Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan

by Ronald Glasser M. D.

  The major and the Army had been bluffing. And why wouldn’t they try to get the best deal they could? When you thought about it, the military had bases all over the world and needed doctors where they had always needed them—everywhere. Getting another twelve months of active duty out of two or three hundred physicians a year was a real bonus. The Army had nothing to lose, so why not try?

  The major though, clearly unprepared for my answer, quickly began to backtrack as he started to look through my papers. “Well,” he said, trying to get back in control, “You are single.” Not looking up, he continued to look through the file, “and that extra year in Japan would allow you to have an accompanied tour … but in your case,” he added as if talking to himself, “that really wouldn’t make much sense.”

  I didn’t know if that was a question or an answer. The major did take one last shot at it. “Are you sure?” he asked, finally looking up. “I mean, Japan can be a pretty nice tour of duty for a single guy.” He left out the part about not getting killed or wounded.

  I learned the next day that everyone else in our Basic Training Class, as in most of the other classes, had extended for that extra year. The Army was true to its word. Everyone who extended did keep his original permanent duty station and did get an accompanied tour.

  To this day, I still don’t know how many physicians were killed or wounded in ’Nam. What I do know is that none of the physicians who extended was among the casualties. From what I was to learn over the next two years, staying that extra year in Germany or Korea or the Philippines didn’t seem to have been such a bad idea.

  I went to the Army Hospital at Camp Zama, Japan for the usual two years of military duty, where, quite surprisingly, the war found me. It was four weeks after I arrived at Zama that the military command in Vietnam sent the 101st Airborne back again into the Ashow Valley. They were mauled, killed, and wounded in that tall elephant grass, with the survivors quickly med-evaced to the nearest surgical hospitals and from the surgical hospitals to us at Zama.

  3.

  ZAMA/THE WOUNDED

  If basic training for physicians at Fort Sam had been the Cliff’s Notes for taking care of the casualties of Vietnam, Zama was the real thing. Before the Vietnam War, Zama had been no more than a 90-bed Army dispensary, a hold-over from the Korean War. In fact, there was little else in military medical facilities in all the rest of Southeast Asia. When President Johnson listened to his military advisers and sent in ground troops to replace the advisers that Kennedy had approved a few years earlier, the military had the choice of expanding the existing medical facilities in Japan, building up those in the Philippines, or starting from scratch in Okinawa. Okinawa was too expensive. The Philippines looked a bit too unstable. So, the Army chose Japan.

  The dispensary at Zama was quickly upgraded to a large general hospital. The Vietnam evacs came in through the large U.S. Air Force base at Yokota, a few minute’s helicopter flight time from Zama. Over the years, smaller specialty hospitals with additional capabilities—neurosurgical, burns, and orthopedic— were built in an arc around Zama throughout the Kanto Plains surrounding Tokyo.

  I had no idea how the Kanto plains looked before the war. At one time, it must have been a pretty place. There were woodblock prints from the Mejia on the walls of the Officer’s Club at Zama that showed the plains tranquil and lovely, nestled comfortably at the foot of the mountains.

  But there was little beauty there when I arrived. Like the wounds, the rivers ran, polluted and ugly, from a dirty green to a metallic gray; the rice and barley fields that used to be there had been replaced by square, filthy factories. Even the air smelled; every day was like living behind a Mexican bus. Still, no one was shooting at you here. There were no ambushes or hunter-killer teams. No one was sending out the LRRPs (Long Range Reconnaissance Patrols) and at night you couldn’t hear them pounding in mortar tubes across the rivers. That was something. You could see it on the faces of the troopers they carried in off the choppers. It didn’t matter to them that the place smelled or that the smoke from Yokahama and Yokuska blotted out the stars. All that counted was that their war was over for awhile and they had gotten out alive.

  It didn’t take any of us any time to figure out how it really worked. The casualties stayed overnight at the 20th casualty staging area at Yokota, where they were stabilized. They were checked by the docs and nurses, re-hydrated if necessary, had their wounds looked at, bandages changed, and their pain medications adjusted.

