Chapter 10
EPILOGUE
GENERALTHOUGHTS ON THE MANAGEMENTOF ORTHOPEDIC CASUALTIES
Colonel William E. Burkhalter, MC, USA (Ret.)
LESSONS LEARNED AND UNLEARNED
In the Vietnam War, perhaps as in no otherconflict, woundexploration, debridement,and avoidance of primary closure became the uniform approach to woundmanagement. As aresult, the infection rate was low and cases of gas gangrene few.Staffing the first hospitalsdeployed to Vietnam by Regular Army officers with some experience ortraining in themanagement of combat casualties was a major factor in eliminating anyneed to relearn, onceagain, forgotten lessons from previous wars concerning wounddebridement and the necessity forleaving wounds open to drain.
Debridement as an operative procedure was noteasily learned,however. The surgeon hadto have the courage to make the liberal longitudinal incisions and thewide excisions of the fascianecessary to expose muscular compartments as well as an intimateknowledge of anatomy sothat he would not damage undamaged structures. Although his lack ofexperience in wounddebridement might have resulted in a less than optimally debridedwound, delayed primaryclosure allowed surgeons to reexamine and redebride the wound in a fewdays, thus avoiding theproblems of frank sepsis with secondary tissue loss.
An integral part of appropriate debridementis fasciotomy orfasciectomy. Fasciotomymay involve the investing fascia of the foot, leg, thigh, forearm, orintrinsic muscles of the hand.It allows exposure of muscle compartments with their subsequentdecompression. The injuriesresulting from certain high-velocity missiles required extensiveexploration and decompressionof all muscle compartments to protect the muscles and adjacent nervesfrom increasedcompartmental pressure and relative ischemia. Similar elevatedcompartment pressures mightfollow venous injury, especially injury to the popliteal vein, or adelay in vascular repairsproximal to the compartment, or crush injuries of the extremity.Fasciotomy in these cases wasin some instances limb-saving.
The need for careful debridement was noteliminated by theantibiotics universally usedafter wounding in Vietnam. Penicillin, alone or in combination withstreptomycin orchloramphenicol, was the usual agent. It was administered, usuallyintravenously, for three tofive days in uncomplicated cases or for as long as several weeks inmore complicated ones. Ourconcern about managing gram-positive organisms
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may have caused some of our difficulty withgram-negative infections in offshore hospitals. Theuse of penicillin alone in orthopedic casualties withoutgastrointestinal soilage seemed to avoidthose superinfection gram-negative problems; it protected againstclostridia and beta-hemolyticstreptococcal infection. As the war progressed, the initial antibiotictreatments seemed useful,but we learned that repeated cultures should be used in deciding whichspecific antibiotics touse. Prolonged treatment, however, was unnecessary and frequently thesource of problems.
As the war proceeded, the emphasis shiftedfrom concern abouttype and duration ofantibiotic to concern about individual wound management and theadequacy of individualdebridements. In spite of the use of antibiotics, attempts to usedelayed primary wound closure inall wounds in Vietnam produced some disastrous results. Delayed primaryclosure had beenemphasized during World War II and the Korean War, when it was commonlyused in extremitywounds, including those injuries with associated fractures and jointinjuries. But wounds createdby the high-velocity missiles fired in Vietnam often resulted inconsiderable tissue disruption.The temporary and permanent cavity phenomenon in the limb was wellknown, and debridementof damaged tissue created a larger permanent cavity within theextremity. In the femoral shaftfracture, skeletal traction maintained the dead space in the thigh.Under these circumstances,wound closure and minimal drainage created the milieu for woundbreakdown. Attempts atdelayed primary closure in high-velocity wounds of the thigh werefraught with an extremelyhigh complication rate. Attempts to perform delayed primary closure oninjuries of the leg withassociated fracture of the tibia also resulted in wound breakdown. Theskin of the anterior aspectof the leg tolerates tension poorly. With minimal skin loss andswelling secondary to fracture,tension closures were common. The skin responded with necrosis andsubsequent sepsis.Relaxing incisions were also associated with considerable skinbreakdown and subsequent tissueloss.
As a result, surgeons managing patients inthe offshorehospitals and in CONUS(continental United States) became disenchanted with the technique ofdelayed primary closurein high-velocity wounds of the extremity. They realized that, eventhough several operativeprocedures had been performed to ensure adequate debridement, woundclosure was not amandatory next step. When wounds were encased in air-occlusivedressings and both drainageand antibiotics were recognized as necessary components of therapy,closure became an electiveprocedure that could be performed when and if the surgeon concludedthat it was indicated,rather than at any specific time.
Largely because of Dehne’s teaching thatfunction aids woundhealing and fractureunion, early functional use of the limb in the wounded patient wasemphasized. It was not to bedelayed because of wound closure, reconstructive procedures, orprolonged debility of parts or ofthe whole patient. Anything technical that compromised early functionalrecovery was believedto be unimportant and a deterrent to total patient rehabilitation. Thiswas exemplified in themanagement of the open tibia fracture with the walking cast and of opencomminuted fracturesof the femoral shaft with the cast brace. The lower extremity amputeewas ambulated with anopen stump in a temporary plaster socket with foot extension. Woundhealing by secondaryintention was accepted in the upper and lower extremities, includingthe hand, so long as earlyfunctional use could be instituted to the injured part. This emphasison functional recovery in thecare of the femoral shaft fracture, for instance, reduced the patient’stime at full bed rest frommonths to a few weeks.
