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Vietnam in context
SPECIAL CONTRIBUTION
Vietnam in Context W. Kendall McNabney, MD Kansas City, Missouri
McNabney WK: Vietnam in context. Ann Emerg Med 10:659-661, December 1981. military medicine, Vietnam; trauma care, Vietnam
The care of the t r a u m a victim is a most i m p o r t a n t concern of a n y EMS endeavor. This association's history is filled with efforts in t r a u m a care. M a n y of the p a s t K e n n e d y lecturers and h o n o r a r y m e m b e r s have d i s t i n g u i s h e & t h e m selves in this p a r t i c u l a r s e g m e n t of EMS, and this m e e t i n g in San Antonio a g a i n signifies the strong i n t e r e s t this organization has in t r a u m a care. Dr. Tommy Thompson, the c h a i r m a n of the A m e r i c a n College of Surgeons Committee on Trauma, will give the K e n n e d y lecture, the m i l i t a r y will give us an entire afternoon of its p a r t i c u l a r b r a n d of t r a u m a care, and t h e r e will be n u m e r o u s papers and subsequent discussions on the topic. It is a t i m e l y topic, a controversial topic, and an emotionally charged topic. Because i m p o r t a n t decisions have yet to be made in this regard, I a m going to briefly analyze a t r a u m a care system of which everyone in this room has at l e a s t some w o r k i n g knowledge, e i t h e r f i r s t h a n d or vicariously: the V i e t n a m War. Despite the u n p o p u l a r i t y Of the war, there was no shame in the records e s t a b l i s h e d by the A r m y Medical D e p a r t m e n t . In the last decade, a n y t h i n g writt e n about t r a u m a care or a system for t r a u m a care will be prefaced by the Vietn a m experience. It is m y i n t e n t to place this experience in the context of c u r r e n t n a t i o n a l needs and resources. The V i e t n a m experience was monitored by daily statistics. Body counts, killed in action, and wounded in action information was corroborated by videot a p e d action on the evening news. The helicopter became the symbol of the war, not only militarily, b u t medically as well. It is no wonder t h a t medical success was u s u a l l y a t t r i b u t e d to helicopter evacuation since it was so visible. Other major factors, such as r e a d y a v a i l a b i l i t y of whole blood, h i g h l y skilled, wellorganized medical teams, well-equipped, s e m i - p e r m a n e n t forward hospitals, and effective m a n a g e m e n t of a v a i l a b l e medical resources, possibly were t a k e n more for granted. Closer scrutiny of all these components will be made. F i r s t of all, w h a t was the record? Of all p a t i e n t s r e a c h i n g US medical facilities, 97.5% survived. This is compared with 95.5% in World W a r II and the Kor e a n War. This record was achieved despite the fact t h a t m a n y m o r t a l l y wounded personnel found alive on the battlefield have come to be counted as hospital deaths. Again, except for r a p i d evacuation, such severely wounded men r a r e l y lived to reach the hospital. In World W a r II it took an average of 10 hours to b r i n g a p a t i e n t to definitive t r e a t m e n t ; in K o r e a it was reduced to five hours; and in V i e t n a m it was one hour. E i s e m a n , 1 after a trip to Vietnam, stated more succinctly t h a t % n A m e r i c a n citizen has a b e t t e r chance for quick, definitive surgical care by board-certified specialists coming out of the j u n g l e or rice p a d d y t h a n were he hit on a h i g h w a y n e a r his home town in the U n i t e d S t a t e s . . . the concentration and organization of the medical m a n p o w e r and e q u i p m e n t necessary to achieve such a level of care half-way around the world from the U n i t e d S t a t e s is awesome." Presented as the Presidential Address at the University Association for Emergency Medicine Annual Meeting in San Antonio, Texas, April 1981. Address for reprints: W. Kendall McNabney, MD, ChaLrman, Department of Emergency Health Services, Truman Medical Center, 2301 Holmes Street, Kansas City, Missouri 64108.
