Part 3: The Life of Gus Kappler MD, Vietnam Era Trauma Surgeon

On one occasion, one of the camp cooks was shot with an M16 by a disgruntled soldier.  “They had a fight.  Someone fired.  I opened the cook up in the ER.  No anesthesia. I put my hand in, and it was mush.  It was 6,000 horsepower of energy, which just decimates everything. There was nothing to fix.  It was all gone.  I was going to put my hand in and take the aorta (the largest artery in the abdomen) and blindly pinch it (to stop the bleeding).  But there’s no aorta.  It was gone.  I had my hand in there, but it was like mixing a bowl of stew.  So that was it.  He died.  Couldn’t save him,” Gus says, nonchalantly.  “That’s just how it was, and you had to accept it.”  

When a patient entered the ER, the first thing to accomplish was to reverse the shock by stabilizing the blood pressure with fluids, and, of course, blood.  Shock is a potentially reversible condition characterized by a fall in blood pressure, with hypoperfusion or lack of blood flow to organs, tissues, and cells with a resultant rise in heart rate, respiratory rate, dilation of pupils, and cool, clammy skin.  Without blood flow and oxygen, individual cells start to fail, toxins build up, and this leads to acidosis, or too much acid in the blood.  When cells fail, cellular machinery stops, and the body temperature drops. Vital enzymes used to catalyze important reactions in the body have a very narrow temperature and PH range in which they must function.  If left untreated, shock spirals into an irreversible condition replete with cell death, multi system organ failure and ultimately, death of the patient.  

Just in time to benefit casualties in Vietnam, researcher Tom Shires, a renowned surgeon, showed that more than blood was necessary to treat shock.  The body needed salt and other ions, also.  In 1880, British physician Sydney Ringer was working with solutions that bathed extracorporeal frog hearts to keep them alive and beating.  He had some success with a combination of sodium chloride, potassium chloride, and calcium chloride.  American pediatrician Alexis Hartmann had the novel of idea of adding sodium lactate to buffer the acid built up in the body by shock.  Thus, Ringers Solution was upgraded to Ringers Lactate, a lifesaving fluid resuscitator that helped to reverse shock.  Battalion aid stations played a key role in the field getting soldiers on fluids before they hit the 85th and other hospitals, thus helping to prevent the onset of irreversible shock before the wounded reached the operating table.  In Vietnam, it was soon learned by trial and error that giving too much Ringers Lactate and blood could cause the lungs harm, a term called Shock Lung, or what’s now called Adult Respiratory Distress Syndrome or ARDS, where lung tissue and capillaries, or tiny blood vessels, become leaky and block the diffusion of oxygen into the blood and the escape of carbon dioxide into the lungs to be exhaled into the air.  Patients would essentially drown to death in their own fluids.  

Blood transfusion in Vietnam was thought to be only about 100 units per month in 1965.  By 1969, it reached a peak of almost 40,000 units per month.  The killing war was in full swing.   One unintended consequence of blood transfusion was transmission of hepatitis B and C, which did not have serologic tests at the time to detect contamination of the donated blood.

To give blood, fluids and volume resuscitators, the surgeons would immediately begin a cut down, which is opening up the skin overlying a large vein to expose the vessel and more easily introduce a large bore catheter into it, thus gaining access to the circulatory system with a good, reliable vessel that is less likely to blow at a crucial time.  Sometimes a subclavian catheter was needed, which entailed a blind needle stick just below the clavicle, or collar bone, accessing the large subclavian vein. 

“I don’t think anybody was ever totally resuscitated. The big thing was the urinary output.  We’d watch that carefully.”  If the patient was urinating, it was a sign that volume was being restored and surgery could more safely be initiated.  On the other hand, if a patient was unstable, and they were bleeding from serious wounds, nothing was going to restore volume unless that bleeding was stopped, making surgery the only option, whether the blood pressure, or urine output was stable or not.

“We were fighting all these holes and all the blood coming out.  The race was to plug these holes, and you just had to judge whether you could get the patient in better shape before you started plugging holes or the hell with it, let’s just plug the holes because we’re never going to catch up trying to stabilize them first, but if they made it to the 85th Evac, chance of survival was 96%, which is pretty remarkable.

“Weapons in war time are high velocity.  Most experts say these projectiles are traveling at 2600 feet per second.  As that missile flies through the air, it creates a shockwave in front of it.  Molecules of air get compressed.  These missiles and that shock wave are filled with kinetic energy, between 4000 and 6000 horsepower.  That shockwave can cause tissue damage by dissociating molecular structure and causing hemorrhage.  Your body is essentially water.  All of a sudden, that kinetic energy dissipates and that becomes the ballistic shockwave, and that travels through everything.  This tears and devitalizes tissue.  It causes a wound that is magnitudes broader than the entrance wound.  Kinetic energy is 1/2 x mass x velocity squared.  The M16 uses a tiny bullet, maybe it weighs 90 grains let’s say.  But it has yaw to it and creates a greater surface area and more energy dissipates when it hits. It was designed that way on purpose.  It’s a smaller bullet though, so it may travel faster, but damage is velocity squared so a lighter, smaller bullet that’s going faster and yawing, is going to cause more tissue damage.”

