Chapter Ten: US Army Burn Unit, Fort Sam Houston, San Antonio, Texas

Chapter 10 Sub-sections

The Army drafted me in spring 1967. I had been continuously deferred during my education, but as a physician was eligible for the draft until age 35. The Viet Nam conflict was escalating and the military was drastically short of physicians. I had graduated medical school in 1958, and at basic training in September 1967 amazingly met ten of my fellow medical school graduates at Fort Sam Houston's Military Field Service School in San Antonio where we were taught how to wear uniforms and salute.

We bivouacked at nearby Camp Bullis to learn compass maneuvering, and to crawl under barbed wire while 50 caliber machine guns fired 18" over our heads. We did this first in the afternoon, and again after dark when we could see the tracers just above our heads. