Adapted from: The Moral Matrix of
Wartime Medicine, The Intima
Columbia University Journal of
Narrative Medicine – Fall 2015
A Moral Matrix 
Jeffrey L Brown, MD [1]
My Arrival
A trim flight
attendant wearing a powder blue skirt and a friendly smile pushed her food cart
down the center aisle. At first glance, this looked like a routine flight. It
wasn’t. The passengers were combat ready troops who were young, somber, and
silent. Some chose sleep to escape from troubled thoughts; others anesthetized
them with the droning noise of twin jet engines. A consequence of our rapid
buildup in Vietnam was that soldiers were transported on commercial airlines.
Doctors like me had only six weeks to transition from civilian to military life
before we shipped out with them. We wore summer weight khaki uniforms but felt
like civilians until the moment that overhead speakers crackled news of our
arrival.
It was late
August 1966 and monsoon rains would continue for another two months. The strong wind that delayed our landing had
just blown by and we walked quickly through hot thick mist that smelled like
wet wool. The sky was gray. All else was olive drab splattered with brown mud:
boots, gear, vehicles – everything. Like other military items stenciled with
descriptors, I was labeled too: captain’s bars, a caduceus, and a black plastic
name tag announced what and who I was to anyone who was interested.
The Camp Alpha processing center was
located near Saigon – now called Ho Chi Minh City. It looked more like a
tropical prison than a welcoming area for incoming troops. Heavily armed guards
patrolled perimeter fences topped with coiled concertina wire. Muddy rainwater
separated neat rows of screened and sandbagged barracks. Malaria-infested mosquitoes fed on hot
sweating skin. And if not for a poorly tested vaccine, fleas from indigenous
rats could infect us with the same bubonic plague that created medical mayhem
during the Middle Ages.
I was housed with junior ranking
officers. War noise and jet lag assured a miserable night’s sleep. At first light, a sergeant appeared. His
ethnicity was nondescript, but his bearing was not. He was professional and unambiguously
intimidating: straight back, athletic build, piercing gaze. Somehow, his
fatigues were pressed and boots shined despite pouring rain and no rain gear.
This was quite remarkable. Either he was secreted away with us overnight or he
possessed special powers that repelled mud and water.
“Attention to orders,” he
barked. We paid attention.
"The following orders have been
changed...."
I was assigned to the 2nd Battalion,
14th Infantry Regiment.
Other names and orders followed.
There were groans.
One came from me.
I stood tall, stepped forward, and
did my impression of an Army officer.
"Sergeant," I said. “I am scheduled to join the 85th
Evacuation Hospital in Qui Nohn. I am classified 3-C because of a medical problem
that disallows my assignment to a combat unit. What is the explanation for this
change of orders?”
Without effort, he morphed into a
hotel manager denying a confirmed reservation.
"Sir,” he said with a hint of condescension. “I am so sorry I can’t help you. Your medical
file is in transit. I suggest you discuss this issue with the doctor when you
get to the two-fourteen in Cu Chi.”
“But you said I am going to be the
doctor at the two-fourteen.”
“That is correct, Captain. Effective
0600 today, you are the battalion
surgeon for the two-fourteen.”
This man had not earned his stripes
for nothing. A few months later I would have responded to this ridiculous
Catch-22 dialogue, but at the time, I was speechless. With luck, maybe a higher
level of stress hormones would lessen my frequent bouts of asthma.
That afternoon, I was convoyed west
to join elements of the “Tropic Lightning” 25th Infantry Division in central
Vietnam. I felt like an imposter wearing a steel helmet, a bulky pre-Kevlar
flak jacket, and jungle boots reinforced against punji stakes. My accessorized
vehicle foreshadowed what came next: Sandbags to keep land mines from exploding
through the floor, a slotted vertical bar to cut throat-high wire strung across
the road, and a locking cap to keep local kids from dropping hand grenades into
the gas tank. We drove through large areas of denuded landscape that were
sprayed with Agent Orange herbicide. We were told it harmed only vegetation;
human toxicity is now measured in parts per billion.
At Cu Chi, my 30 medics were armed
and did not wear Red Cross insignia. Before being embedded with 900 infantry
troops as their only doctor, I was issued an M-16 rifle and a .45 caliber
pistol. Notwithstanding the Geneva Convention and my lack of weapons training,
the Viet Cong were known to target medical personnel.