It turns out, it’s not a new concept.  Kappler remembers seeing revolutionary war bullets in museums that were carved with an X, specifically to get the lead ball to expand and create more damage.  It turns out, humans have been trying to kill with maximal efficiency for a very long time.  

Kappler remembers one soldier who “Had enough of Vietnam and positioned his M16 beneath his chin and pulled the trigger.  The blast blew away 20% of his lower face but missed his brain.”  The man was drowning in his own blood as it flooded the trachea and entered the windpipe.  Dr. Kappler performed an emergency tracheostomy to protect the airway.  There wasn’t any ENT or ophthalmology at the 85th so the patient was transferred to Da Nang for reconstruction directly after the trach.  If the operating theatre was overrun and the wounded piled up beyond a 16-hour workday, further casualties were diverted to other hospitals.

Booby trap injuries were extremely common, and massive, grotesque damage often resulted.  Patients presented with one or both legs blown away, genitalia missing, mud and debris imbedded within the wounds, exposed splintered bone, black and charred, pulverized muscle and tissues, with large flaps of skin peeled back around the whole macabre mutilation.  If forceps were applied to muscle and it didn’t contract, the muscle was debrided and thrown in the trashcan next to the operating table.  Vein grafts were common and the greater saphenous vein on the inside of the thigh was often used to reconnect severed vessels.  Muscles were often harvested to surround the vein graft otherwise they would fail.  The muscle served as protection and, more importantly, allowed the vena comitantes, or the veins of the veins, to form and nourish the graft.  Veins have valves in them to pump blood against gravity back to the heart and to prevent the back flow of blood.  Arteries do not have valves.  Veins for grafts must be harvested and then reversed once sewn into the damaged vessel, otherwise the valves of the vein would retard blood flow through the vessel.  So, the distal end of the vein had to become the proximal portion of the graft. Not adhering to this simple rule could be very embarrassing for the surgeon and very unfortunate for the patient. 

“The vein graft is living tissue.  So, you must cover it with living tissue so that it maintains a blood supply.  And often you’ve debrided so much muscle, you don’t know what to use to cover it with.  So, we became ingenious in shifting muscle groups around.  We would move the sartorius or the plantarus, which is a little muscle behind your knee.  We’d move that.  If you couldn’t get the muscle coverage, the repair would blow.  That’s why we kept those patients for two weeks.  Usually, patients were gone the next day.  Chest and vascular patients were kept the two weeks because you didn’t want those grafts failing in the air on the way back to the states.  If the vein tissue dies, what you did is going to fall apart with it and the patients are going to bleed.  Veins need to be fed. They don’t get nutrients from the inside of the vessel.  They get nutrients from the surrounding tissues.”  

Dr. Kappler refers to this type of surgery as spaghetti and meatball surgery.  Devitalized arteries, veins, and severed nerves were the spaghetti, and pulverized muscle the meatballs.  “Surgical treatment involved removing the dead tissue: deciding on a level of amputation through undamaged tissue, which guaranteed viable skin, bone and muscle that would heal and avoid infection and accommodate rehabilitation.  Preserving the knee joint and as much bone length as possible was imperative to aid in the future prosthetic design.  The skin and subcutaneous tissues were not closed, as in all war-zone procedures, to avoid infection. If all went well, the patient would leave the 85th Evac the following day.  At the next hospital, the wounds would be closed in four to five days.  This technique was referred to as delayed primary closure.”  (Kappler, Welcome home from Vietnam, finally, 2015, Xlibris, page 91.)

Dr. Kappler goes on to describe a patient wounded by an AK47 in the shoulder. “Bleeding from the entrance and exit wounds was minimal, and his vital signs were stable.  He was conscious, alert, and oriented.  There were no signs of shock.  No pulse could be found at the left wrist, indicating from the location of the entrance wound through the clavicle, or collar bone, a probable axillary artery injury (a large artery that traverses the shoulder area).  A chest x ray revealed a shattered clavicle (collar bone) and scapula (shoulder blade).  The bullet traveled safely away from the thoracic (chest) cavity, but despite that, the upper half of the left lung was completely opacified (white), on chest X-ray. The lungs on a chest x ray normally appear black for they are air density.  This abnormal, opacified area of lung was water density.  The lung had been damaged by the hydrostatic shock wave and was not capable of exchanging oxygen (in that area).  In the operating room, I identified the axillary artery disruption, harvested a portion of saphenous vein from his thigh, turned it around so the valves wouldn’t block the flow of blood and restored blood flow to his arm and hand by reversing the vein conduit and bridging the gap between the open ends of the injured artery.”  (Kappler, Welcome home from Vietnam, finally, page 78) 