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The Helicopter As Ambulance The helicopter o r i g i n a l l y was used in the K o r e a n War to rescue downed pilots. Because of t h a t success, the principal function soon became c a s u a l t y evacuation w h i c h developed r a p i d l y in V i e t n a m w i t h t h e familiar UH-1 (Huey) helicopter. The helicopter's utility was m a x i m i z e d by the t e r r a i n , lack of a d e q u a t e roads and h i g h w a y s and, most i m p o r t a n t , a i r superiority over the enemy. No combat soldier was more t h a n 35 m i n u t e s from hospital care. A t the peak of the war, 116 air a m b u l a n c e s were deployed. Six to nine p a t i e n t s could be transported, depending on w h e t h e r the p a t i e n t required a l i t t e r or was a m b u l a t o r y . T h e r e was a crew of four - - a l l knowledgeable in medical care and evacuation. Their w i l l i n g n e s s to t a k e n e c e s s a r y r i s k , c o m b i n e d w i t h necessary skill, m a x i m i z e d recovery of critically injured patients. This was especially true on so-called ~hoist missions" on which the h o v e r i n g crew was made t h a t much more vulnerable. Hostile fire, however, was no g r e a t e r risk t h a n were accidents associated with bad w e a t h e r and fatigue. Medical evacuation flights averaged 35 minutes. In one two-year period, 39 crew members were killed and 210 were wounded in those u n a r m e d aeromedical missions. 2 Is the success story of the helicopter limited to Vietnam? Because the United S t a t e s is not s i m i l a r to Vietnam in r e g a r d to h i g h w a y system, t e r r a i n , and abundance of hospital facilities, one would have to say the helicopter's role will be different. First, the cost is about five times g r e a t e r per u n i t of t r a n s p o r t a t i o n . 3 Because of cost, benefit m u s t be documented. Speed and, therefore, distance covered is the p r i m a r y benefit. Difficult-to-get-to t e r r a i n , such as mountains, woods and water, and traffic j a m s and snow storms are other examples. Thus the more r e m o t e the p a t i e n t - v i c t i m is from hospital care, the g r e a t e r the use for the helicopter ambulance. Noise level, limited space, and occasional w e a t h e r problems g e n e r a l l y are not considered to be major problems. Medical capabilities of ground a m b u l a n c e s u s u a l l y exceed those of helicopters. 4 It would a p p e a r t h a t unless there are major technological changes, the helicopter a m b u l a n c e will r e m a i n adjunctive to ground a m b u l a n c e and be limited to remote areas and/or be combined with other functions such as police work, traffic surveillance, or e n v i r o n m e n t a l surveillance. In the S t a t e of M a r y l a n d , helicopters have such d u a l roles, t h u s m a k i n g t h e helicopter a m b u lance more feasible.
Communication The medical radio n e t w o r k facilitated the helicopter evacuation system. It allowed for reliable information to be r a p i d l y d i s s e m i n a t e d to locate p a t i e n t s and determine extent of injuries; allow for r e g u l a t i n g of patient load to each hospital; and give advance notice to hospitals of p a t i e n t arrival. Because combat casualties tend to be sporadic, this type of medical control kept patients going to the n e a r e s t hospital t h a t could take care of them. Surgical backlog was also monitored so t h a t the medical r e g u l a t o r had a continuous status report of each hospital's actual p a t i e n t load and projected workload. The l a c k of a d v a n c e notice for large n u m b e r s of c a s u a l t i e s stymied the orderliness t h a t the staff desired. Five m i n u t e s m a d e a significant difference.
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The c i v i l i a n c o u n t e r p a r t of this scheme, called ~categorization," is sometimes difficult to i n i t i a t e and even m o r e difficult to k e e p c u r r e n t . A l t h o u g h t h e m i l i t a r y had neurosurgical, dialysis, and b u r n centers, p a t i e n t s were n e a r l y a l w a y s assessed and stabilized f i r s t in n o n - c e n t e r h o s p i t a l s . The m i l i t a r y (to my knowledge) never used t r a n s m i s s i o n of biological data, such as telemetry. W h i l e the h a r d w a r e for e m e r g e n c y communication is g e n e r a l l y a v a i l a b l e in the U n i t e d States, the problem is more one of acquiring d a t a and keeping t h e m disseminated. The 911 system is still not universal in this country. The ubiquitous citizen band radio has done much to add to h i g h w a y safety. I will cover more when discussing medical control.
