This essay was originally published in the Chattahoochie Review, and was picked as a Notable Essay of 2000 by Best American Essays of 2001. THE SURGEON'S LITTLE HELPERS by Susan O'Neill Military hospitals in Viet Nam performed all kinds of surgeries. We had, after all, surgeons from just about every specialty that existed--orthopedic surgeons, general surgeons, ear-nose-and-throat surgeons, eye surgeons; I even recall one excellent plastic surgeon, whose insistence upon elegant, exact, teeny-tiny stitches drove his less precise fellow "cutters" up the wall. I saw, in my year in-country, many heroic, sophisticated and complex procedures. I saw surgery performed on beating hearts; I saw complicated abdominal resections; I saw exacting work on the nerves and tendons of injured hands; and I saw many, many expertly-performed amputations. These procedures were done under less than ideal conditions. It was always, for instance, warmer than it should have been in the operating rooms, even though they were usually air-conditioned. Air filtration was pretty much an impossible dream. There were, inevitably, flies. And, of course, most of the wounds were horribly dirty to begin with. Dramatic miracle surgeries aside, probably the most common operation we performed was a very unsophisticated, very basic procedure called "debridement." It was what you did when your patient had been wounded by, say, a fragmentation grenade or a land mine, something that destroyed a lot of tissue in an area outside the sealed, sterile body cavities. Something that packed the wounded limb or buttocks with dirt, bits of metal and shards from bones that lay near the injured flesh. During our basic medical training at Fort Sam Houston, Texas, we had been told that this sort of wound was the object of modern weaponry. If you kill a man, they told us, you eliminate one soldier. If you wound a man gravely but not fatally, you eliminate more; other potential fighters are sidetracked because they feel obliged to stop long enough to move their injured buddy from the field. Such compassion was a strategic disadvantage. The guns we used, M16s--and those that THEY used, AK 47s--were also designed to complicate an injury. At Fort Sam, the munitions experts took us out to the firing range, where they shot an M16 round into a target that was essentially a bone encapsulated in a thigh-sized mold of firm gelatin. They then showed us the entry wound--a round, neat, bullet-sized hole in the front of the mold--and the exit wound, which was a fist-sized deficit in the rear. After the round entered, they explained, it expanded, shattering the bone. The bone then became its own internal fragmentation grenade, exploding small, sharp pieces through the softer tissue behind it. I assume the VC and the NVA had their own equivalent of Fort Sam Houston, because they, too, managed to get the desired effect from their weapons. Our hospitals received many, many young soldiers, both US and Vietnamese, who had massive tissue damage. We also received many, many Vietnamese civilians--young and old, of both sexes--who suffered the same types of injuries because they had stepped on land mines, or because they had accidentally wandered between a weapon of one sort or another and its target. Or, perhaps, because they had been the target. We seldom knew the why of these patients; we just worked on them. Day and night; night and day. This is what we did when we met one of those perfect war wounds, a gaping hole packed with clotted blood and gritty red clay, the flesh hanging in shreds: First, we flooded the hole with saline, washed it with surgical soap, flooded it with more saline, painted it with betadine solution, and draped it in sterile covers--covers that were far cleaner than the wound itself. Then, depending on the severity of total body damage or the number of patients in the OR at the time, all of us who were not needed to hand instruments or hold retractors--doctors, nurses and techs--took up the heavy sterile scissors called "Mayos" and began to cut away the dead tissue. This was "debridement." We snipped away bits of muscle until we reached tissue that twitched when we cut, which meant it was alive. We trimmed dead bits of small blood vessels away until we reached those that bled--they were alive. These, the surgeon--or, if he was impossibly busy and the vessel a minor one, the nurse--would tie off. We would also pull out bits of metal or stone or dislodged bone or dirt as we went, while the patient slept peacefully under the anesthesia mask. Since the wounds were filthy, antibiotics were a must; they were given in high doses with the patient's IV fluids. Also, because the wounds were filthy, we very seldom closed them during the first operation. Instead, once we cleared out the dead tissue, we packed the open wounds with gauze. We would begin by laying a sterile gauze sponge, soaked with sterile saline, on the newly-debrided area, right on the open flesh. Then, we would pack more gauze, crumpled up in fluffy fistfuls, on top of that, filling in the hole. Finally, we'd wrap the whole thing in rolls and rolls of spongy gauze Kerlix bandages. We might wrap a sterile ace bandage over the whole thing to hold everything secure. And we'd tape it all