My Moral Matrix:
Forged During the Vietnam War
Jeffrey L Brown, MD [1]
Adapted from:
Brown JL. The Moral Matrix of Wartime Medicine, The Intima
Columbia University
Journal of Narrative Medicine – Fall 2015
And the NY Times, At
War, Dec 20, 2012, Long After War Moral Questions Linger
My Arrival
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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 gave
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 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’m 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 Lightening” 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 sharp wire strung throat-high 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 from its dioxin byproduct is now measured in parts per
billion.
At Cu Chi, my 30 medics were armed and
didn’t 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, 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 hadn’t chosen a career path and joined the military to
avoid being drafted, but this assignment didn’t 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 high-pitched 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 wasn’t 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 wasn’t a dog-loving person, and I had little empathy
for the depth of this man’s emotion. His combat platoon received sniper fire the
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 blood stream 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 his sadness, betrayal, anger, and
resignation. "I feel really
miserable, sir," he said.
I didn’t possess
the medical magic that might have saved this dog’s life, nor the wisdom needed
to comfort this grieving man. I felt the pain of admitting to my incompetence.
I failed this soldier and promised myself that I would learn how to do better. But
for now, 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 didn’t seem like an option. And,
like a mother running into traffic to save her child, I ran toward them, as if
the danger didn’t 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 depended on a random series of near misses. If a boot
struck the ground here, we were okay. If it struck there – we weren’t.
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. A
voice behind me 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 burned into my memory. We didn’t 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 I remained in a
transitional state, something reminded me of Vietnam every day – the phantom
smell of blood mixed with mud or 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 and 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.
I sighed 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 had 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 can’t be 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 aren’t and they disorder a person’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 they 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 didn’t 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 didn’t affect you – you are an idiot!”
“Is there an official diagnostic
code for this?” I asked.
In that Vietnam
setting, professional terror was 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.
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 didn’t
know what they and their families would choose. These decisions made us weary,
and we would have to live with the consequences.
Morality was determined
in that 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 right and wrong became kaleidoscopic. There would be no do-overs for these
choices. Only the do-laters we hoped would 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 fate will bring.
But, if we –
Regained our 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
Dr. Jeffrey L Brown is a retired pediatrician who teaches as a Clinical
Professor at New York Medical College and an Emeritus Associate Clinical
Professor at Weill Cornell Medicine. 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.
Click for photos at this Photo Link
Jeffrey L Brown MD
Website: JLBMD.com
Email: jeffrey_brown@nymc.edu
Mobile: 914-552-5013
[1]
Clinical Professor of Pediatrics, New York Medical College
Emeritus Associate
Clinical Professor of Pediatrics in Psychiatry, Weill Cornell Medicine
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