I was 26 years old, one year out of
medical school, and just a few weeks earlier worked as a medical intern in a
teaching hospital. I had not chosen a career path and joined the military to
avoid being drafted, but this assignment did not resemble the training program
I was promised. Clearly, the person who got me into this mess deserved a stern
reprimand. Unfortunately, the culprit
was me.
The Mercy Killing
My first week in the field was
uneventful; the few patients I saw had minor complaints. On the morning of the
eighth day – during my transition from mostly asleep to almost awake – I heard
a shout. "Where’s the doctor?” the voice said. I grabbed my gear and came running.
Framed in the center of an empty dirt road, the backlit silhouette of a young soldier walked toward me, awkwardly, as though he was afraid of dropping something fragile. His deuce and a half (2½ ton truck) was parked to the side with its engine still running. He wore a helmet but no body armor, and his shirt shined with sweat and dark red blood. An M-16 rifle was slung over his left shoulder because he was cradling a scraggly, malnourished, mixed-breed dog. Its brown fur was matted from the fine misty rain and it was whimpering in the most pitiful way.
The cause of the dog’s pain was
obvious. A two-inch shard of whitish bone protruded through the torn flesh of
its right hind leg. The soldier tried valiantly to protect the injured leg from
moving but the dog’s cries evidenced his limited success. Despite holding the
dog, he stood mostly at attention and addressed me in the staccato voice used
for military report. "It was an accident, sir. I never saw him. It was
dark, my headlights were dimmed, there was a thud, I exited the vehicle, and
this is how I found him." The dog was not wearing tags or a collar.
"Does he belong to anyone?" I asked. "I don't think so, sir. He
just shows up. We play with him and feed him, but I’ve never seen anyone
actually looking after him."
Involuntary tears left tracks on both cheeks. He studied the dog's pained face with affection usually reserved for close friends and relatives. I am quite certain that today I would protect my dog’s life with my own, but at the time, I was not a dog-loving person, and I had little empathy for the depth of this man’s emotion. His combat platoon received sniper fire a day before. Two members of his squad were killed, others seriously wounded, and these tears were shed for a stray dog.
Successful treatment of this pathetic
patient required the skill of a surgeon, a proper medical environment, and
prolonged convalescence. These did not pertain to me, the situation, or the
dog. Like all doctors assigned to military units, my title "surgeon"
was vestigial from battlefields of earlier wars, not based on surgical
training. The equipment in my aid station was meager, and to make matters
worse, we were packing up supplies before moving out the next day.
One of my medics approached from the
rear. "I’m sorry,” I said in a calm voice. “There isn’t much we can do
except relieve its pain.” The dog was placed on a poncho at a spot shielded
from the rain. I kneeled in the mud and carefully propped the injured leg to
what I thought was a comfortable position. The dog yelped. I flinched. Without
conversation, the medic handed me some ampoules of morphine. An average soldier
weighs about six times more than this dog, so I reasoned that half an adult's
lethal dose should end its life in a compassionate way. Army medics love giving
morphine, and for good reason. No matter how severe their patient’s injury, it
relieves pain and anxiety quickly. On the dark side, a large dose inhibits
breathing and can cause death.
I located the
vein that runs down the dog’s foreleg, inserted the needle, and administered the
first dose. Injecting it directly into the bloodstream increases potency and
protects against erratic absorption. Almost immediately, the dog closed its
eyes and seemed at peace. I was relieved; sometimes pain causes more distress
for the doctor than the patient. Thankfully, I thought, this will be over soon.
It wasn’t. I injected a second larger dose, and then a third …. Nothing much
happened. The dog’s breathing slowed a bit but was not shallow. I doubled the
next two doses. The dog was still breathing normally, and his pulse was strong
as ever.
This was not
going well. If death was the goal, it seemed nowhere in sight. And now I was
outside my comfort zone. I had never used medical knowledge to end a life and
didn’t like the way it made me feel. I wondered if I miscalculated the dose or
my pragmatic morality was being tested. Was it remotely possible some spiritual
force was telling me it is not this dog’s time to die?
I held my ground and injected more
morphine …. The dog was still breathing …. more morphine …. still breathing ….
And then, without warning, the dog was dead. I stopped breathing too, devoid of
thought, air, and sound. When I recovered, I refused to tell myself that I put
the dog to sleep or out of his misery. It seemed necessary to acknowledge what
I had done.