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COMMUNICATIONAND CONSULTANTS
Orthopedic surgery inwartime deals withlarge numbers of casualties who, by the nature of theirinjuries, require weeks or months of continuing care andrehabilitation. The interchange ofinformation between the initial treating physician in Vietnam and thereceiving physicians inCONUS was vital for optimal care. But orthopedics, as a subunit undersurgery in the U.S. Armyadministrative system, had no way of direct information exchange amongorthopedic elements inVietnam, the offshore hospitals, and CONUS. Although orthopedicsurgeons in the United Stateswere constantly trying to get information to surgeons in the Republicof Vietnam about problemareas, and orthopedic surgeons in Vietnam were interested in thefollow-up treatment andprogress of the patients, communication of this information wasdifficult.
The information and recommendations generatedduring the VietnamWar by fivesurgical conferences on management of battle casualties held at varioussites in the Pacific alsocirculated very slowly. These conferences were attended by physiciansfrom Pacific Command,Vietnam, and CONUS, from all three services, but few of theirconclusions about the initial andearly management of battle-wounded patients affected the treatingphysicians in Vietnam,probably because of the lack of a full-time, traveling orthopedicconsultant with the authority toeffect administrative or professional changes in the Republic ofVietnam. During their entireyear in the country, many orthopedic surgeons never saw anotherorthopedist, except the oneswith whom they were assigned.
We strongly recommend that in futureconflicts, full-timetraveling orthopedicconsultants be available at all echelons with autonomous authority foradministrative changes.Having orthopedic consultants in the forward area, offshore, and inCONUS would allow readyexchange of information and better assessment of management options. Tohave a consultantwhose primary interests and training are in fields other thanorthopedics to act as an orthopedicconsultant is counterproductive, dangerous, and not conducive to thefree flow of information orinterchange of ideas.
CONTINUITY OF CARE AND REHABILITATION
Since in wartime a singlepatient may betreated by different physicians before arriving ata definitive treating hospital, chronological medical information aboutwhat has transpiredduring the transfer is important. But if you mention medical recordsand their administration toany combat physician who served in Vietnam, his discomfort indeximmediately goes up. Inmany instances, lack of an adequate clinical record made patientmanagement a severe problem.The medical record for the patient repeatedly transferred from onefacility to another usuallycontained considerable administrative data repeated over and over butvery little medicalinformation. We believe that some type of electronic cassette recordershould be placed into theevacuation system on which comments can be made and from which theinformation can beretrieved about what has happened previously to the patient. Thecassette, designated for medicalinformation only, would have no erasure button. It could easilyaccompany the patient like a dogtag around his neck, making the information constantly available alongthe evacuation chain. Byusing the cassette, the
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status of a peripheral nerve injury at thetime of debridement in Vietnam, for example, could beimmediately available to the physician treating the patient in CONUS.Standardization ofplayback capability is needed. Such a system would certainly result ina more complete medicalrecord and eliminate poor penmanship as a factor.
Once a patient reached the definitivehospital in CONUS, thequestion arose as towhether this was really the definitive hospital for him. Was thishospital responsible for his long-term rehabilitation, both physicaland psychological? Was this hospital capable of managing allhis needs until discharge from the service or return to duty? Thesequestions were but some ofthose related to the administrative aspects of the patients’ injuriesthat concerned all orthopedicsurgeons treating long-term, severely injured patients. Throughout theentire war, the problem ofhospital responsibility was never resolved.
Two types of Army units and the VeteransAdministration systemwere in the group ofdefinitive hospitals that cared for the wounded who faced longhospitalization. The militarysystem had a Class I or station hospital and Class II or general orteaching hospital. The VeteransAdministration also had hospitals throughout the country that variedconsiderably in theirindividual capabilities. In the administration of the evacuationsystem, orthopedic patients wereinitially sent to a military hospital close to their home. This couldbe a Class I or Class II hospitalwith an orthopedic service and a physical therapist.
Col. Raymond Bagg has pointed out thatpatients who have nochance of returning toactive duty should be rapidly separated from the service. He advocatedthat this separation beaccomplished as soon as possible because of the financial loss to thepatient. For instance, a PFCU.S.M.C. with a bilateral above-knee amputation would not be capable ofbeing returned to duty.In this case total CONUS hospitalization could amount to six to sevenmonths. VeteransAdministration compensation would amount to $638 per month during theVietnam War, whileactive duty pay during the same time would be $180 per month. This paydifferential amounts toabout $3,092 for over six months of hospitalization.
