Reflections on the War: Then and Now
By: Raymond C. Truex, Jr., MD, FACS, FAANS and Kristen Sandel, MD, FACEP, FAAEM
Editor’s note: There have been many parallels drawn between the coronavirus pandemic and a time of war. Medical professionals have faced decisions and circumstances unprecedented for many of their generation. In the article below, Medical Director Raymond C. Truex, Jr., MD, FACS, FAANS, a Vietnam War veteran and retired neurosurgeon, first shares his war-time experience, explaining the emotions and effects he saw on a generation. Kristen Sandel, MD, FACEP, FAAEM, an emergency room physician and chair of the Berks County Medical Society Executive Council, is on the front lines fighting COVID-19 and shares her experiences in the war on this virus.
Then
Raymond C. Truex, Jr., MD, FACS, FAANS
We commonly see reference to our current battles as “being at war” with the coronavirus. That, of course, is a metaphorical reference to actual military conflict. Upon consideration, there seem to be many parallels between our current medical struggles with the virus to what I experienced as a military physician in the Vietnam War some 50 years ago.
While I can clearly remember my war memories, as a semi-retired physician, I am not on the front lines of the current fight to save lives from the coronavirus, so I have enlisted the experience of Kristen Sandel, MD, an ER physician and current chair of the Berks County Medical Society Executive Council, to compare and contrast what she sees today with my recollections of the past.
In 1969, after completing a rotating internship and a year of general surgery residency, my deferment ran out, and under the Berry Plan, at 27 years of age, I was sworn in as a Lieutenant in the U.S. Navy Medical Corps. I quickly learned that the U.S. Marine Corps is a branch of the U.S. Navy, and that the medical support for the Marines comes from the Navy. By virtue of my surgical training, I was qualified to serve with the Fleet Marine Force. After six weeks of basic training at Camp Pendleton in California, I shipped out to the Far East. When I arrived in Vietnam, I was assigned to the 3rd Medical Battalion, 3rd Marine Division in Quang Tri, in the northernmost province of Vietnam. This was what we now refer to as a MASH unit. It served as the emergency referral hospital for Marines fighting the North Vietnamese Army regulars in remote outposts along the DMZ, which are legendary in Marine Corps lore, such as Khe Sanh, The Rockpile and Con Thien.
I was assigned to several duties, on a rotating basis. These duties included working in the triage unit, as a first assistant in one of the four OR’s, or being helicoptered into a rural Vietnamese village to provide medical care to the impoverished and poorly served local populace. These forays were called MedCAPS (Medical Civilian Action Program).
Viewing the current viral crisis, as I understand it from the remote vantage point of my home, there are some striking similarities or contrasts between my wartime experiences and what physicians on the front line are facing today:
Triage
In medical school, I was introduced to the concept of triage, but had no practical experience with it. That changed immediately upon my arrival at 3rd Med. Triage is the process of rapidly determining during a mass casualty which of three categories an injured patient falls into:
a. Those who will probably live with minimal medical intervention
b. Those who will probably die even with aggressive medical intervention
c. Those who will possibly live only with aggressive medical intervention
During a mass casualty situation, the number of emergency patients overwhelms the medical resources, and physicians must give priority to those patients in the last category, in order to salvage those with the best chance of survival. During my Vietnam experience, the triage unit could transform from sleepy to overwhelmed in a matter of minutes when a firefight broke out.
The helicopters would start arriving with their casualties, an alert sounded, and it rapidly became an “all hands on deck” situation.
As a physician, being forced to make life and death decisions is a very psychologically distressing proposition. Trying to comfort a mortally wounded Marine, knowing the situation to be hopeless, cuts to the core. The prevailing ethos in the Vietnam era was to “suck it up” and bury any psychic distress you might be experiencing. We now know that this leads to PTSD, common among military veterans of all generations.
Dangerous working conditions
Working at 3rd Med was relatively safe, compared with what the front-line Marines were experiencing on a daily basis. But compared to civilian life, this was dangerous duty. We experienced almost nightly rocket attacks, during which we had to get into our sandbag bunkers and hunker down until the attack subsided. There were times when, while under rocket attack, we would have to perform surgery wearing helmets and flak jackets. There was the always present danger that our compound could be overrun by a massed assault, such as happened during the Tet offensive a year earlier. I slept with a loaded M-16 at my bedside, should that occur.
The invisible enemy
The Vietnam War was the first conflict for the U.S. Military in which the enemy did not wear uniforms. We were basically fighting a guerilla war against the Viet Cong, who blended into the civilian population.
It was impossible to determine who was an enemy and who was a friend. Even small children were enlisted to throw hand grenades into US military vehicles, then disappear into a crowd.
There were other unseen enemies. We had to take Dapsone and Chloroquine tablets to prevent mosquito bite-induced Malaria, and Typhoid fever was endemic in the area. Almost everyone at some point battled “jungle rot,” a tropical fungal skin disease.
