Part 2: The life of Gus Kappler MD, Vietnam Era Trauma Surgeon

 Dr. Gustav Kappler grew up in Lake Ronkonkoma, a small town in Suffolk County, Long Island. The freshwater lake was formed eons ago by retreating glaciers and the name is an Algonquian Indian expression meaning “lake boundary.”  Legend has it the lake was said to have special healing powers, and this drew plenty of pre-depression era tourists.  The town did nothing to dissuade this notion, of course.  There were also rumors it held piranha, which was nonsense, but it did contain a distant relative, a harmless species called Pacu. Gus was the son of Gustav Jr. who attended Cornell University and starred on the athletic field, as captain of both the Cornell soccer team and baseball team.  According to Dr. Kappler, he also ran liquor from Canada down to Ithaca during prohibition, to “make a little extra money on the side.”   

Before long, Gustav Edward Kappler III was born.  Gus’ mother was unhappy with the name Gustav, and called Gustav by his middle name, Eddie, instead.  When he moved away to college down the line, he became Gus again.  Gus learned to shoot a bow and arrow and shot frogs regularly down by the lake.  “I’d cut the legs off, and sell them to local restaurants.”  Gus began dissecting the frogs (minus the legs) and, as a result, became interested in the sciences. He had a chat with his high school guidance counselor and exclaimed “I want to be a blood chemist.”  The guidance counselor looked perplexed and then replied, “You mean a doctor, I suppose,” and Gus said, “Yes, I guess I do.”  Gus soon decided on a future in surgery, “After all, I was already cutting up frogs.”

He met Robin, his high school sweetheart and future wife, who was originally from Brooklyn but had moved out to nearby Lake Panamoka.  Soon they were off riding horses together in the Adirondacks.  Like his father, he matriculated at Cornell and majored in Chemistry with a pre-med curriculum.

Gus made the freshman basketball team, but soon fell behind in his studies and realized something was amiss.  He had yet to be diagnosed with a condition called dyslexia, a reading and language disorder that was not well known in mainstream medicine at the time.  Because it took him longer to read and write, he found he had to make the difficult decision to quit basketball to survive the rigors of a pre-med education. Intelligence was not an issue, recognizing and comprehending words were.  He fared better with the mathematics and symbols of chemistry and physics then writing English papers.  Gus persevered and got through, and eventually attended Cornell Medical College, whose main teaching hospital was The New York Hospital on the upper east side of Manhattan.  His class of one hundred consisted of only 6 women, one Black, and one Asian.  

Gus chose Medical College of Virginia (MCV) for residency.  In 1957, Dr. David Hume performed the first kidney transplant at MCV and Dr. Richard Lower performed the first heart transplant in 1968.  “Dr. Hume was the Chief of Surgery.  He was involved in some of the first transplants.  He was one hell of a surgeon.  Unlike some places, they let you scrub into surgery during your first year, so boom, I was going to MCV.  Richmond was still segregated at the time, so there was a white hospital, E.G. Williams at the Medical College of Virginia, with a white ER, and a black hospital, St. Philip’s, with a black ER.  We rotated through both.  There were no black doctors at either hospital.”  St. Philip’s was Richmond's segregated hospital from 1920 into the early to mid 1960’s.  MCV admitted its first black nursing student in 1957, whereas St Philip’s hospital had been training black women to be nurses to take care of the black patients since 1920.  Segregation was alive and well in Richmond at the time, but its time was coming to a close.  In 1965, MCV formally ended segregation of its hospitals and clinics. 

The race to be the first institution to transplant a heart in the South was in full gear when Bruce Tucker, a black man, was admitted to MCV in 1968.  He had suffered severe head trauma and was brain dead, and his heart was harvested from his body, but without patient or family consent, and was transplanted into the chest of a severely ill white patient who desperately needed a healthy heart in order to survive Dr. Kappler remembers extensive attempts were made by MCV to contact Mr. Tucker’s family, but to no avail.  This was refuted by the patient’s brother.

“I was there when it happened.  Hume was taken to court and charged with manslaughter and went to trial.  He was acquitted, and as an outcome of that trial, we changed the definition of death.  He (Tucker) was one of the first patients to have his heart and kidneys removed while his heart was still beating.”  Since transplants were relatively new, protocol was uncertain, but, at least in this case, nobody was able to finalize consent.  The operation proceeded despite that, and the family sued, and the matter went to court. Without consent, it was felt to be an assault on the body of this black man.  