Based on finances alone, certainly earlyseparation isindicated. However, if this changefrom military to civilian status changes rehabilitation relationshipsor goals or results inadministrative transfer, greater loss may result in the future.Severely injured patients need allthe support we can provide since they are relatively fragile for aconsiderable time after acombat-related injury. Administrative changes that increase financialreward but also increaseinstability may be counterproductive. Indiscriminate and repeatedtransferring of patients withchanges of physician and therapist after the vital process ofrehabilitation has been institutedreduces its effectiveness. As soon as the patient’s physical conditionallows, he should be sent toa specialized treatment center for definitive care.
The Army’s Class I hospitals were frequentlystaffed byphysicians who were in militaryservice for only two years. Most of these physicians had one year inthe Republic of Vietnamand then one year in a Class I hospital, or vice versa. The presence ofan orthopedic surgeon foronly one year in the management of complex orthopedic injuries injecteddissimilarities intraining, lack of experience, and limited continuity of care into thesituation. These men,although fully trained, Board-certified and Board-qualified, werecaring for complicated cases ina relatively isolated system with only minimal experience.
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The Class II hospitals were adequatelystaffed with medical and paramedical individuals but hadlimited beds and holding facilities. In addition, they were unable toreceive, treat, and completelyrehabilitate all the orthopedic casualties from Vietnam. Thus therewere frequent transfers ofpatients from Class I to Class II hospitals and from Class II medicalcenters to the VeteransAdministration system in a haphazard fashion based on administrativerequirements. Thetransfer usually occurred in the middle of the rehabilitative processand was dictated by bedrequirements, transfer or discharge of medical or paramedicalpersonnel, or the policy to get thepatient as close to his home as possible. These transfers interferedwith rehabilitation, introduceda new treating team to the patient, and frequently changed therehabilitative goals.
In any decision concerning rehabilitation oforthopedic patients,occupational and physicaltherapists are essential. In most military hospitals the occupationaltherapist became an upperextremity therapist, while a physical therapist concentrated on thelower limb. These two groupswere involved, daily or several times daily, in the treatment of eachpatient. These were theindividuals who implemented and modified the early functional use ofthe damaged limb conceptmentioned previously. The physical therapists were directly concernedwith the lower extremityamputee from early ambulation in the plaster-of-Paris socket to woundclosure to definitiveprosthesis. In the patient with the cast brace for femoral shaftfracture gait training, muscletraining and encouragement were required. The occupational therapistswere concerned withtraining the patients in the activities of daily living, withperipheral nerve testing, and with earlyprosthetic training of the upper extremity amputee. In addition, theyfabricated splints, testedpatients, and helped patients with peripheral nerve injuries reeducatetheir upper extremities toperform voluntary motion effectively. Such activities were carried outnot just in CONUS but inthe Republic of Vietnam and in offshore hospitals as well. Theseinnovative, interested,intelligent individuals were of immense value to both patient andphysician, and disruption of therelationship they had developed with the individual patient and of thecourse of rehabilitationthat they had started with him was harmful to his progress.
The lack of continuity and its adverse effects uponrehabilitation werea serious medical problemthroughout the war in Vietnam. The role of patient rehabilitation inthe recovery process requiresfurther study and better application. To avoid the professionalproblems that I have mentioned,we recommend the development of the professional center concept as itexisted in World War II.Because they would be staffed by medical, paramedical, andrehabilitative personnel, theseprofessional centers could become definitive care centers in CONUS tomanage patientscompletely from reception from overseas to definitive disposition.Whether the center is a U.S.Army hospital or a Veterans Administration hospital makes littledifference. That is anadministrative decision. But this approach would eliminate theindiscriminate transfer of acombat-wounded soldier from hospital to hospital and team to team,reducing his motivation andnegatively affecting the entire rehabilitative process.
The dispersion of orthopedic patients throughoutCONUS complicated evencollecting thecomprehensive data needed to study the care and rehabilitation oforthopedic patients, alwaysdifficult in wartime. When the group of orthopedic surgeons was broughttogether in 1972 towrite this history, we knew it would be an immense undertaking, notmerely because of the sheernumber of words but because of our
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desire to write a history useful fororthopedic surgeons in the day-to-day practice. Our statementsand conclusions had to be supported by scientific data, but, because ofthe difficulty of retrievingthe information we needed, most of the clinical data in the chapterscame from records collectedby individual authors rather than from a central retrieval system. Theestablishment of centers forhand, peripheral nerve, amputee, and other medical problems insignificant numbers would makeit possible in the future to collect data and alter treatmentmodalities on the basis of pastexperience. A center concept for complex orthopedic injuries isessential if usable managementoptions are to be learned in future wars. So long as these complexorthopedic cases are widelydispersed, clinical data retrieval will be, at best, haphazard.
This chapter has coveredin a general way thepractice of orthopedics during the era of the war inVietnam. It contains lessons learned, lessons relearned, and somelessons that we believe shouldbe forgotten. In addition, it mirrors our frustrations regardingdissemination of professionalorthopedic information within the evacuation system and our immenseconcern for our patientsand their total rehabilitation. Our recommendations to improve thesystem are made because ofthis concern and our desire to improve patient care.
