LAUSR

Hard times don't create heroes. It is during the hard times when the hero within us is revealed. Bob Riley Military medical doctors, through their healing practices, have always played a critical role in military campaigns. The actual contributions of physicians to such campaigns have varied over the centuries, dependent on many factorsincluding the actual science-based knowledge of the physician; his or her surgical skills; the presence of qualified assistants; quality hospital backup; access to needed medications, blood transfusions, and intravenous solutions; efficient patient transport services; and the support of public health specialists. As I reflect on my medical experience during the Vietnam War more than 50 years ago, I can appreciate the benefits and opportunities that I had as a U.S. flight surgeon at a base in the Mekong Delta of Vietnam in the mid-1960s. I had a great support team of well-trained medics. We had eight ambulance helicopters flown by brave and gifted pilots. Our team was assigned to the South Vietnamese Army that was fighting the battle in the Delta. I had a small, well-equipped hospital/clinic with plenty of supplies and medicationsenough to allow us to work with the civilian population in the area. I had blood transfusion capabilities and a surgical capacity. My backup hospital was the excellent 3rd Field Hospital in Saigon. Our small base had potable water, excellent sanitation, and a top-notch immunization program. Despite complaints about the food, we all ate well. Add to that excellent mail service, a 1-year deployment, and 2 separate weeks of rest and recuperation. Life was goodoccasionally dangerous, but good. Our experiences varied, but most physicians returned home, picked up their medical practices where they left off, and moved forward. We all felt that we did some good, but we were not heroes. We just did our jobs. On my return to Vietnam in a medical teaching capacity in the late 1990s, I became aware of starkly different experiences. Over a 20-year period of twice-yearly visits to the Bach Mai Hospital in Hanoi and to other medical teaching centers in Vietnam, I met, worked with, interviewed, and learned about the medical professionals among the ranks of the Viet Minh, Viet Cong, and North Vietnamese Army during the war. For all that these persons accomplished, we have little in writing: a diary by Dr. Dang Thuy Tram (1), a few chapters in a book by James G. Zumwalt (2), a New York Times article (3), and some information from documents captured by the Central Intelligence Agency. Prominent in these writings are the names of Drs. Le Co Dai, Nguyen Huy Phan, Vo Hoang Le, and Tong Thi Xuyen. I was further informed by conversations with Dr. Bui Quang Pho, who ran a hospital on the Ho Chi Minh Trail. Other discussions with Profs. Do Dinh Dich, Vu Van Dinh, and Nguyen Thi Du broadened my knowledge of the commitment to medicine of these persons. Except for Dr. Dang Thuy Tram, who was killed during her second year of front-line medical service, the others served between 8 and 15 years far from home in environmentally harsh settings on the Ho Chi Minh Trail or underground at Cu Chi, a network of tunnels that extended over 100 miles from the Saigon area to the Cambodian border. Most of them began their service during the First Indochina War. Prof. Do Dinh Dich was one of the six physicians who supported the 50000 Viet Minh soldiers during the 2-month Battle of Dien Bien Phu. During that period, he helped oversee the care of 10000 casualties without the support of an onsite hospital facility. A few of these physicians ran large hospital complexes under constant threat of bombing raids. Most spoke of shortages of medicine and supplies and of diseases and wounds suffered by themselves and their patients. One physician ran a hospital complex with more than 1000 patients that had 400 staff members. Along with patient care, the staff was required to tend to small cassava farms; fish; and hunt wild pigs, monkeys, tigers, elephants, and deer to feed the patients. Patient transport was often inadequate or nonexistent. Surgery had to be done under difficult circumstances, often at night, with poor lighting from flashlights and bicycle generators (Figure). These procedures were at times hindered by monsoons or performed deep in underground tunnels. Postoperative infections were common because of malnutrition, poor wound healing, delayed arrival at a hospital site, and a lack of effective antibiotics. Lifesaving blood transfusions were not readily available and often required person-to-person infusion (frequently from a staff member to a patient), allowing for only small amounts of blood between 50 and 100 mL to be transfused. Figure. Improvised operating room in a mangrove swamp in the U Minh Forest in the Mekong Delta. Photograph by Vo An Khanh. Originally published in Ba V, Bao V, Chinh ND, Dinh DD, Khanh VA, Nam M, et al. Memorial of a Glorious Time. Ho Chi Minh, Vietnam: Nha Xuat Ban Tong Hop Thanh Pho Ho Chi Minh; 2003. Reprinted with permission from Nha Xuat Ban Tong Hop Thanh Pho Ho Chi Minh. Excellent surgery was performed by skilled, very experienced surgeons. They worked under tremendous hardships, often under enemy fire, for lengthy periods, separated from family and friends. During their long deployments, they experienced many deaths among their young patients and developed illnesses and wounds themselves. All implied that they did the best that they could with what they had over extended periods. All were proud of their work. They did not want to write about their experiences; they wanted to forget them. True to their commitment to their cause, none of them complained about poor financial or retirement benefits. All returned quietly to prominent medical positions in their country. All received medals and documents attesting to their medical contributions. Many sent their children to study medicine in the United States (one of whom I had the privilege of precepting). By any definition, these men and women might have been termed medical heroes. They would not agree. They would say they were just doing their jobs. Long years and too many wars have taught me that our profession displays a heroism devoid of politics and ignorant of borders and boundaries and that, in its purist sense, reveals a dedication above salary, promotion, rank, or privilege. Whether on the run in the Dark Ages when branded as magicians rather than healers or dying by the hundreds during the plague years, whether enduring ridicule when sounding the alarm about microbes or performing lifesaving surgery standing knee-deep in swamp water, the best of us have forged ahead selflessly, doing what is required of us. Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "Healing the Wounds," by C.E. Bartecchi.