Lack of supplies
The U.S. Marine Corps prides itself on doing more with less, relying on esprit de corps, discipline and courage of the individual marine to complete the mission. On the medical side, however, this presented a difficult problem, as we were often faced with shortages of medical supplies, particularly antibiotics. We had Pen VK and Tetracycline, and that was pretty much it. If a Marine had a serious injury infection requiring more sophisticated antimicrobial therapy, we would have to medevac him to an offshore US Navy hospital ship, or to a Navy hospital in Japan.
Disruption of personal life
The military veterans of most wars, and certainly of mine, experienced the separation of the physician from his family and personal support network. There were no “accompanied tours” in the Vietnam combat zone. Further, we had no cell phones to communicate with the home front. For us, we had only snail mail, the delivery of which was haphazard and always delayed. There were no female nurses; their function was assumed by Navy Hospital Corpsmen.
Psychological trauma and drug use
The stresses of war, both for the soldier and for the military physician, were both immediate and long-lasting. The Vietnam War introduced to the civilian U.S. population what would become today’s “War on Drugs,” primarily by way of returning Vietnam War veterans who used and became addicted to marijuana and heroin.
The use of these drugs was a mechanism by which those psychologically traumatized by war could deal with that stress. The delayed stress effects came to be known as PTSD, but that was a term or phenomenon that we were not familiar with at the time. It remains to be seen how the stress of dealing with the coronavirus may manifest as future addictive disorders in today’s front-line health care workers.
Thank you for your service
During the Vietnam era, there was extreme division of public opinion between those opposed to the war and those who supported it. After a public revelation of a military massacre of innocent civilians at My Lai, many in the public came to see the military draftees, many of whom were forced to participate in the war against their will, as “baby killers.”
The resulting disrespect for returning Vietnam veterans, plus the failure to put a U.S. stamp of victory on the war, led most veterans to feel resentful at this lack of public appreciation for their fulfilling of their patriotic duty. Fortunately, the tide of public opinion has corrected with the passage of time, so that the country for the most part now appreciates more what the Vietnam veterans endured.
Civil disobedience
During the late 1960s, public opinion about the validity of the war effort became divided, to some degree, along generational lines, pitting the “Baby Boomers,” who were against the war, against their parents, “the Greatest Generation,” who had fought and won World War II and tended toward unquestioning patriotism.
Civil disobedience for the first time became common in ways never seen previously, such as burning of the flag and draft cards, and by the riots in the streets during the Chicago Democratic Convention in 1968. The Vietnam War became the focal point in time where Americans began to distrust their government, and to push back to express their disagreement with unjust public policy.
I will be very interested to hear how Dr. Sandel compares or contrasts these takeaway issues from the Vietnam War to the current struggles in the treatment of the coronavirus, or if she identifies any additional areas of similarity.
Now
Kristen Sandel, MD, FACEM
Thank you Dr. Truex for your service and for being one of the best physicians and individuals that I have ever known. Your candor is invaluable, and much appreciated, as we can only learn from experiences such as yours while encountering situations such as this pandemic.
As I reflect on the past few months during the COVID-19 pandemic, there have been numerous articles written about the virus itself, epidemiology, treatment protocols and breaking medical research. What has been lacking in some of these assessments is how this novel virus has affected the way we see each other in health care as well as some of the lessons learned about our patients and community.
In speaking with emergency health care workers across the spectrum (nurses, medics, patient care assistants, advanced practice providers, physicians, etc.), we agree that we have become a more cohesive unit as a whole. The amount of empathy and compassion that we now show each other is more than we have ever seen in our careers.
In the past, while we appreciated everyone’s role on the team, we did not always express our respect for each other. We also noticed a sizable improvement in our communication amongst the team. From triaging a patient with the paramedics in the ambulance bay to assessing for virus risk to working to resuscitate a patient, we have been more cognizant of our verbal and non-verbal communication, ensuring that the patient and each member of the team remain safe.
Need to triage
The days of the traditional triage that I was accustomed to over the past 20 years in Emergency medicine are over. During the pandemic, we had to first triage if the patient (whether in the emergency department entrance or the ambulance bay) was at risk for the COVID-19 virus, and then triage the acuity of the illness.
As one legend in emergency medicine has said, “there is no emergency in a pandemic.” Each member of the team needs to ensure they are protected before assisting others. As the pandemic endured, many staff members decided to wear their protected gear for every patient encounter. As Dr. Truex mentioned, this is an invisible enemy and even those we think of at low risk could be and are infected.
Dangerous working conditions
We learn early as emergency medicine residents to be prepared for the worst. At times, there is very little notice of dangerous situations that arise in the emergency department. Our medical schools and residencies try to prepare us for these types of situations, but until you are immersed in this environment, it is very difficult to understand or simulate.
The wonderful thing about emergency medicine is that the staff in the department is very adaptive, nimble, and can change protocols and processes quickly, sometimes daily or hourly. This trait ensures that both patients and staff are as safe as possible at all times.
One of the challenging things with this virus is that we are learning more about it each day, meaning our medical treatment changes day to day. Fortunately, we are all trained for this and we are able to adapt quickly.