The artery itself wasn’t injured by the bullet.  The shock wave had barreled past the axillary artery and disrupted the intima, or the lining of the tube-like vessel, creating a dissection in the wall of the artery, thus closing off the flow distally down the arm.  With no blood flow, the tissue of the arm will die without intervention. “I moved the pectorals minor up and then the top part of the pectoralis major and part of the anterior head of the deltoid to cover the graft.”  With blood flow restored, the arm was saved. 

Kappler goes on to say “the kinetic energy (of a bullet strike) creates, through the resultant ballistic hydrostatic pressure wave, a temporary wound channel 27 times the size of the permanent wound channel.  With that supersonic expansion, a vacuum is created in the temporary channel and atmospheric pressure forces surrounding debris into the wound: dirt, vegetation, cloth, etc.  As Kappler puts it, “Human vaporization is the result.”

Sometimes, a soldier would require dozens of units of blood to restore lost blood volume that occurred between battlefield and the end of his operation.  In aged, chilled blood, clotting factors wane over time.  In fresh warm blood, clotting factors abound, and bleeding is much less.  Per Dr. Kappler, there were often long lines of soldiers ready and able to donate blood to the wounded at any given time.  Any expired blood was sent to the Vietnamese doctors treating the south Vietnamese soldiers (ARVN)

Abdominal surgeries could be difficult due to the 22 feet of soft, coiled bowel crammed into the abdominal cavity.  Kappler felt his job was mostly to find the injured bowel, a chore in itself, remove the devitalized tissue and anastomose the bowel ends back together or create a conduit to the skin (colostomy). If caused by shrapnel, there might be as many as 50 fragments scattered within the cavity.  These were left alone, at least on Dr. Kappler’s end.

“After surgery’s were done, there would be a drain in the middle of the OR and we would walk over to it, blood sloshing around in our boots when we walked, strip down, take a hose, and wash the blood off our bodies.  This was a daily event.”

On a slow day in March of 1971, Dr. Kappler was summoned to the ER to see a solitary wounded soldier who lay on a gurney, awake and lucid, but missing both legs, in what he describes as the worst wounds he ever encountered during his tour.  The following is Dr. Kappler’s description in his own words from his book meshed with the author’s interview for continuity.  

This particular soldier “had been chosen to be decimated when the VC triggered the explosion of a command detonated salvaged US antitank mine as his patrol passed by the concealed enemy.  These poor young men on patrol, it was like playing Russian roulette.  Every step they took could be their last step.  Because the VC were experts.  They were experts at planting mines.  The wounds were vicious.  Mutilating.  Usually there were injuries to both legs, and not infrequently to abdomen and chest. Sometimes, you can picture exactly what happened from looking at the wounds.  You can see the soldier stepped on a booby trap with his left foot and blew the foot off.  You can then envision his other leg was just coming forward at the same time and just blew all the muscle and tissue off the knee and lower thigh.  A lot of those wound up as amputations because you just couldn’t get rid of all the dirt and debris (contaminating the wound.).  Then there’s the others around the victim, who get hit with some fragments.  That’s why you would walk with intervals between each soldier (spaced out, to limit the casualties).  Most of the booby traps were laid and left and whether they were tripped or not was potluck.  But some of them were triggered by the enemy watching from the woods.  They never blew up the first or last guy. They always blew up somebody in the middle to play with the American’s mind.  

The VC would often take our used syringes and make triggers out of them.  They would run wire into the barrel of the syringe from the bottom where the needle would go.  Then run a copper wire down to the plunger.  And when you push the plunger down, the circuitry was completed, and the thing would go off.

So, this young man was blown up.  He was the only one injured and he was relatively close to the hospital. They gave him a unit of blood on the way.  The choppers brought him in. He was alert, oriented, speaking, with normal vital signs.  But everything from his belly button down was pulverized.  Genitalia were gone.  His x ray showed the pelvis was split wide open and debris, mud and dirt were blasted into his lower body.  But he was alive.  If the operating room was full of people, we would have let him go, maybe put him off to the side and do him last, but he still would have been done (if he was still alive).  By our triage standards, was he expectant or salvageable?  Should I hide him from the world and infuse him with perhaps too much morphine to hasten his death.  I was inundated with different opinions about what to do.  These opinions were a blending of both the warzone and stateside moral codes.  All I knew was that I had to appropriately treat this wounded American for not only would not doing so have morally destroyed me but also subjected him to a prolonged and horrible path to death.