Once again, the
soldier slung the rifle over his shoulder. Taking great care to protect the
dog’s injured leg, he hugged its warm limp body to his chest. His tear-filled
eyes stared directly into mine. This innocent dog’s death symbolized the misery
that surrounded us. Plain words expressed sadness, betrayal, anger, and
resignation. "I feel really
miserable, sir," he said.
I did not possess
the medical magic that might have saved this dog’s life, nor the wisdom needed
to comfort this grieving man. I felt pain admitting to my incompetence. I
failed this soldier, and surely hoped that one day I would have the skill to do
better. I nodded, looked away, and said nothing.
The Mine Field
Most troops greeted me with “Hey Doc,
let me show you something.” It is impossible to maintain decent hygiene living
in the jungle or wading through rice paddy water, so the "something"
was usually skin that was lacerated, abraded, ulcerated, blistered, weeping, or
infected with bacteria and fungi. There are no private body parts in this
setting, so I got to know these guys pretty well in short order.
Our battalion was conducting search
and destroy operations in Tay Ninh province near the Cambodian border. We were
the bait used to draw enemy soldiers out of hiding. My new home was a small
sandbagged tent that doubled as the forward medical aid station. It was located
less than 100 yards from the perimeter machine guns, which meant we could be
under fire while treating casualties. The triage and treatment area consisted
of two canvas stretchers called litters that rested on metal racks; we
increased capacity by laying ponchos over the mud. There was no suction,
oxygen, or blood products – none of the medical stuff I had taken for granted.
Changes in tactics and helicopter evacuation had relegated combat doctors to
the role of highly trained medics, and battalion surgeons were gradually being
transferred from field duty to medical facilities; the added risks were not
justified.
Shortly after arriving, I embarrassed
my novice self by leading my medics on a frantic search for burn dressings. I
heard there was a firefight and imagined soldiers with flame throwers. I didn’t
know that a “firefight” is an exchange of small arms fire. About five weeks
later, that same inexperience compelled me to join two medics who were treating
a critically wounded soldier. He had wandered into a well-marked minefield and
they were having trouble keeping him alive. The area was seeded with “Bouncing
Betty” landmines that contained a small first charge that lifted the second
waist high before exploding. They inflicted gruesome damage and an unfortunate
misstep mangled this man so badly there was no place to apply tourniquets. Not
helping my medics did not seem like an option. And, like a mother running into
traffic to save her child, I ran toward them, as if the danger did not pertain
to me.
The man was writhing and
screaming. His bleeding slowed as his
blood pressure dropped and he went into shock. I injected him with morphine,
applied pressure dressings to gaping wounds, and managed to start IV fluids.
Then, we lifted his battered body onto a litter, exchanged glances, shrugged to
acknowledge the frailty of our existence, and without speaking – we simply
walked out. It was a humbling experience.
Detonating a single mine could kill us all. Our survival relied on a
random series of near misses. If a boot struck the ground here, we were okay.
If it struck there – we were not.
An evacuation
helicopter was in transit and we were covered with blood. This young soldier’s
wounds were lethal, but the end came when he threw-up blood, gasped, and
breathed vomit deep into his lungs. One
of his buddies pleaded, "Do something! Do something!" But with no suction available, our attempts
at clearing his airway and resuscitation were futile. It was hopeless. All we
could do was watch him struggle to breathe, suffocate, and die.
It was over so
quickly, I didn’t notice which of my brave medics assisted me or the name of
the dead soldier. His friend’s pleadings are still in my memory. We did not
speak about this incident again. The next day would be another day.
The Wall
I was attending a
conference in Washington, DC when I visited the Vietnam Veterans Memorial for
the first time. The sun was shining, the air was crispy cold, and there was a
trace of snow on the ground. I had been happy practicing pediatrics in a New
York City suburb for 15 years, but something reminded me of Vietnam every day –
sometimes, the phantom smell of blood mixed with mud; other times, the
unexpected image a wounded soldier. It made me feel like a military doctor
dressed in civilian clothes. I felt much older than my age. I had little
patience for daily concerns that bothered my friends and workmates; they often
seemed trivial, petty, or naïve.