Traditionally, death occurred when the heart stopped beating.  This was biologic death.  When the courts acknowledged brain death, that changed the legal definition and was essential for launching the discipline of transplant medicine.  

Brain death is defined as an irreversible, biologic event that consists of permanent cessation of critical functions of the organism as a whole (Wijdicks EFM, Brain Death, Lippincott Williams and Wilkins, Philadelphia 2001, page 175).  Since the brain is essential for integrating the functions of the bodily organs into the complex coordinated dance we call life, the definition allows for other tissues and organs to still be functioning. But without a functioning intelligence center, or cerebral cortex, and without a functioning primordial center called the brainstem, which is hardwired to the heart, lungs, and cranial nerves, the brain is considered to have stopped functioning on the whole and legitimate death is declared despite functioning of the other organ systems.  A hallmark of Brain death is the absence of reflexes such as the gag reflex in the back of the throat, or what makes us gag when a doctor sticks a tongue depressor in our throat, the corneal reflex on the front of the eyeball, which causes the eyelid to blink when touched, and the reactivity, or dilation and constriction, of the pupils.  There is also apnea, the absence of spontaneous breathing.  A coma, on the other hand, is a potentially reversible state where reflexes and basic functions are maintained.  We now know that this is the exact scenario of how and when you harvest organs with the best preservation rate, to save the lives of others who need them.  The organs are taken when the body is alive, but the brain is dead. Hume, Kappler, and the rest of the interns and residents were paving new ground in medicine.

                                                                 ***

Although great for developing and sharpening medical skills, residency could be harsh on relationships.  Of the twelve couples that entered residency with Dr. Kappler, only two couples survived the five-year ordeal.  “On the weekend, we started on Saturday morning and ended whenever you finished on Monday night.  It was every other night and every other weekend.  It was torture.  But everybody had to do it.  We were learning.  The good part was you got to do and assist in a lot of surgery and get involved in the surgical decisions.  We were gung-ho for surgery.”

After residency, it was straight to Vietnam.  “I got my orders to Phu Bai.  Turns out, Phu Bai was the armpit of Vietnam.”  According to Kapler, there was a facetious phrase everyone at the 85th Evacuation Hospital used to quote. “Phu Bai’s Alright.”  Often, they would draw a Charlie Brown figure with that phrase coming out of his mouth.

No one picked him up from the airport, so he had to hitch.  “I got to the hospital compound and it’s hot, dusty, dirty.  The compound was enclosed in concertina wire populated with thousands of miniature razor blades.  The hooches are all on stilts, made from plywood, corrugated metal on top.  Sandbags all over the roof.’  Some of the housing was surrounded by 55-gallon rusting drums filled with sand for added protection against attack.  “I got to the orderly room, and I look up and there’s Roger King.  He and I had trained together, and it made all the difference in the world.”  They soon became the go-to surgeons.  “That’s why no one ever bothered us despite our behavior.”

“Even though I went to an Ivy League school, I felt I was no more important than the guy who was cleaning the instruments or scrubbing the floor.  We were all equal and we all had to do our jobs in concert to get things done.  We would work as a unit and I insisted we be on a first name basis, no doctor.  Occasionally I wore my fatigues.” Typically, Gus donned a sleeveless, Tie-dyed shirt, Bermuda shorts, love beads and broken peace necklace.  Kappler had seen the movie MASH several months prior to Vietnam and he decided mimicking Hawkeye Pierce’s irreverent behavior was a good way to stay mentally healthy.  He did, and it worked for him.  

Phu Bai was just 20 miles from the first exit of the Ho Chi Minh trail.  It was triangulated by Hue, Da Nang, and the A-Shau valley, which was the area of heaviest fighting at the time.  Without knowing it, Kappler had landed right smack in the thick of it.  By his reckoning, the 85th Evac handled 50% of the casualties in the Vietnam war between 1970 and 1971. 

