Part 4: The Life of Gus Kappler MD, Vietnam Era Trauma Surgeon

So, I performed a bilateral hemipelvectomy, one side first, then the other side, which I had never done before.  You make an incision in the groin and go towards the back.  You ligate the Iliac artery and vein and cut the sciatic nerve.  I remembered to save part of a flap of skin from the buttocks to use as a cover to the stump.  I serially resected both hips with remaining lower legs, and used a bone saw to cut through the bones of the lumbar spine above the sacrum.  In the abdomen, you divide the bowel and make a colostomy (attach the bowel end to the skin).  And then you had to do the same to both ureters to bring the urinary tubes out onto the abdominal wall.  You stopped the bleeding as best you could, irrigated things out, and then brought up the buttocks flap of skin to make a stump of his torso just below the belly button.  Then I amputated his right arm because his right arm was blown apart.  I have since read articles about doing this procedure where they’ve got a neurosurgeon, an orthopedic surgeon, and they’ve got five different specialists in the room, (but in Vietnam), it was just Roger and me just going along and doing what we thought we should do next.  Then I gave him a tracheostomy because you have this volume of intestinal content pushing up against his diaphragm (and not allowing his diaphragm to lower and fill the lungs).

He woke up. First thing they do when they wake up is feel to see if they still have their “family jewels". He did not, of course.  He lived for another 15 days and then died of sepsis (bacterial infection in the blood). While he was there, this brigadier general came by.  A whole bunch of guys had been wounded and they are giving out Purple Hearts and stuff.  And I had this kid under a cradle and he (the General) sort of walked right by this kid.  And there I was in my tie-dyed shirt and Bermuda shorts and my love beads and my teardrop peace sign.  And I walk up to this general and said “Let me show you something.”  (We returned to this soldier’s bed he had just bypassed) and I throw off the sheet.  The general took one look and turned pale.  He didn’t know what to say, so I said “Doesn’t he deserve any medals, General?” 

I was mad.  These kids were being sacrificed for no reason. Then they dropped the IQ requirements and you’d get these kids that could hardly write their name or add or subtract and put them through basic training and send them right to Nam.  There were two Vietnam Wars.  Before 1968, when there was still discipline and the quest was to do what was right, win the war, save the world from communism, whether or not it was ill conceived.  The second Vietnam War was after TET, in late January 1968, when soldiers started to say, “I’m just going to try to survive this thing,” and discipline and order collapsed.  The fabric of the army was falling apart and if a lieutenant started telling you to take that hill, and he started up that hill, you just might shoot him in the back.  Or you might throw a smoke grenade under his hooch.  These young people didn’t want to be sacrificed.  And they started reacting.  No one wanted to be the last person killed in the war.  And all of a sudden, heroin becomes a problem.  The VC used heroin as a weapon.  The mama sans would bring it in to camps and in the field.  They’d have it stashed in every orifice.   This stuff was so pure, you could overdose.  They used it as a weapon, making it available and interfering with the functioning of the GI, creating addicts and creating rebellion.”

Kappler continues.  “In Vietnam, heroin was ubiquitous. Two physicians and a few corpsmen established a Halfway House to address the growing problem.  Mike, an internist, was astonished at the extent of heroin use.  He arranged to have an audience with a highly placed general in 1 corps headquarters in Da Nang, to inform him of the problem.  After stating his case, Mike was threatened with a corps marshal and ten years in Leavenworth (prison) if he continued to spew his “lies.”  He obviously shut up. …. Eventually, through urine testing at discharge, the metabolites of heroin could be detected.  Troops started to be tested, especially those who were about to leave the country and many were positive.  Therefore, Operating Golden Flow was instituted wherein one could not leave Vietnam with a positive urine for heroin.  I’ve been told by very reputable sources that addicts were given free access to marijuana to soften their detox.  Once a clean urine was achieved, they were sent home without counseling, VA referrals, or follow-up only to resume their habit stateside.  Inconceivable!”