Blood Program The m i l i t a r y blood p r o g r a m was one of the least publicized but most impressive contributors to survival of the severely injured. I say impressive because of the combination of a l t r u i s m and logistics required to place large volumes o f whole blood in a war zone without sacrificing safety. It m u s t be r e m e m b e r e d tl~at most of the blood sent to V i e t n a m was the ~essence" of a donor population - low titer O blood. A l t h o u g h the l a t e r stages of the war necessitated the use of type-specific and even crossmatched blood, prior to t h a t only off-shore hospitals in J a p a n and the P h i l i p p i n e s used type-specific blood. The logistics of d r a w i n g the blood in the continental US, and then processing, t r a n s p o r t i n g , and distribu t i n g so t h a t it could be t r a n s f u s e d before it was 21 days old in a hostile e n v i r o n m e n t 12,000 miles away, is a tribute to this program. The luxury of h a v i n g ~universal donor" blood in large q u a n t i t i e s a v a i l a b l e in surgical hospitals (and even further forward) no doubt affected s u r v i v a b i l i t y of the more critical patients. There has never been a need to e m u l a t e the Vietn a m Blood P r o g r a m in t h e US, as t h e a v a i l a b i l i t y s t a n d a r d g e n e r a l l y has been met. The fact t h a t all blood sent to V i e t n a m came from 11/2 million volunteer donors - - all from m i l i t a r y personnel, t h e i r dependents, and civilian employees of m i l i t a r y i n s t a l l a t i o n s - - is an a s t o u n d i n g record for a n y v o l u n t e e r donor program. 2
Staffing and Facilities Much is w r i t t e n about the t e a m approach to the m u l t i p l e - s y s t e m - i n j u r e d p a t i e n t . Because of the nat u r e of t h e w a r , ~ s a f e " e n c l a v e s w e r e s c a t t e r e d t h r o u g h o u t t h e country. W i t h i n t h e enclaves were s e m i p e r m a n e n t h o s p i t a l s t r u c t u r e s which, for t h e most part, did not move d u r i n g the war. Because of this stability well-equipped, air-conditioned o p e r a t i n g rooms staffed by w e l l - t r a i n e d physicians, nurses, and corpsmen allowed for not only r e s u s c i t a t i o n b u t definitive care w i t h i n m i n u t e s of injury. This p a t t e r n has been the prototype for regionalization of t r a u m a care. More t h a n 1,200 young surgeons served in Vietn a m on 12-month rotations. Because n e a r l y all came from civilian t r a i n i n g programs, it was necessary to p a i r t h e m with experienced surgeons or allow for an o r i e n t a t i o n period. S i m i l a r l y , n u r s e s a n d corpsmen came into the country w i t h basic knowledge and skills r e q u i r i n g r e o r i e n t a t i o n to b a t t l e conditions. Lessons
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learned were s y s t e m a t i c a l l y h a n d e d on v i a symposia and other exchange modalities, such as consultants. The consultants also made hospital a s s i g n m e n t s after interviews and r e v i e w i n g the physicians' p a s t experiences. Organized research was carried out by the Walt e r Reed A r m y I n s t i t u t e of Research. A l t h o u g h t h e r e were scores of j o u r n a l articles concerning t r a u m a care in Vietnam, the m a j o r i t y were probably published after the p e a k of the war.
Organizational Structure The m i l i t a r y as an organization is often criticized for its rigidity, conservatism, and waste of resources. In the case of medical activity, however, this organization becomes the a n t i t h e s i s of the medical system in this country. General Neel s u m m a r i z e s this by stating, '~The preferred o r g a n i z a t i o n for e m p l o y i n g and cont r o l l i n g m i l i t a r y m e d i c a l r e s o u r c e s is t h e v e r t i c a l medical command a n d control system which reached its epitome in V i e t n a m . M e d i c a l service i n t e g r a t e s treatment, evacuation, hospitalization, supply service, and c o m m u n i c a t i o n s c o m p o n e n t s . T h e r e m u s t be strong professional medical control from the most forw a r d to the most r e a r w a r d echelon to achieve maxi m u m effectiveness and efficiency in medical service support with the u t m o s t economy in the utilization of scarce h e a l t h care resources: '2 T h a t s t a t e m e n t should sound familiar; only the t e r m i n o l o g y varies from current trauma care planning. Can a t r a u m a care system used in combat by an o r g a n i z a t i o n t h a t is preoccupied w i t h death, i n j u r y and t h e i r avoidance be compared with a free society t h a t prides itself on the rights of the individual? The discipline of the autocratic system is well accepted as a necessity in the combat military, b u t r e v e r t s back to civilian m e n t a l i t y in this country. For instance, compare the V i e t n a m w a r casualties with our own motor vehicle accidents. In 1969 alone, 11,000 more fatalities occurred due to motor vehicles t h a n occurred in all 11 years of the war. There