The history of Vietnam is complex.  The following is a simplified summary, starting from

1847, when emperor Tu Duc is enthroned as King and begins to persecute Vietnamese Catholics converted by French missionaries, in an act of defiance to outside colonial influences.  In 1858, France and Spain seize south Vietnam.  This leads to the formation of French Indochine, which includes south Vietnam and Cambodia, with Laos added in 1893.  At the end of World War 1, Ho Chi Minh, a rebellious, youthful leader, is rejected by the leaders at Versailles in a plea to reunite Vietnam and proclaim self-independence.  In 1930, Ho Chi Minh organizes the Vietnamese Communist Party in exile in Hong Kong.  During the early days of World War 2, France invites the Japanese into Vietnam to help them in their on-going war with China.  Soon afterwards, Ho Chi Minh, tired of colonial rule, founds the Viet Minh movement to oust the French and now the Japanese, from their homeland.  Late in the war, the French are expelled by the Japanese who declare Vietnam, Laos, and Cambodia independent.  Soon after WW2, Ho Chi Minh declares North Vietnam independent.  The French try to wrestle back control of their colonies post-war but are eventually defeated through guerrilla warfare, and an ingeniously complex tunnel system that supports the guerrilla war. Through the Geneva Accord in 1954, Vietnam becomes divided into communist Northern Vietnam, and Southern Vietnam, a corrupt, nepotistic, pseudo-democracy under the rule of Prime Minister Diem.  Diem is a Catholic and his repressive regime against Buddhists causes a guerrilla movement in the countryside, which gains increasing popularity against his rule.  In 1959, the North Vietnamese formally back the guerrilla movement and begin military incursions into South Vietnam.  Kennedy sends in the green berets in 1963 as “military advisors.”  Meanwhile, Diem continues the French colonial laws persecuting the Buddhists, who made up much of the country. 

Protests begin among the Buddhists themselves, which are violently suppressed by Diem.  A Buddhist, Thich Quang Duc, sets himself on fire and burns himself to death in the middle of a Saigon intersection, which is captured on film and horrifies the world.  High school and university students In Vietnam enter the ruckus and begin large demonstrations in favor of the monks.  The situation spirals further out of control and Kennedy and the CIA have Diem assassinated.  After Kennedy’s assassination, Lyndon

Johnson escalated US involvement after a minor incident involving gun boats in the Gulf of Tonkin. The US is now at war in Vietnam, ostensibly for trying to prevent the spread of communism through Southeast Asia.  (The Vietnam War, Smithsonian DK publishing, 2017).

 A 3-mile-wide demilitarized zone separated South and North Vietnam.  By 1965, US escalation initiatives had blockaded the DMZ and the offshore shipping lanes, and soldiers, food, supplies, and war machinery began to be diverted down the so-called Ho Chi Minh Trail, then only a series of grass trails cut through the jungle, with dense jungle foliage above for natural cover.  The trail paralleled the border of Laos, Cambodia and South Vietnam and soon became a conveyer belt for all sorts of war-related movement south.  Upwards of 75,000 “youth volunteers” maintained the road year-round. 

 Dr. Kappler elaborates.  “It’s a trail that enters Laos (and Cambodia) and runs just outside the border of Vietnam all the way down to Saigon (in the south) and the Mekong Delta.  And there are exits from it at key points.  You’ve got men pushing bicycles with saddlebags.  You’ve got women carrying armaments.  I mean, just like ants, just traveling (down the road).  Traveling in the mud.  And after a while (years) there were trucks driving down it.  It widened a lot.  Ho Chi Minh went to Versailles during negotiations to end World War 1.  He was a young man, in his twenties.  He asked, “Can you arrange for us to have a united Indochine (Laos, Cambodia, Vietnam)? 

He went to the World War 2 negotiations as an older gentleman.  Same question.  Colonialism was going out the window, but Truman backed the French.  He had more trade responsibilities with the French than with Vietnam.   The French wanted to maintain their colonies and their rubber plantations.  If Truman had agreed, the French would have had to give up Vietnam and Indochine would have been united, and you never would have had a Vietnam War.”  

 NVA soldiers infiltrating the south soon rose from 6,000 in 1964, to 69,000 in 1967, to over a hundred thousand by 1969.  (Inside the VC and the NVA, Michael Lee Canning and Dan Cragg, Fawcett Columbine, 1992. New York) Similarly, the trail widened to include some paved roads and even truck traffic.  Auto repair shops were set up in caves.  Goods also moved on the river in Sampans.  Village bunkers were hidden and used to supply the trail with rice, guns, ammunition, and other supplies.  The US military was challenged to locate the trail through the dense jungle canopy.   At the trail's height, US intelligence aerial photographs detected 15,000 objects on the Trail in a single day (The Vietnam War, the definitive illustrated history, DK/Penguin Random House, 2017).  As a result, what followed was the American secret bombing campaign of Laos and Cambodia, which created a scandal when uncovered by Daniel Ellsberg and published in the New York Times.  Later, in what became known as the Pentagon Papers, Ellsberg went to jail for refusing to identify his sources for the story, which revealed sensitive, highly classified war information.  