  ’Nam is always hot, sometimes 110 in the shade, and most of the casualties had been humping it for days. There might have been half a million men in Vietnam by 1968, but only about 100,000 did the fighting. You didn’t see much combat as a clerk typist sitting in Saigon or a supply sergeant in Cam Ran Bay. Those who did the fighting were fighting all the time.

  The fluids these kids would get at the 20th did give them the edge. If they were critical or just seriously ill and the decision was made that they couldn’t wait, they’d be med-evaced by chopper as soon as they got off the C-141s to Zama or one of the other three hospitals.

  There was once a tennis court at Zama, out near the administration building. During the Tet Offensive, the fence had been torn down and the asphalt used for another helipad. Apparently, no one had thought or even considered putting back the fence. It was simply understood that the tennis court stayed a landing pad. Maybe those in charge were not expecting another Tet, but neither where they expecting the war to end any time soon. At least that much was clear from the very moment I arrived from the States.

  And this is how it worked for the 58,264 who would be killed and the 350,000 who would be wounded. This was Vietnam and this was military medicine that was, in fact, 1968 civilian trauma medicine brought to the battlefield. The difference of course was the medics. Not many city ambulance drivers or EMTs would have to run through machine gun fire to get to the wounded. But that happened all the time in ’Nam. It happened so often that the VC and NVA would hit the point on a patrol and try not to kill him but to get him screaming for help and then they would get the medic too. He’d come, they knew he would.

  And it is the same in Iraq and Afghanistan. The Iraqi insurgents and the Afghan Taliban will set their explosives to kill or wound as many soldiers and marines as they can, but they will also put out secondary charges to get the medics who, they too are sure, will come. The two enemies—even decades apart—would rather wound our troops than kill them. If you are dead, you are dead. But to be wounded means that others in your squad or platoon have to give up the fight to take care of you and if possible carry you to safety or at least out of the fight. It is always better to wound the enemy in a firefight than to kill them.

  Back then, the Army prided itself that anyone hit was no more than ten minutes away from the nearest surgical or evac hospital. Technically, they were right. But like so much in the military, then as now, they weren’t quite accurate. Once a dust-off did pick you up, it was usually a ten-minute flight to the nearest surgical or evac hospital, maybe a little longer if you were really lit up and the chopper had to overfly the nearest surgical facility and go on to the closest evac hospital. But the choppers still had to get in and get the wounded troopers out. By the time I got to Zama, over 3,000 choppers had been shot down and more than one medic had to watch the wounded die because they’d run out of plasma and couldn’t be resupplied, or the med-evac couldn’t get in to pick up the casualty. Basically, the wounded bled to death. And that happened a lot. If there was anything positive that came out of the “shock and awe” of Vietnam, it was the advances in vascular surgery that were pushed forward by the large number of high velocity wounds, with their vascular and organ damage, that happened on the battlefields of Southeast Asia.

  But if you were alive by the time the medic got to you and certainly if you were still alive by the time they managed to stop the bleeding, start an IV for some blood or plasma, and managed to put you on the chopper, you’d most likely live. And that is what happ
ened a lot of the time and that is what the medics were trained to do. In a very real way what the medics did was little more than Boy Scout stuff, but at the time so was a great deal of medicine itself, especially surgery. In the late 1960s, surgeons were still doing radical mastectomies for breast cancer while hip replacements were just being developed in England.

  Vascular surgery in the form of coronary by-pass was beginning to come into its own, while the first dialysis machines—the size of grand pianos—were being fitted with wheels to be used in intensive care units. There were no CT scans or MRIs available in any X-ray departments anywhere, and no antibiotics to treat resistant staph infections, and nobody had any idea what was causing Toxic Shock Syndrome, Lupus, Scleroderma, or Multiple Sclerosis.