were over two million injured as a result of auto accidents, or over seven times the n u m b e r in 11 y e a r s of war. One of eight beds is occu~ pied by an accident victim. Compared with the civilian toll of killed and wounded, Dr. H a r d a w a y says the A r m y toll in V i e t n a m was a ~drop in the bucket. ''5 The regionalization of t r a u m a care is a u t o m a t i c in the m i l i t a r y in combat. But when a civilian population has more impressive statistics of d e a t h and d i s a b i l i t y by a less feared e n e m y - - the automobile - - the care is absorbed by the existing system. The controversy is more complicated t h a n financial and philosophical consideration and setting priorities. Helmets for motorcyclists reduce m o r b i d i t y and m o r t a l i t y j u s t as steel h e l m e t s do for i n f a n t r y m e n . Both appliances are u n d e s i r a b l e from the s t a n d p o i n t of comfort and freedom; n e i t h e r will be worn without t h r e a t of a r r e s t or court m a r t i a l , despite the fact t h a t statistical chance of s u r v i v a l is enhanced by doing so. No one sees h i m s e l f as the next victim - - it will always be the other guy. Is this not the d i l e m m a of t r a u m a care? T h a t accidents are p r o v i d e n t i a l , and therefore care would be j u s t as randomized? In a free society this m a y t a k e longer to come. The m i l i t a r y is not a free society, and thus the contrast. Medicine and the m i l i t a r y m a y be in conflict in
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times of war. There is no question t h a t effective medical support enhances a n y m i l i t a r y mission. The well being of the soldier in the field or the willingness to t a k e necessary risks is contingent on the confidence that medical support is good, or adequate. I m a g i n e the security i m p a r t e d to the troops by t h e sight of a helicopter dropping out of the sky and r u s h i n g the wounded to a well-equipped and well-staffed hospital. The military uses much of its resources in medical care, h u m a n rescue, and p r e s e r v a t i o n of life. For possibly the first t i m e in US history the A r m y Medical Department, during the V i e t n a m War, had more t h a n the obvious role of giving medical support to its own forces. This is a note of concern, and not a disclaimer. Decisions to provide or withhold care are traditionally questions of medical priorities and/or ethics. However, u n d e r t h e M e d i c a l Civil Action P r o g r a m (MEDCAP), formal p r o g r a m s were introduced utilizing medical care as a weapon to influence the e n e m y or n e u t r a l civilians. Discussing some of the difficulty in providing medical care for South Vietnam, V a s t y a n 6 coined the t e r m ~ideological triage," meaning the pollution of both medical priorities and professional ethics by political principles and strategy. Patient c a r e in t h e U n i t e d S t a t e s is a f f e c t e d directly or indirectly by the government. A t r a u m a care s y s t e m h a s federal g o v e r n m e n t priority. The m a g n i t u d e of t r a u m a dictates t h a t a lot of resources will be involved. Benefit weighed a g a i n s t cost m u s t be documented. Given the t a s k of providing medical care for the victims of t r a u m a in this country, one could l e a r n two selective principles from the Vietn a m e x p e r i e n c e : 1) t h e r e m u s t be a s y s t e m w i t h a c c o u n t a b i l i t y at a l l levels; a n d 2 ) t h e r e m u s t be e n o u g h f l e x i b i l i t y to m a x i m i z e use of e x i s t i n g resources. These s t a t e m e n t s m a y sound somewhat trite, but in the context of V i e t n a m and post-war we have discovered t h a t t h e r e is a l i m i t to resources - - even for the care of our precious young. The proposed s y s t e m of t r a u m a care should be openly debated at all stages of p l a n n i n g and implementation. N o t h i n g should be t a k e n for g r a n t e d nor be t r e a t e d as sacred. The challenge is to improve on the V i e t n a m system, and to e m u l a t e only when it cannot be bettered. The m i l i t a r y did a superb job of medically supporting an u n p o p u l a r combat adventure. M a n y lessons were learned and, I hope, not forgotten. As the t r a u m a care system develops in this country, I hope the same boldness and innovative t h o u g h t t h a t went into the major principles of V i e t n a m medical care will surface, and pervade our t h i n k i n g and actions. REFERENCES 1. Eiseman B: Combat casualty management in Vietnam. J Trauma 7:53-63, 1967.
2. Neel S: Medical support of the US Army in Vietnam, 1965-1970. Washington, DC, Department of the Army, 1973. 3. Flexer M: What potential for helicopters in EMS? J A M A 49:60-62, 1975. 4. Reddick EJ: Evaluation of the helicopter in aeromedical transfers. Aviat Space Environ Med 50:168-170, 1979. 5. Hardaway RM: Contributions of army medicine to civilian medicine. Milit Med 138:409-412, 1973. 6. Vastyan EA: Civilian war casualties and medical care in Vietnam. A n n Intern Med 74:611-624, 1971.
