How War Shaped a Specialty

The Vietnam War left behind a positive legacy of improved trauma care.

Most of the emergency physicians of my generation have unpleasant childhood memories of the long conflict—at its height in the mid 1960’s—that was the Vietnam War. Whether it was a family member or neighbor’s son killed in the jungles of Vietnam, the ugly protests that divided the country, or TV images of napalmed children, the legacy of this unpopular war is mostly negative. Over 47,000 servicemen died in action, and another 11,000 died of non-combat causes [1]. The costs were huge, and the objective of the war – to prevent a communist government from gaining power – was not achieved. However, one good thing to come out of the misery of the Vietnam War was the advancement of trauma care, and the impetus to make civilian care as good as military casualty care.

A number of eventual emergency physicians were deployed in Vietnam, and their experiences drove them to want to improve the overall dismal state of trauma care in the US. Military medicine had advanced from WWII through the Korean War (as depicted in the M*A*S*H* television series), and reached new levels of efficiency and quality in Vietnam. A sophisticated system of rapid battlefield resuscitation of hemorrhagic shock, evacuation to a field hospital, and near immediate movement to the operating room decreased mortality and morbidity. Mortality rates for wounded soldiers who survived to get to field hospitals, which were around 4-5% in WWII, were cut in half in the Vietnam War [2].

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Edward (Mel) Otten enlisted in the Army at 17-years-old and became a medic in Vietnam. After his war duty, he went to Kenyon College and the University of Cincinnati for medical school and his emergency medicine residency. He stayed on at Cincinnati as an award-winning teacher and faculty member who remained very involved in EMS and disaster management.

As a medic, Otten was part of a team that could resuscitate the wounded in difficult circumstances:

“We could bring in a helicopter, which we called a ‘dust off’….As a medic I would try to stabilize a patient as best as I could, which mainly involved bleeding control. We would just put tourniquets on people; we put pressure dressings on….You give them morphine and ….albumin, and ringers lactate…. (Otten, 2003)

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Kendall McNabney, MD, a surgeon who served in Kansas City and later started an emergency medicine residency at Kansas City General Hospital in 1973, noted:

“What I think improved trauma outcomes in Vietnam was the availability of O negative blood. It was everywhere—by the gallons.” (McNabney, 2003)

Otten and other medical providers in Vietnam worked as members of tightly organized teams that could get a wounded soldier from injury to a field hospital in 20 minutes, and into surgery in 5-10 minutes after that. Upon returning to the US, Otten worked as an EMT in Ohio. He soon realized that the military management of trauma was far ahead of standard emergency care in the US. He noted:

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“When I went to college I worked on an ambulance in college…  I would go to emergency rooms and the doctors knew less about how to take care of these things than I did…. We were doing lots of stuff that we had learned about in the Army, but the civilians hadn’t learned about it yet.  Civilian emergency departments were still run by either the people you didn’t speak English or were bad doctors or people who were just doing their monthly rotation in the emergency room, so every month some psychiatrist, the dermatologist, the internist, the surgeons had to spend time in the emergency room doing their emergency room care so it was very inconsistent. I think the surgery was very good then. The problem was …the guy who gets hit by the car in the street…by the time he gets to the emergency room the emergency room doctor doesn’t know what to do and so they don’t save him for the surgeon.”(Otten, 2003)

Surgeons who served in Vietnam also realized that they had a lot of work to do to bring civilian trauma care to a level near what was achieved during the war. Trauma centers were established in the 1970’s at some major teaching hospitals and the statewide trauma care system was developed in Maryland.  A high impact development was the creation of the Advanced Trauma Life Support course in 1978, and its adoption and dissemination by the American College of Surgeons in 1980. Kendall McNabney and other early surgeons who moved in to emergency medicine were key liaisons between surgery and emergency medicine in trauma care.

Before US trauma care could evolve to a system that would better serve those with serious injuries, one missing element had to be populated – trained emergency physicians in hospital emergency departments. If we remember that there were zero residency-trained emergency physicians in 1970, it is not surprising that the rag-tag collection of physicians who worked in ED’s at that time were often unprepared to handle serious trauma cases. The growth of the field of emergency medicine parallels the systemization of trauma care. Emergency physicians had a major role in training EMS providers to provide lifesaving early interventions and begin resuscitation, and to focus on rapid transport to designated American College of Surgeons trauma centers. In many cities, aeromedical programs developed to bring highly trained providers directly to accident scenes. Developed in a multidisciplinary way by trauma surgeons and emergency physicians, emergency department protocols, streamlined and standardized trauma care. Prioritization of trauma cases and trauma-oriented resuscitation by anesthesiologists, along with new operative approaches, improved trauma ICU care, and rehabilitation further reduced morbidity and mortality. Although it took longer that many hoped, the disparity between war-time trauma care and civilian care in US hospitals was significantly reduced.

The military’s concept that drills and situational training were an essential part of forming a highly functional team did not have broad adoption in civilian medicine for almost two decades. One success story has been the TeamSTEPPS program, which came out of grants that were funded by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. Medical centers and simulation centers, with emergency medicine leading the way, developed this approach for organized communication and team roles to enhance patient care and safety. Over the past 20 years, this comprehensive program has expanded to train thousands of medical providers and staff to perform better in rapid response situations [3].

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Thousands of young lives were lost in the Vietnam War, and thousands more veterans and civilians suffered injuries and illness that changed the courses of their lives. Many people feel regret, remorse, and frustration that the war ever occurred. But one positive thing to emerge from the pain and carnage of this war was a commitment to raise civilian trauma care to a new level. Many medical providers took their grim experiences in Vietnam and repurposed them to transform EMS, ED, and in-hospital trauma care. It is no understatement to say that due to this, thousands of lives have been saved in our communities. That is a legacy we can be proud of.

This article was derived from Dr. Zink’s book, “Anyone, Anything, Anytime – A History of Emergency Medicine” (Elsevier-Mosby, 2006).  Quotes from Dr. Otten and Dr. McNabney were from a telephone interviews conducted by Dr. Zink in 2003. 

REFERENCES

1. http://www.historynet.com/vietnam-war;
2. Heaton LD: Army medical services activity in Vietnam, Military Medicine 131:646-647, 1966.;
3. https://www.ahrq.gov/teamstepps