(Before TET), “our country would say, we’re winning.  Our body count is good.  Don’t worry.  Your sons are dying for a good cause.  Suddenly, the NVA and VC were able to infiltrate, via the Ho Chi Minh Trail, and scatter to all these South Vietnam cities under American control and, for a while, take them back.  And then (Walter) Cronkite’s the one that first said, “We’re losing the war.”  And it just brought to the surface the propaganda being fed and published by the Washington Post and New York Times about how we’re winning and what great things we’re doing.”

Gus stated that occasionally a CIA operative would be brought in.  They could often be found lurking in the shadows of Laos and Cambodian and occasionally get themselves into situations that deteriorated.   “We knew the choppers.  It took about maybe 20 minutes to get to the border of Vietnam and Laos.  When the chopper was taking 45 minutes to get to us, you knew they were coming from (an area) where they shouldn’t be.  And then all these spooks would show up.”  According to Dr. Kappler, it was mandatory for another spy to be present before injecting narcotics or putting a CIA operative under anesthesia for fear the agent would inadvertently spill covert information.  Gus thought this over-dramatic until his main Vietnamese interpreter in the ER, someone that he trusted and relied on, turned out to be VC and was summarily executed.  

“We had Taiwanese soldiers there (in Vietnam).  And Australian, Thai, and South Korean.  The South Koreans were vicious.  They didn’t fool around.  If they went into a village and someone offered them drugs, someone’s head would be on a spike at the village entrance the next morning.  

Dr. Kappler does not regret going to Vietnam, but he is haunted by the fact that he often had to make decisions that condemned some young soldiers to death, while trying to save others that were deemed more salvageable.  Triage is a routine part of any form of disaster medicine.  One must assess the magnitude of the disaster, and then apportion to each casualty their chance of survival.  Intimately involved in that decision are considerations such as how much time their injuries would take to fix, the number of surgeons available, how much blood they would require, the extent of their injuries and their overall prognosis.  All casualties were treated, but the least injured and the horribly injured with the lowest chance of survival, were apportioned to the end of the line.  Their wounds would be addressed last, provided they lived that long. These decisions weighed heavily on Dr. Kappler and speaks to the concept of what he calls the peacetime moral code versus the wartime moral code.  

Back home in the States, supplies are limitless, consultation readily available, and access to both common and expensive medicine is at your fingertips.  One doesn’t often have to consider a moral code.  The sicker a patient is, the harder and longer you worked on that patient, irrespective of all other factors, until the patient stabilized or died.  In war time, other considerations weigh heavily on the decision making, making the decisions seem morally wrong for peace time but perfectly acceptable and understandable for war time.  Unfortunately, the human psyche has difficulty veering from the peace time moral code and this creates conscious and subconscious conflict within the mind.  The peace time code follows the Hippocratic oath, or what we think the Hippocratic oath means, which is I will do no harm, and I will do whatever is in the best interest of each individual patient.  In Vietnam, the war time moral code reigns supreme and you may have to consciously delay care or abandon treatment of a severely wounded soldier whose injuries might take hours of futile work to repair to spend your limited time and resources on some who are more salvageable.  Making these decisions is difficult enough but living with the consequences of having made them can have lasting effects and lead to post traumatic stress disorder, depression, or substance abuse, later down the line.  

The Code of Hammurabi was one of the first written codes detailing the King’s expectations of its citizens in a civilized society.  The Code was written on stone around 2000 BC by vassals of King Hammurabi of Mesopotamia.  It stood tall and was a centerpiece of the town so no one citizen could declare they were ignorant of its 282 decrees that governed behavior.  The Ten Commandments were a series of values or moral laws given by God to Moses on Mount Sinai.  They are similar in that they were both codes to govern by but differ in that the Code of Hammurabi was more about actual law and recompense and punishment to the victim and the perpetrator, respectively, whereas the Ten Commandments were a set of moral law or virtues, such as thou shalt not steal, thou shalt not murder, thou shalt not covet thy neighbor's wife or goods, etc.  The commandments were said to number more than ten but the concept of “ten” for better remembrance, eventually took hold.  