The invisible enemy
As I mentioned previously, we know we have invisible enemies. We deal with them on a daily basis. This novel virus is very difficult to detect and to predict. What was known in February is not nearly what we know today.
We learned that at some point, we have to assume that everyone has been exposed or infected, and have to prepare and protect ourselves and our other patients. Most of our staff early on decided to wear masks, gloves, eye protection and gowns for each patient, knowing that later in the encounter, we will discover they actually were experiencing COVID-19 symptoms.
Lack of supplies
As you may have seen in the news, it is well known that there has been a lack of personal protective equipment in the medical community. That being said, I cannot say enough about the community efforts to ensure we have adequate personal protective equipment if we have a shortage in our institutions. Clearly, it is very difficult for any health care facility to purchase and store enough personal protective equipment to be utilized not to mention last for their staff through a pandemic.
The community has really rallied and donated supplies, whether it was masks and gloves, or 3D-printed items. The amount of love and support from these companies and individuals was greatly appreciated and will forever be remembered.
Disruption of personal life
As you may have read in other articles, health care workers’ personal lives have been greatly disrupted. Many have self-isolated for weeks and months as to not spread the virus to their families, friends or community members. This action has left many feeling isolated and lonely.
Fortunately, we have had a wonderful group of coworkers and friends to rely on to be our rocks during this time of need. For me personally, I have relied on virtual meetings with friends from high school, college, medical school and residency to help keep me grounded and mentally well. An unexpected positive from this pandemic is that I was able to connect with friends I have not heard from in years due to our busy lives and they have been angels in my world.
Our emergency department patients
We have also learned a great deal about our patient population. The emergency department treats many older adults who have hearing disabilities and rely heavily on reading our lips. Only when we donned masks at all times did we realize the extent of this issue within a large segment of our patient population.
We also were more mindful of our dementia patients who now have a team of professionals in full personal protective equipment caring for them, but do not understand why we are wearing these items. The emergency department may have seemed like a scarier and less friendly environment to these patients if we did not communicate extensively with them and make them feel safe and secure.
We learned that there were fewer “medical emergencies” with more patients calling the emergency department to assess if their symptoms warranted a visit, rather than dialing an ambulance or immediately coming by car. Patients did not want to be exposed or expose others to this debilitating virus and many sought care in alternate environments with telemedicine visits or in urgent care settings. Patients who did seek care in our department were extremely kind, many thanking us for everything that we do on a daily basis.
Thank you for your service
We learned that the community really appreciated our efforts as frontline providers and were very generous in their support. Whether it was car parades, candle lights, cards with words of encouragement and thanks, or the tremendous amount of food that was provided, the community rallied around the hospitals giving us hope and support when we needed it the most.
Civil disobedience
Fortunately, we have not seen the violent civil disobedience that Dr. Truex and the rest of America experienced during the war. We have seen protests, mostly peaceful, regarding the stay-at-home orders, as well as the closing of many businesses trying to flatten the curve. The economic hardship that many citizens are going through was a very steep price to pay to try to keep the public healthy and safe.
The pandemic has forever changed the landscape of health care, but there are many positives that will be taken away from this time. Although we do not know what will be written medically about this pandemic in the years to come, we did learn to better appreciate each other, each patient and our community as a whole.
Final thoughts
Raymond C. Truex, Jr., MD, FACS, FAANS
Some of the observations we have made are obvious and timeless. Working with invisible infectious agents has presented danger to the physician from the time of the Bubonic Plague in the 14th Century, for example. We may be able to decode the DNA sequence now, but the risk to the physician remains.
Other of the observations represent a sea change in the way Americans see things and react to what they see, an example of this being the willingness of our fellow citizens to criticize public policy and push back with civil disobedience against what they perceive as injustice. This type of behavior would have been anathema to my parents’ generation and is a direct consequence of the Vietnam War.
Some of the changes are overdue. The recognition of the sacrifices of front-line health care workers has evolved from the public recognition that injustice was done to the returning Vietnam veterans, who returned from combat only to be vilified.
Finally, the current pandemic, like the Vietnam War, may bring permanent changes in the way we think and in the way we act. The “new normal” may be telemedicine, or it may be in the way we stockpile masks and ventilators and prepare for future pandemics.
It has been a very interesting exercise for Dr. Sandel and me to develop our thoughts about the issues confronting medicine on the frontlines over time, and we hope that you find our observations to be interesting and thought provoking. Or perhaps you disagree or have other thoughts about what the future may bring. In any case, we hope to hear from you.
Please note: This article was submitted for publication prior to the civil unrest surrounding the alarming social injustices brought to light in our country in June 2020. Within this article, the authors referred to the mild protests regarding the reopening of our economy. The severity of the events that have occurred since are not taken lightly. The Foundation of the Pennsylvania Medical Society Board of Trustees stands with staff, supporters, donors, beneficiaries and clients who are taking a stand against systemic racism that permeates all sectors of society. Political injustice and lack of economic opportunity are abhorrent to all humans’ rights. The Foundation stands as an authentic ally for a civil society that supports dignity and humanity for all individuals.