10:12 (December) 1981
Vietnam in Context W. Kendall McNabney, MD Kansas City, Missouri
McNabney WK: Vietnam in context. Ann Emerg Med 10:659-661, December 1981. military medicine, Vietnam; trauma care, Vietnam
The care of the t r a u m a victim is a most i m p o r t a n t concern of a n y EMS endeavor. This association's history is filled with efforts in t r a u m a care. M a n y of the p a s t K e n n e d y lecturers and h o n o r a r y m e m b e r s have d i s t i n g u i s h e & t h e m selves in this p a r t i c u l a r s e g m e n t of EMS, and this m e e t i n g in San Antonio a g a i n signifies the strong i n t e r e s t this organization has in t r a u m a care. Dr. Tommy Thompson, the c h a i r m a n of the A m e r i c a n College of Surgeons Committee on Trauma, will give the K e n n e d y lecture, the m i l i t a r y will give us an entire afternoon of its p a r t i c u l a r b r a n d of t r a u m a care, and t h e r e will be n u m e r o u s papers and subsequent discussions on the topic. It is a t i m e l y topic, a controversial topic, and an emotionally charged topic. Because i m p o r t a n t decisions have yet to be made in this regard, I a m going to briefly analyze a t r a u m a care system of which everyone in this room has at l e a s t some w o r k i n g knowledge, e i t h e r f i r s t h a n d or vicariously: the V i e t n a m War. Despite the u n p o p u l a r i t y Of the war, there was no shame in the records e s t a b l i s h e d by the A r m y Medical D e p a r t m e n t . In the last decade, a n y t h i n g writt e n about t r a u m a care or a system for t r a u m a care will be prefaced by the Vietn a m experience. It is m y i n t e n t to place this experience in the context of c u r r e n t n a t i o n a l needs and resources. The V i e t n a m experience was monitored by daily statistics. Body counts, killed in action, and wounded in action information was corroborated by videot a p e d action on the evening news. The helicopter became the symbol of the war, not only militarily, b u t medically as well. It is no wonder t h a t medical success was u s u a l l y a t t r i b u t e d to helicopter evacuation since it was so visible. Other major factors, such as r e a d y a v a i l a b i l i t y of whole blood, h i g h l y skilled, wellorganized medical teams, well-equipped, s e m i - p e r m a n e n t forward hospitals, and effective m a n a g e m e n t of a v a i l a b l e medical resources, possibly were t a k e n more for granted. Closer scrutiny of all these components will be made. F i r s t of all, w h a t was the record? Of all p a t i e n t s r e a c h i n g US medical facilities, 97.5% survived. This is compared with 95.5% in World W a r II and the Kor e a n War. This record was achieved despite the fact t h a t m a n y m o r t a l l y wounded personnel found alive on the battlefield have come to be counted as hospital deaths. Again, except for r a p i d evacuation, such severely wounded men r a r e l y lived to reach the hospital. In World W a r II it took an average of 10 hours to b r i n g a p a t i e n t to definitive t r e a t m e n t ; in K o r e a it was reduced to five hours; and in V i e t n a m it was one hour. E i s e m a n , 1 after a trip to Vietnam, stated more succinctly t h a t % n A m e r i c a n citizen has a b e t t e r chance for quick, definitive surgical care by board-certified specialists coming out of the j u n g l e or rice p a d d y t h a n were he hit on a h i g h w a y n e a r his home town in the U n i t e d S t a t e s . . . the concentration and organization of the medical m a n p o w e r and e q u i p m e n t necessary to achieve such a level of care half-way around the world from the U n i t e d S t a t e s is awesome." Presented as the Presidential Address at the University Association for Emergency Medicine Annual Meeting in San Antonio, Texas, April 1981. Address for reprints: W. Kendall McNabney, MD, ChaLrman, Department of Emergency Health Services, Truman Medical Center, 2301 Holmes Street, Kansas City, Missouri 64108.