  But there were concentrated blood volume expanders, and with the advances in vascular surgery, the ability to suture up torn blood vessels and put in blood vessel grafts, along with a growing understanding of the physiology of shock and blood loss. All that was to come together in the jungles and rice paddies of Vietnam, Laos, and Cambodia, as it did in the trauma centers in our largest cities.

  In all major traumatic injuries, whether during an ambush along a trail in the Mekong Delta, a firefight in the Central Highlands, a motorcycle or a car accident on a major U.S. freeway, what kills you is blood loss. Bleeding from a penetrating chest wound or an abdominal injury, unless the bleeding can be stopped, is universally fatal. It has always been that way. Indeed, when Alexander Hamilton was shot in the abdomen by Aaron Burr, he told the physician in attendance at the duel that “this is a mortal wound.” And it was. Hamilton had bled to death by the next afternoon.

  But if the bleeding can be stopped with compression, a surgical pack, or the use of a tourniquet or a clamp, and if you could get some blood or plasma and pain medications to deal with the developing shock in a timely fashion—and then get to a hospital for a more definitive and if necessary reconstructive surgery where damaged organs can be removed or sutured, and blood vessels either grafted or tied off—usually within an hour of being wounded on a battlefield or injured in an accident on a freeway—you’ll most likely survive.

  In modern trauma medicine, it’s called the “golden hour.” And that’s what the medics did in ’Nam. They tried, and many times succeeded, in keeping the wounded alive through that golden hour. They packed wounds, gave injections of morphine, put on tourniquets, carried needles to start IVs in order to hang bottles of plasma and when they had to—and only if they had to—cut open the neck to do an in-the-field tracheotomy in order to clear the airway of blood and keep the injured soldier or marine breathing, or at least give them the chance to keep breathing until they could make it to a chopper.

  There would be a difference in our next two big wars, Iraq and Afghanistan. There would be fewer deaths and more brain and extremity injuries. Our wars of bleeding to death would be over and in their place were amputations and traumatic brain injuries. The difference would not only be the result of different weapons and a better understanding of the biochemical and physiologic effects of severe trauma to the human body, but more effective body armor.

  A large part of what would become a rather astonishing 16 casualties to every death in Iraq and Afghanistan against the 2.4 casualties to deaths in Vietnam would have to do with the development of effective body armor. There was a kind of body armor in Vietnam. They were flack vests that protected the chest, along with the heart and major blood vessels going to the lungs, brain, and abdomen. But the vests were heavy and the armor plates within the vest did not cover all the areas of the upper torso, leaving spaces between the vests and the body as well as between the plates. And ’Nam is hot and wearing a twenty-pound vest while carrying a full pack and having to hump it for miles through dense humid jungle was simply not considered to be worth the effort or the discomfort, especially since those vests didn’t always work.

  The gaps in the vests left areas of the chest unprotected and the soldiers and marines could clearly see the immediate and overall results, especially when the vests were hit by a 30-caliber round fired from a few yards away or a 50-caliber round fired from anywhere. The steel plates themselves could be pierced. In short, the vests did not cover enough of the body and they did not stop the fully jacketed AK-47 rounds, and for the most part didn’t protect soldiers from mortars, anti-personnel mines, or shrapnel wounds.

  But looking back at it now, maybe it was because these kids were all draftees and so didn’t view themselves as professionals, or maybe it was because the vests didn’t work all the time, or maybe it was just the heat, or maybe it was simply easier to forget about any kind of protection and hope for the best. It was probably all four. Vietnam was that kind of place.

  But all that changed by October 7, 2001, when U.S. forces entered Afghanistan to destroy Al Qaeda and defeat the Taliban. A significant part of Iraq’s and Afghanistan’s astonishing survival rates began there in the mountains of Tora Bora.

  Today’s armor is made of a combination of ceramic plates and Kevlar. The new vests are lighter and more flexible than the 1960s Vietnam-era vests, and they cover more of the trunk and torso. During the search for Osama Bin Laden, a Special Forces trooper in the mountain ranges of the tribal areas of West Afghanistan was shot at close range. Rounds from an AK-47 hit him in the chest. The trooper dropped to the ground, but a few moments later rose up to shoot and kill his attacker.

