Other sites | 3 | 2 | 220 |
1For a 24-month period.
2Including multiple wounds.
Source: Statistical Data on Army Troops Wounded in Vietnam, January1965-June 1970, Medical Statistics Agency, Office of the Surgeon General, U.S.Army.
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injuries than others. Thus the 14 percent of the wounds located in the headand neck region accounted for 39 percent of the fatalities. This was followed by19.3 percent fatal wounds in the thorax; 17.9 percent, abdomen; 16.1 percent,multiple sites; 6.8 percent, lower extremities; and 0.9 percent, upperextremities. Twenty to thirty percent of the penetrating head wounds brought infrom the field in Vietnam were classed as "expectant" cases, andlittle could have been done for them; however, the mortality rate for the otherswas rather low because of early evacuation, extensive use of blood, and thepresence of fully trained neurosurgeons in the combat zone. Most of theabdominal fatalities were from extensive liver destruction or multiple organinvolvement.
Certainly the data on relative lethality of wounds and the distribution bycausative agent showed the advantage of wearing properly designed body armor.Had helmets been worn, they would have proved very effective against fragments,although little could be done in the event of a direct hit by a small armsround. To quote Lieutenant Colonel (later Colonel) William M. Hammon, MC:"If our combat troops . . . were to wear the helmet, we believe that about1/3 fewer significant combat casualties wouldneed to be admitted to a neurosurgical center here in Vietnam." Flak vestsdid prove effective against three-fourths of the fragments which struck thethorax, thereby increasing the percentage of gunshot wounds to other areas ofthe body to 75 percent of chest wounds.
Troops in static positions, or in air or ground vehicles, usually wore bothhelmets and flak vests, but soldiers on the move found the body armor too heavyand too hot. Some commanders (and some individuals regardless of the commanddecision) decided to forego the protection rather than accept the reduction inmission capability and the increase in heat casualties.
Specific Advances
The continuous thrust of the U.S. Army Medical Department in combat surgeryis on the development of better procedures and ancillary techniques for the careof the wounded. In Vietnam, concern centered on the areas of anesthesia, bloodand plasma expanders, treatment of burns, wound healing, shock, and surgicalroutine.
Anesthesia
Most surgery in Vietnam hospitals was done under a general anesthetic,usually thiopental induction and maintenance with halothane, nitrous oxide, andoxygen. Most anesthesiologists favored halothane, with its rapid action, ease ofadministration, nonflammability and applicability
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to all cases; also, it did not produce nausea and did not mask critical dropsin blood volume.
Local anesthetics were used only for very minor wounds and a few delayedprimary closures. Employment of spinal anesthesia was very limited. The emphasiscontinued on development of safe, simplified methods of portable inhalationanesthesia.
New concepts for assisting the breathing of the critically injured were alsodeveloped to meet Vietnam requirements. Prolonged mechanical support wasnecessary in some cases to minimize oxygen deficiency, and while respiratorswere ordinarily used, the possibility existed that harmful bacteria might beintroduced since proper sterilization was not always feasible under combatconditions. New respiratory assistance devices, eliminating or reducing thatpotentiality, were tested.
Blood and Plasma Expanders
Frequently transfusions of whole blood were initiated long before thecasualty reached a facility with the capacity for cross-matching blood, and inthese cases, type O low titer blood was used. As a rule, any patient who hadreceived four or more units of type O low titer was continued on this type,while those with less than four were matched at the hospital.
Massive transfusions (one surviving patient had received 92 units), althoughlifesaving, presented problems of their own. A tendency toward bleeding appearedafter multiple transfusions, but it was found that fresh frozen plasma or, ifpossible, freshly drawn blood could control the condition. Also, the patientwhose body temperature dropped as a result of extensive transfusion became aserious problem. Two evacuation hospitals utilized microwave ovens to warm thewhole unit of blood in seconds to counter this condition.
Burns
The most unfortunate aspect of the burn injuries incurred in Vietnam wasthat more than half were accidental and therefore preventable. Burns associatedwith enemy fire, while fewer in number, accounted for almost 70 percent of thefatalities because of their severity and associated wounds. A factor in the highmortality was that most combat burns occurred in an enclosed space, such as anarmored personnel carrier or a bunker, and were, therefore, complicated byinhalation injuries.
Burn cases were stabilized in-country and then evacuated to the 106th GeneralHospital in Japan, where a special burn unit had been established. Of the burnstreated by the 106th, 27 percent returned to duty, 66 percent were evacuated tothe burn unit at Brooke Army Medical Center, Fort Sam Houston, Tex., and 7percent died.
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Sulfamylon ointment was employed to prevent infection. If evacuation to Japanwas delayed more than 48 hours, treatment was initiated in Vietnam. Since thestandard treatment of phosphorus burns with copper sulfate solution was found tobe toxic in itself, their management became even more difficult and debridementof the wound grew more important.
Wound Healing
The Surgical Research Team, WRAIR (Walter Reed Army Institute of Research),tested in Vietnam several experimental items developed to aid wound healing. Anantibiotic preparation, packaged as an aerosol, was distributed to aidmen invarious tactical units. Immediate use on an open wound acted to retard bacteriagrowth, and resulted in decreased morbidity. Tissue adhesives which had lowtoxicity, degraded relatively rapidly, and spread well proved valuable insurgery on the lung, kidneys, and liver. The Surgical Research Team utilizedthem with excellent results as early as 1968.
Shock
Shock was a killer which was checked somewhat by the rapid evacuation systemand the whole blood available to the wounded in Vietnam. Yet even so, mortalityrates were increased by a postoperative pulmonary complication known as shocklung or wet lung where the lung or thorax had been traumatized. By the time thecondition could be detected by X-ray, it was usually too advanced to respond totreatment. However, after extensive investigation, Colonel James P. Geiger, MC,surgical consultant from June 1969 to June 1970, identified the mechanics of theproblem and demonstrated that the complication could be forestalled by the useof diuretics in those likely to be so afflicted. This treatment significantlyreduced the morbidity and mortality in the syndrome.
Surgical Routine
An outstanding feature of medical service in Vietnam was the quality andextent of care given in the battle area. Any type of medical or surgicalspecialist was available in the combat zone. For example, by the spring of 1968,there were 10 neurosurgeons at five Army hospitals, supervised by aboard-certified neurosurgeon.
Sophisticated operations were handled as a matter of routine. Laparotomieswere done "on suspicion" (which proved positive in about 25 percent ofthe cases) in a zone where heretofore there was a degree of reluctance tooperate even when abdominal penetration was certain. Primary repairs wereperformed on veins which had simply been ligated in earlier conflicts, andfasciotomy, cutting the tissue sheathing the
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muscles and reducing pressure on the muscles, was not uncommon. In a fewinstances, limb salvage was possible by constructing an extra anatomic bypass,tunneling a graft through a new route around the area, until the wound healedand a permanent vascular graft could be inserted. The expert surgeon, supportedby a skilled medical team and well-equipped facilities, provided a quality ofcare superior to that in any previous conflict.