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The Helicopter As Ambulance The helicopter o r i g i n a l l y was used in the K o r e a n War to rescue downed pilots. Because of t h a t success, the principal function soon became c a s u a l t y evacuation w h i c h developed r a p i d l y in V i e t n a m w i t h t h e familiar UH-1 (Huey) helicopter. The helicopter's utility was m a x i m i z e d by the t e r r a i n , lack of a d e q u a t e roads and h i g h w a y s and, most i m p o r t a n t , a i r superiority over the enemy. No combat soldier was more t h a n 35 m i n u t e s from hospital care. A t the peak of the war, 116 air a m b u l a n c e s were deployed. Six to nine p a t i e n t s could be transported, depending on w h e t h e r the p a t i e n t required a l i t t e r or was a m b u l a t o r y . T h e r e was a crew of four - - a l l knowledgeable in medical care and evacuation. Their w i l l i n g n e s s to t a k e n e c e s s a r y r i s k , c o m b i n e d w i t h necessary skill, m a x i m i z e d recovery of critically injured patients. This was especially true on so-called ~hoist missions" on which the h o v e r i n g crew was made t h a t much more vulnerable. Hostile fire, however, was no g r e a t e r risk t h a n were accidents associated with bad w e a t h e r and fatigue. Medical evacuation flights averaged 35 minutes. In one two-year period, 39 crew members were killed and 210 were wounded in those u n a r m e d aeromedical missions. 2 Is the success story of the helicopter limited to Vietnam? Because the United S t a t e s is not s i m i l a r to Vietnam in r e g a r d to h i g h w a y system, t e r r a i n , and abundance of hospital facilities, one would have to say the helicopter's role will be different. First, the cost is about five times g r e a t e r per u n i t of t r a n s p o r t a t i o n . 3 Because of cost, benefit m u s t be documented. Speed and, therefore, distance covered is the p r i m a r y benefit. Difficult-to-get-to t e r r a i n , such as mountains, woods and water, and traffic j a m s and snow storms are other examples. Thus the more r e m o t e the p a t i e n t - v i c t i m is from hospital care, the g r e a t e r the use for the helicopter ambulance. Noise level, limited space, and occasional w e a t h e r problems g e n e r a l l y are not considered to be major problems. Medical capabilities of ground a m b u l a n c e s u s u a l l y exceed those of helicopters. 4 It would a p p e a r t h a t unless there are major technological changes, the helicopter a m b u l a n c e will r e m a i n adjunctive to ground a m b u l a n c e and be limited to remote areas and/or be combined with other functions such as police work, traffic surveillance, or e n v i r o n m e n t a l surveillance. In the S t a t e of M a r y l a n d , helicopters have such d u a l roles, t h u s m a k i n g t h e helicopter a m b u lance more feasible.
Communication The medical radio n e t w o r k facilitated the helicopter evacuation system. It allowed for reliable information to be r a p i d l y d i s s e m i n a t e d to locate p a t i e n t s and determine extent of injuries; allow for r e g u l a t i n g of patient load to each hospital; and give advance notice to hospitals of p a t i e n t arrival. Because combat casualties tend to be sporadic, this type of medical control kept patients going to the n e a r e s t hospital t h a t could take care of them. Surgical backlog was also monitored so t h a t the medical r e g u l a t o r had a continuous status report of each hospital's actual p a t i e n t load and projected workload. The l a c k of a d v a n c e notice for large n u m b e r s of c a s u a l t i e s stymied the orderliness t h a t the staff desired. Five m i n u t e s m a d e a significant difference.
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The c i v i l i a n c o u n t e r p a r t of this scheme, called ~categorization," is sometimes difficult to i n i t i a t e and even m o r e difficult to k e e p c u r r e n t . A l t h o u g h t h e m i l i t a r y had neurosurgical, dialysis, and b u r n centers, p a t i e n t s were n e a r l y a l w a y s assessed and stabilized f i r s t in n o n - c e n t e r h o s p i t a l s . The m i l i t a r y (to my knowledge) never used t r a n s m i s s i o n of biological data, such as telemetry. W h i l e the h a r d w a r e for e m e r g e n c y communication is g e n e r a l l y a v a i l a b l e in the U n i t e d States, the problem is more one of acquiring d a t a and keeping t h e m disseminated. The 911 system is still not universal in this country. The ubiquitous citizen band radio has done much to add to h i g h w a y safety. I will cover more when discussing medical control.
