Excerpt from Blood of The Common Sky, Publisher: Astor and Lenox
As the rain continued into December, I began volunteering at the Vietnamese civilian hospital, the USOM [U.S. Overseas Mission] in downtown Da Nang. I was afforded this respite from clinic and triage time because of the arrival of four new doctors, and partly because of the more enlightened military command strategy of using the skill of the doctors and dentists as a gesture of good will to the people of Vietnam. The civilian hospital was under-staffed, but frequently supplemented by U.S. civilian volunteer surgeons. We were encouraged by our CO, Dr. Escajeda, to help out with the backlog of work there, when it was quiet at C Med.
The gray cement-block building was old, run down and crowded. The beds were so tightly spaced that it was hard to get between them to examine a patient. Each bed accommodated two or three people. We became accustomed to the nasal, many-toned flow of their language as the interpreters helped with their stories. The dominant smell was of dirty clothing and linen mixed with cook fires for food that families encamped in the courtyard had prepared. One entire ward was filled with two patients per bed, each patient facing the opposite direction from each other, and over the top of the beds, there was a jungle of traction ropes and pulleys for stabilizing fractured femurs. All nursing care, bathing, and feeding were left to the families.One of the notable cases that I had was a repair of the radial nerve on a young boy who had suffered a deeply lacerated arm in an accident three weeks earlier. The radial nerve is one of three major nerves that control function of the hand and arm. The boy could no longer flex his wrist as a result of the injury. I had seen such a procedure performed at Penn before I had left, but I had never performed it myself. It is one thing to witness a procedure, and another thing to decide to go ahead with it. I had examined the boy several days earlier, and discussed the procedure with one of the C Med surgeons. It was a matter of exploring the injured area, identifying the severed radial nerve and reconnecting it. Nerves grow slowly (one millimeter a day), so it would take months to determine how successful the repair was in returning function to the hand.
Nerve repairs on Marines were performed up to a month post-injury, after they had been evacuated back to the States, and then done by a hand or plastic surgeon specialist who had access to resources not available to us in the field, such as an operating microscope and postoperative physiotherapy.
I did the repair on the boy’s arm, found the ends of the cut nerve and sewed them together. Perhaps because of my technical success with that radial nerve repair,
I was asked to return to the civilian hospital to explore a brachial plexus shrapnel injury which had occurred a month before. The injury had left this man’s right arm useless.
The brachial plexus looks like a complex wiring box. The nerves exit from the bony spine that lies at the junction of the neck and the chest, in the space above the clavicle. It then wraps around the artery and vein, and follows these vessels down the arm. Gaining surgical access is difficult, requiring a very small incision to an area that is a complex entanglement of nerves and blood vessels. The challenge is akin to building a ship in a bottle.
By accepting the challenge, I seriously overestimated my skill and underestimated my lack of experience. The flattery of being asked had clouded my judgment. What had resembled an electrical box before the gunshot, now, after a month of healing, looked as though cement had been poured into the box, fusing all the structures together. The first nerve we found was too close to the spinal cord to graft.
The moment of truth occurred when the USOM doctor and I each found out, over the anesthetized patient, how little experience the other one had. I was in over my head. I felt like a Marine deep in a jungle having led my squad into the wrong valley. We both realized that we should not proceed, and backed out without doing any harm to the nearby major vessels.
That close call paid off for the rest of my career, by making me a safer surgeon. I had crossed a forbidden line in surgery, where the exhilaration of my own sense of challenge betrayed my duty “to first do no harm.” The maturity and wisdom of knowing when not to intervene takes more time to cultivate, but surely is as valuable as the knowledge of how and when to intervene.
On Christmas Day, the temperature reached 90 degrees, with intermittent rain. The day came and went like every day that week, without much notice. Mom sent me cookies, but I forgot to thank her. All of us in C Med were so buried in our personal loneliness and depression that we had little holiday spirit. A lightly decorated, dehydrated pine tree had been set up in the triage tent, and the cooks made the biggest effort, serving us a lunch of turkey with cranberry sauce.It may have been a very plainspoken meal, but it was delicious.
Many of us went outside afterwards for a game of volleyball, which remained for us at C Med the only happy, carefree respite. The married men with children at home were the hardest hit by the fact that it was Christmas. All of us had been in the medical profession long enough to get used to working on major holidays when we’d rather be at home. But the constant visual confrontation of maimed soldiers and Vietnamese citizens had become a torment. Vietnam was stretching into a year-long macabre and joyless working holiday.
Caring for sick children at the USOM Hospital on light days that winter did prove to be a helpful change of pace. When I found teenaged siblings stigmatized with massive goiters, I recalled my earlier humbling experience of working on the man with the injured brachial plexus, and I recognized that they needed expert anesthesia and experienced surgeons to do it right. I arranged to bring the children over to our hospital, and then removed the massive thyroids with the help of our trained surgeons.
For children with burn scars, I asked for advice, and read up on plastic surgery reconstruction. Often a burned hand would have been wrapped in a bandage, and the fingers then would have sealed together like a mitt as the hand healed. I was able to successfully give some children functional fingers again by using a “Z”- plasty technique (converting the longitudinal scar that crosses a joint to a zigzag).
This civilian work made me start thinking of what kind of work I would do in the future, after the war. I needed to nurture a sense of the future because the present was becoming so painful.