The Vietnam Veterans Memorial is
located in the National Mall. Its
serenity belies the chaos and violence that killed 58,000 soldiers who are
remembered there. The clean peaceful lines were designed by Maya Lin, a Chinese
American architect, who wanted to bring focus back to the soldiers and away
from the divisive war. It is called “The Wall” because its most distinguishing
feature is a series of graceful and beautifully landscaped black granite panels
that record soldiers’ names by dates of death. Each name follows the next in a
run-on style that creates an unsettling impression that the list might never
end.
There were tears in my eyes as I read
the name of each person who died while I was in-country. There were many and it
took longer than expected. I rushed back to my meeting, had a late dinner with
friends, and returned to my hotel. I was agitated and could not sleep. At 3
a.m., I called a taxi that took me back to the memorial. I was not dressed for
the drop in night-time temperature and stood shivering, at attention, in front
of this polished wall that was lit to the intensity of daylight. I read each
name again, more slowly than before, and was overwhelmed by emotion. Not
because I recognized the names – but because I didn’t recognize them. I had comforted some of these men and
watched them die but did not know who they were. Killed soldiers weren’t just
replaceable during that war, the public’s antagonism had made them disposable.
I found comfort knowing that most had not died alone. I and others like me
could bear witness to their final moments.
Medical personnel cherish their work
when they are doing something to keep patients alive. We don’t always
appreciate the pastoral importance of being present when someone dies. Our
presence at death creates an existential bond that is never broken – even when
we don’t recognize names of the dead that are written on a long black wall.
A Moral Matrix
Post-traumatic
stress symptoms are manageable – until they disorder a patient’s life. Anxiety,
hypervigilance, self-doubt, and depression are expected, but time
disorientation is not. Past events blend into the patient’s present-day self,
making them contemporary. Aging veterans
are physically and emotionally vulnerable and have more time for reflection.
Older folks are always surprised when they become symptomatic years after the
precipitant trauma occurred. When I told a psychologist I did not think my
late-in-life symptoms were caused by my time in Vietnam, he smiled. “You
treated critically wounded patients in a minefield and under fire, you watched
them die, and you disarmed a disturbed soldier while he was threatening to
shoot you. If you think this did not affect you – you are an idiot!” Maybe
his diagnosis was correct. “Is there an official diagnostic code for this?” I
asked.
Military medical personnel discover
that professional terror can be far worse than fear of personal injury. It was
only possible to fulfill our medical responsibilities if we made do with what
we had – not what we wished for. The best we could do was redefine acceptable
outcomes and performance. Conflicts between military mission and obligations to
individual patients were the most difficult to navigate: providing medical care
that keeps troops combat-ready might send them to their deaths.
A soldier with a severe headache
relies on our intuition to decide whether he should go on patrol; a wrong
decision places him and his squad at risk. A critically ill patient at a
hostile landing zone might die without immediate transport; not waiting until
it is secure adds danger for the medevac team. I naively thought that keeping
every patient alive was an uncomplicated goal until I treated patients with
severe brain injury and multiple amputations. Should we keep them alive because
we can, or spare them and their families years of pain? Even worse, we did not
know what they and their families would choose. These decisions made us weary,
and we had to live with the consequences.
Morality was determined in the
moment. Trying to stay alive while an enemy was trying to kill us, especially
one with no sense of basic decency, resulted in choices that were certain to
harm innocents – and our moral selves. Enemy soldiers tortured and hid behind
civilians; women and children became unexpected assassins; everything was
booby-trapped and might explode at any moment.
Rules that were once painted in the primary colors of rights and wrongs
became kaleidoscopic. There would be no do-overs for our choices. Only the
do-laters we could use to improve the future. ####
Youth is not wasted on the young.
If we were wiser
When we were younger,
We’d
not make mistakes
And
feel the pain
We need to learn
What life will bring.
But –
If we regained the youth that’s
passed
Exuberance
would overwhelm the past.
And
we’d no longer be
Those
smarter folks
Like
you and me
Who’ve
learned to see the world
Through
older wiser eyes. – JLB
About the Author
Dr. Jeffrey L Brown is a recently retired pediatrician who
teaches as a Clinical Professor at New York Medical College and Weill Cornell
Medical School. He served in Vietnam
during 1966 and 1967 as an infantry battalion surgeon, a brigade surgeon, and
then as a clearing company commanding officer.
He received a Combat Medical Badge for his service and was awarded the
Bronze Star medal for valor.
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