Blood Program The m i l i t a r y blood p r o g r a m was one of the least publicized but most impressive contributors to survival of the severely injured. I say impressive because of the combination of a l t r u i s m and logistics required to place large volumes o f whole blood in a war zone without sacrificing safety. It m u s t be r e m e m b e r e d tl~at most of the blood sent to V i e t n a m was the ~essence" of a donor population - low titer O blood. A l t h o u g h the l a t e r stages of the war necessitated the use of type-specific and even crossmatched blood, prior to t h a t only off-shore hospitals in J a p a n and the P h i l i p p i n e s used type-specific blood. The logistics of d r a w i n g the blood in the continental US, and then processing, t r a n s p o r t i n g , and distribu t i n g so t h a t it could be t r a n s f u s e d before it was 21 days old in a hostile e n v i r o n m e n t 12,000 miles away, is a tribute to this program. The luxury of h a v i n g ~universal donor" blood in large q u a n t i t i e s a v a i l a b l e in surgical hospitals (and even further forward) no doubt affected s u r v i v a b i l i t y of the more critical patients. There has never been a need to e m u l a t e the Vietn a m Blood P r o g r a m in t h e US, as t h e a v a i l a b i l i t y s t a n d a r d g e n e r a l l y has been met. The fact t h a t all blood sent to V i e t n a m came from 11/2 million volunteer donors - - all from m i l i t a r y personnel, t h e i r dependents, and civilian employees of m i l i t a r y i n s t a l l a t i o n s - - is an a s t o u n d i n g record for a n y v o l u n t e e r donor program. 2
Staffing and Facilities Much is w r i t t e n about the t e a m approach to the m u l t i p l e - s y s t e m - i n j u r e d p a t i e n t . Because of the nat u r e of t h e w a r , ~ s a f e " e n c l a v e s w e r e s c a t t e r e d t h r o u g h o u t t h e country. W i t h i n t h e enclaves were s e m i p e r m a n e n t h o s p i t a l s t r u c t u r e s which, for t h e most part, did not move d u r i n g the war. Because of this stability well-equipped, air-conditioned o p e r a t i n g rooms staffed by w e l l - t r a i n e d physicians, nurses, and corpsmen allowed for not only r e s u s c i t a t i o n b u t definitive care w i t h i n m i n u t e s of injury. This p a t t e r n has been the prototype for regionalization of t r a u m a care. More t h a n 1,200 young surgeons served in Vietn a m on 12-month rotations. Because n e a r l y all came from civilian t r a i n i n g programs, it was necessary to p a i r t h e m with experienced surgeons or allow for an o r i e n t a t i o n period. S i m i l a r l y , n u r s e s a n d corpsmen came into the country w i t h basic knowledge and skills r e q u i r i n g r e o r i e n t a t i o n to b a t t l e conditions. Lessons
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learned were s y s t e m a t i c a l l y h a n d e d on v i a symposia and other exchange modalities, such as consultants. The consultants also made hospital a s s i g n m e n t s after interviews and r e v i e w i n g the physicians' p a s t experiences. Organized research was carried out by the Walt e r Reed A r m y I n s t i t u t e of Research. A l t h o u g h t h e r e were scores of j o u r n a l articles concerning t r a u m a care in Vietnam, the m a j o r i t y were probably published after the p e a k of the war.
Organizational Structure The m i l i t a r y as an organization is often criticized for its rigidity, conservatism, and waste of resources. In the case of medical activity, however, this organization becomes the a n t i t h e s i s of the medical system in this country. General Neel s u m m a r i z e s this by stating, '~The preferred o r g a n i z a t i o n for e m p l o y i n g and cont r o l l i n g m i l i t a r y m e d i c a l r e s o u r c e s is t h e v e r t i c a l medical command a n d control system which reached its epitome in V i e t n a m . M e d i c a l service i n t e g r a t e s treatment, evacuation, hospitalization, supply service, and c o m m u n i c a t i o n s c o m p o n e n t s . T h e r e m u s t be strong professional medical control from the most forw a r d to the most r e a r w a r d echelon to achieve maxi m u m effectiveness and efficiency in medical service support with the u t m o s t economy in the utilization of scarce h e a l t h care resources: '2 T h a t s t a t e m e n t should sound familiar; only the t e r m i n o l o g y varies from current trauma care planning. Can a t r a u m a care system used in combat by an o r g a n i z a t i o n t h a t is preoccupied w i t h death, i n j u r y and t h e i r avoidance be compared with a free society t h a t prides itself on the rights of the individual? The discipline of the autocratic system is well accepted as a necessity in the combat military, b u t r e v e r t s back to civilian m e n t a l i t y in this country. For instance, compare the V i e t n a m w a r casualties with our own motor vehicle accidents. In 1969 alone, 11,000 more fatalities occurred due to motor vehicles t h a n occurred in all 11 years of the war. There were over two million