together. Then we'd send the patient wherever he was supposed to be sent. Sometimes, if his other injuries warranted it--head or spinal wounds or other traumas that we were not equipped to treat safely--we'd evacuate him out, usually to Japan. If there was no rush to send him out, we'd send him in, to one of our own surgical wards. After a day or two or more had passed, we'd bring him back in for further wound debridement. We'd put him to sleep, and cut off all that bulky bandaging we'd put on him the last time. That was when, in many cases, we found the maggots. The thought is repulsive. The first time I saw maggots in a wound, white and plump and squirming under the stained gauze, I nearly vomited. The doctor who was operating merely said, "Ah--the Surgeon's Little Helpers." This was his explanation: Maggots are the larvae of flies. However, unlike the flies that spawned them--who've been in some truly disgusting places--maggots are not really a source of filth in themselves. In fact, they're clean, newly-hatched and quite virginal--but in order to live, they must eat what we consider filth. In this case, it was dead tissue. By debriding, we were also removing dead tissue. So the maggots and the surgical team were allies, working toward the same goal. Maggots, being maggots, get no real respect; we summarily washed them out of the wound and disposed of them with the old bandages. Then we went about our business, re-trimming the dead flesh. Depending upon the relative cleanliness of what came out of our mutual efforts, we then re-packed the wound, or we sewed it up. Some of these wounds could not be sewn up because they would have to be covered with skin grafts--which were usually done elsewhere. Sometimes, they could be--in the case of an amputated limb, for example, once the wound was clean, then the surgeon might sew the flap of live flesh over the end of the bone. The wonder was that so many men with so much wrong with them managed to live. It helped that they were young; it helped that they were usually in excellent condition, well-fed and well-exercised. It helped that med-evac teams--the pilots and staff who manned the huey helicopters painted with red crosses that airlifted the injured from the battlefield--were daring and quick. It helped that the doctors were efficient and competent, and that the nurses and techs were well-trained--and that we all worked so well together to save these men. Of course, after all that work on the part of so many people, once he had been hospitalized, debrided, sewn up and released, the patient was often sent back into battle. Which made many of us wonder what the point of this whole thing might be. Consider. To do this rather barbaric procedure of debridement required hours of expensive hospital time. It required thousands of dollars in medical supplies--linens, anesthesia gases and chemicals, disposable gloves, blades and sutures, gauze, IV gear and bottles of solutions, blood, antibiotics, saline, soaps, betadine, unguents, and so forth. It required the ministrations of at least one surgeon--whose time was like gold back in the States--and an absolute minimum of two support staff members, one of which was a nurse. And an anesthetist. And it required all this two, three, maybe four times over. That was just for the hospitalization. This man was also evacuated from the battle field by helicopter--which involved a precision piece of aviation equipment, lots of fuel, a trained pilot and crew, and emergency medical equipment and supplies. So all this time, money and care--all these resources and personnel--are spent making this soldier well once again. And he is sent back into battle. Where, in some cases, he is re-injured--which starts the cycle over again. Or killed. In either case, no one seems to have profited. The surgeon added nothing to his store of knowledge--all he did was cut and tie and bandage and sew, things he could've done as an intern. Nor did the anesthetist, nor the surgical staff. There was no monetary return for spent supplies, no bonus for the spent time. The patient lost valuable flesh, perhaps his valuable life. Even the Surgeon's Little Helpers were dead. Seems to me we would've been well ahead of the game to have avoided sending the soldier out to get injured in the first place. Unless all we were doing was testing our weaponry. And hell, you can do that with a bone in a jello mold. BIO: I'm the author of Don't Mean Nothing: Short Stories of Viet Nam, a fiction collection drawn loosely from my experience as an Army nurse during the Viet Nam war. It was published in hard cover by Ballantine, and is currently out in paperback through UMass Press. I've published fiction and non-fiction in all kinds of media, including Chattahoochie Review, where this piece was originally published and Amazon Shorts (short stories sold independently on Amazon.com for 49 cents each--a kind of reader's iPod concept). I live in Eastern MA with my husband, co-edit an ezine for flash fiction called Vestal Review, am about to become a grandmother for the second time, and spend much of my time trying to market a long, intricate novel called American Family. My website is: http://susanoneill.us Susan O'Neill
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