  According to those who were there, it was like seeing Lazarus rise from the dead. Only this Lazarus rose up with an M-4 still in his hand. It was something that simply had never happened in any other war. Today’s more effective body armor, which better protects the chest, heart, lungs, back, and upper abdomen, is a major part of the new survivability. But both our country and our casualties have paid an unexpected and unanticipated price for enduring as well as surviving.

  In a way, we have been lulled by our own successes in simply keeping our troops alive—as if death is the only measure of risks on the battlefield—into a strange kind of reverie. Despite the growing sophistication of our battlefield medicine and the new body armor, the orthopedic wards at Walter Reed are becoming filled with numbers of multiple amputees not seen since the Civil War. The wounded are being admitted to the surgical hospitals with a new diagnosis of “polytrauma” for those with brain, muscle, skin, and extremity injuries. More and more beds are being added as well to the neurosurgery units, and the orthopedics wards, with longer waits in the rehabilitation and PTSD clinics of the VA hospitals. What has changed in these new wars is that our troops are now being blown up rather than just shot.

  But back in Vietnam, the medics did manage to keep those they could alive, in order to get them to the surgical hospitals, and the surgical hospitals fixed what they could, in order to pass them on to the evac hospitals, who sent them on to us in Japan, where our job was to finally fix what could be fixed, in order to finally get them home.

  But getting them home could take quite some time, and even with that, we might not be sending them back exactly the same as when they’d been sent to ’Nam. Still, we tried, and did the best we could, but it wasn’t like today and medicine wasn’t all that sophisticated.

  There wasn’t a great deal that we could do to make things right in the late 1960s. Lower extremity prosthetic devices, unlike the devices of today, gave only support, while the upper extremity prosthetic devices were little more than hooks. There were no intra-cranial monitors and the numbers of available antibiotics were limited, in the face of more complicated and difficult to treat infections.

  ’Nam, besides being hot, was a very dirty place where most of the wounds were contaminated, if not when the troopers were hit, then as they were carried through the clouds of dust and dirt raised by the rotor blades of the med-evac choppers as the engines were feathered to be ready for a rapid take off.

  Eventually, but usually within days, the majority of surgeries at Zama became no more than cutting out what had finally become clear was dead, needed to b
e removed, or involved taking off what was no longer, or would never be, functional, and then kind of sitting back and hoping for the best. Compared to today, it was a patchwork kind of medicine, but if we could beat the infections and handle the major organ system damage, we would be able to get them home.

  The survival rate for those who were carried off the choppers at Zama was over 98 percent. Even those who should have died would surprise us by somehow managing to survive. We took pride and comfort in that much. But it wasn’t easy. I remember one of the soldiers the plastic surgeons had kept for the whole time I was at Zama. He was there the day I arrived and was still there the day I left. They couldn’t do what the plastic surgeons can do now, so they kept him as they tried multiple and painful reconstructions to rebuild his face, which had literally been blown away by an exploding RPG. All of today’s minimally invasive techniques and laser surgeries, along with the use of synthetic polymers for structural reconstructions, were decades off. So with the initial results not going that well, the surgeons simply kept him at Zama.

  Over the years that I was there, the face did get better, or at least more recognizable as a face, or we simply got used to seeing what was there and thought that, all things considered, it was going pretty well. With more surgeries and additional skin flaps followed by even more reconstructions of his mouth and nose, and then his lips and eye lids, with the passage of time, we thought that he did look better, though we feared that when he would finally be sent home someone would either look away, or be foolish enough to ask what had happened to him.

  And then there was Max Cleland, a young lieutenant in the First Air Cav who was later—much later—to become the junior Senator from Georgia. He was not only one of those survivors who made it to the med-evac chopper, but in many ways the poster boy for Vietnam, for the evac chain, for Zama, for both the stupidity and confusion of the war as well as all the courage, suffering, and bravery.