A conflict arises when in society, we are brought up to live by a certain moral code.  Then, during war time, we are told to forget that code; that killing, or murdering, is not only ok, but good.  In fact, the more the better.  Thus, it follows it is easier to kill when you can dehumanize the enemy.  And it is easier to rape, (or covet thy neighbor's wife), when you have dehumanized the enemy.  Or take war souvenirs (stealing), which might include guns, knives, trinkets, scalps (during the Indian wars), or commit atrocities like severing genitalia and stuffing them in the mouth of the victim, a favorite pastime of the NVA.  Man is an animal and has primordial instincts and desires that our higher intellect tries to suppress or keep in check.  But despite this higher intellect, it is the only animal that will kill for pleasure.  An Animal will only kill for food and to protect itself.  But not man.  Despite this higher intellect, man will also kill unnecessarily and for pleasure sometimes.  The only thing that keeps man from killing is civilization, but if you take away civilization, his most basic instincts are unleashed.  When you are asked to kill daily, atrocities become a little easier.  When viewing it from the peace time moral code, it’s deplorable.  But soldiers are not in peace time.  If they killed the enemy and showed bravery doing it, and with no remorse, not only would they not be punished, but they would also be exalted as a hero and might get a medal for their deeds.  These same soldiers would be crawling through the bush one day, and, several days later, be on R and R in Saigon or walking down Main Street in their hometown.  This is not only culture shock, but moral shock.  When back on Main Street, these same soldiers learn to repress thoughts of killing, it is no longer “good,” or something they would be commended for.  It is reprehensible again, something they would be put in jail for.  Two different societal responses to the same behavior, not only worlds apart, but days apart.  When soldiers are forced to repress their memories, the psyche takes hold and conveniently hides the emotional responses to their deeds in a corner of the subconscious, later to re-materialize in the form of anxiety, depression, nightmares, difficulty with relationships or employment, in what we now know as PTSD.  

Dr. Kappler feels the brain of a 22-year-old soldier is not mature enough to handle the emotions and moral consequences of what he was asked to do in wartime, thus creating internal conflicts that are continually being suppressed and never dealt with.  He feels the Veterans Administration has let soldiers down by ignoring this common and pervasive disorder among returning soldiers from all wars.  After World War 2, he thinks the soldiers benefited from long boat rides home that took several weeks.  The soldiers had time to interact amongst themselves and were able to decompress before being thrust back onto Main Street and society.  They were given more of an opportunity to share their feelings, confess the deeds they felt were wrong and that they regret; to repent, to cleanse their soul through camaraderie with other “sinners,” to know they were not alone for their self-perceived “wickedness of moral character.”  Dr. Kappler envisions a world with much less PTSD if the VA embraced a slow reintroduction of the soldier to normal society over months.  In between, the soldier would be put through a regimented program, a sort of decompression Club Med experience, in a nice, safe setting, perhaps with softball and soccer and basketball games in conjunction with regular meetings, with no officer’s present and no notes taken, to share their “confessions” to the group, and allow themselves absolution and forgiveness.  The current method is to repress the memories and deeds with alcohol, drugs, or, over time, worsening mental health until, after age 50, they decide suicide is the only option to escape the inner turmoil.

As reported by Reuters in February 2013, there were at that time twenty-two active-duty military personnel and veterans killing themselves each day…. More than sixty-nine percent of veteran suicides occur in veterans fifty years or older… a majority served in Vietnam and have for decades been suffering progressively (more) severe PTSD. 

In Gerontologist, 2016, Eve H. Davison suggests that “in later life many combat veterans confront and rework their wartime memories in an effort to find meaning and build coherence.” (Gerontologist, 2016, Vol. 56, No. 1, Eve H. Davison, PhD.)

According to Kappler, the Vietnam veteran may “intentionally re-engage with experiences they avoided or managed successfully earlier in life.”  In other words, the warrior may suffer PTS (not yet a disorder), even if he appeared well adjusted for all the intervening years. From day one, the inducted men and women are exposed to a machismo culture within which they, whether deployed or not, teeter on the brink of a confusing moral limbo fluctuating between the moral code of peace and the moral code of war.  With the brain's inability to totally define a supportive moral code, there also occurs a progressive inability to process fear, anxiety, depression, dependency, learned helplessness, and fight or flight responses that arise from the primitive brain.  We now call this mental state PTSD.   (Kappler, Welcome Home)