injured as a result of auto accidents, or over seven times the n u m b e r in 11 y e a r s of war. One of eight beds is occu~ pied by an accident victim. Compared with the civilian toll of killed and wounded, Dr. H a r d a w a y says the A r m y toll in V i e t n a m was a ~drop in the bucket. ''5 The regionalization of t r a u m a care is a u t o m a t i c in the m i l i t a r y in combat. But when a civilian population has more impressive statistics of d e a t h and d i s a b i l i t y by a less feared e n e m y - - the automobile - - the care is absorbed by the existing system. The controversy is more complicated t h a n financial and philosophical consideration and setting priorities. Helmets for motorcyclists reduce m o r b i d i t y and m o r t a l i t y j u s t as steel h e l m e t s do for i n f a n t r y m e n . Both appliances are u n d e s i r a b l e from the s t a n d p o i n t of comfort and freedom; n e i t h e r will be worn without t h r e a t of a r r e s t or court m a r t i a l , despite the fact t h a t statistical chance of s u r v i v a l is enhanced by doing so. No one sees h i m s e l f as the next victim - - it will always be the other guy. Is this not the d i l e m m a of t r a u m a care? T h a t accidents are p r o v i d e n t i a l , and therefore care would be j u s t as randomized? In a free society this m a y t a k e longer to come. The m i l i t a r y is not a free society, and thus the contrast. Medicine and the m i l i t a r y m a y be in conflict in
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times of war. There is no question t h a t effective medical support enhances a n y m i l i t a r y mission. The well being of the soldier in the field or the willingness to t a k e necessary risks is contingent on the confidence that medical support is good, or adequate. I m a g i n e the security i m p a r t e d to the troops by t h e sight of a helicopter dropping out of the sky and r u s h i n g the wounded to a well-equipped and well-staffed hospital. The military uses much of its resources in medical care, h u m a n rescue, and p r e s e r v a t i o n of life. For possibly the first t i m e in US history the A r m y Medical Department, during the V i e t n a m War, had more t h a n the obvious role of giving medical support to its own forces. This is a note of concern, and not a disclaimer. Decisions to provide or withhold care are traditionally questions of medical priorities and/or ethics. However, u n d e r t h e M e d i c a l Civil Action P r o g r a m (MEDCAP), formal p r o g r a m s were introduced utilizing medical care as a weapon to influence the e n e m y or n e u t r a l civilians. Discussing some of the difficulty in providing medical care for South Vietnam, V a s t y a n 6 coined the t e r m ~ideological triage," meaning the pollution of both medical priorities and professional ethics by political principles and strategy. Patient c a r e in t h e U n i t e d S t a t e s is a f f e c t e d directly or indirectly by the government. A t r a u m a care s y s t e m h a s federal g o v e r n m e n t priority. The m a g n i t u d e of t r a u m a dictates t h a t a lot of resources will be involved. Benefit weighed a g a i n s t cost m u s t be documented. Given the t a s k of providing medical care for the victims of t r a u m a in this country, one could l e a r n two selective principles from the Vietn a m e x p e r i e n c e : 1) t h e r e m u s t be a s y s t e m w i t h a c c o u n t a b i l i t y at a l l levels; a n d 2 ) t h e r e m u s t be e n o u g h f l e x i b i l i t y to m a x i m i z e use of e x i s t i n g resources. These s t a t e m e n t s m a y sound somewhat trite, but in the context of V i e t n a m and post-war we have discovered t h a t t h e r e is a l i m i t to resources - - even for the care of our precious young. The proposed s y s t e m of t r a u m a care should be openly debated at all stages of p l a n n i n g and implementation. N o t h i n g should be t a k e n for g r a n t e d nor be t r e a t e d as sacred. The challenge is to improve on the V i e t n a m system, and to e m u l a t e only when it cannot be bettered. The m i l i t a r y did a superb job of medically supporting an u n p o p u l a r combat adventure. M a n y lessons were learned and, I hope, not forgotten. As the t r a u m a care system develops in this country, I hope the same boldness and innovative t h o u g h t t h a t went into the major principles of V i e t n a m medical care will surface, and pervade our t h i n k i n g and actions. REFERENCES 1. Eiseman B: Combat casualty management in Vietnam. J Trauma 7:53-63, 1967.
2. Neel S: Medical support of the US Army in Vietnam, 1965-1970. Washington, DC, Department of the Army, 1973. 3. Flexer M: What potential for helicopters in EMS? J A M A 49:60-62, 1975. 4. Reddick EJ: Evaluation of the helicopter in aeromedical transfers. Aviat Space Environ Med 50:168-170, 1979. 5. Hardaway RM: Contributions of army medicine to civilian medicine. Milit Med 138:409-412, 1973. 6. Vastyan EA: Civilian war casualties and medical care in Vietnam. A n n Intern Med 74:611-624, 1971.
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