The Vietnamese tunnel system, first utilized to defeat the French, was widely expanded against the Americans.  Easily dug through limestone and clay, their length was estimated in the hundreds of miles.  The tunnels were multi-layered and deep.  They could withstand ground bombing by American B52’s and the weight of tanks maneuvering above.  Tunnel rats were American soldiers who bravely crawled through these tunnels rooting out the enemy.  They were often small and slender to slip through the tight, winding passages.  Inside, they found hospitals with operating rooms, sophisticated ventilation systems, trap door entrances and exits, some of which were concealed in pig pens on the surface to avoid US dogs that were used to sniff out the enemy.  The tunnels sometimes led to blind ends, where booby traps or VC would be lying in wait to snuff out the unsuspecting soldier.  Their entrances and exits, which were sometimes underwater and could only be accessed by submersion, were mined, and most were booby trapped.  One of the many gruesome booby traps were of the trap door variety where a soldier's bodyweight would force him through a purposefully weakened, shallow floor which ended in a fall with impalement on a series of punji sticks, or sharpened bamboo poles, nestled together, smeared with feces, and pointed upward.  Some trap doors triggered from above by trip wire, and dropped hand grenades, scorpions, or poisonous snakes onto the unsuspecting tunnel rat.  The tunnel rats carried a periscope-like flashlight that could see around corners, a knife and a pistol.  The VC tunnel system was elaborate, replete with wells for water, underground school classrooms, bunk beds for sleeping quarters, and storage rooms carved out for weapons, ammo, and supplies.  The Vietcong became nocturnal creatures, sleeping during the day, and venturing out into the jungle by night.  They survived by eating rice and when necessary, rats.  Trench foot, snake, scorpion and rat bites were common, as were respiratory illnesses, infectious diseases and vitamin D deficiency, given the lack of sunlight.  They even dumped their dead in the tunnels to decompose and fester, exuding horrific odors, to hide the “kill count,” from the obsessed American commanders on the surface.  The higher the kill count the pentagon could tout, the more incentive to continue the war. 

“Everything they needed was in those tunnels,” states Dr. Kappler. “They had hospitals and plenty of storage.  Some of that was already there from the war with the French.  You’re never going to defeat an indigenous population no matter how mighty you are.”  For all the arrogance of the pentagon, these simple peasants turned out to be savvy, clever and formidable opponents, indeed.  

Because of their earlier battles with the French, the Vietnamese understood the Western mind and used this understanding in devising booby traps.  One such incident involved a curious soldier who, seeing a Styrofoam cup lying in the middle of the jungle, made the unfortunate decision to try and pick it up.  Lifting the cup triggered a trip wire which exploded an anti-tank mine.  “This was actually my first case,” states Dr. Kappler.  “The mine blew the soldiers genitalia off, detaching his urethra from his bladder, and blew apart his legs.  They put an experienced surgeon in with you when you were new.  So, we’re in there and the iliac vein is bleeding like crazy.  I packed it off and it’s still bleeding.  So, I just said, “I’m going to tie it off (the bleeding vessel)”.  And this supposedly experienced surgeon said, “You can’t do that, his legs are going to swell (from lack of venous return).”  I said, who gives a shit, and I tied it off.”  According to Kappler, the choice was having the patient bleed to death from the injured vessel or tie the large iliac vein off and accept the consequences.  He also knew the iliac had naturally occurring collaterals (additional roadways) that could release some of the pressure.  The attending surgeon called the Chief of Surgery over who concurred with Dr. Kappler, and the issue was never discussed again.  “After that, the other surgeons never bothered Roger and me.  They could see we knew what we were doing.  We had done a lot of surgery at MCV prior to Vietnam.”  Kappler and his friend and fellow surgeon, Roger, were bold and confident.  They began to stand out and earn respect. Shortly thereafter, Kappler flew to Saigon to take his surgical board exam.  Such was the army that, here was Kappler, shipped to Vietnam and immediately involved in some of the most difficult surgery there was, and he hadn’t even taken his surgical boards yet.  He took the boards, passed, and was immediately flown back into the maelstrom.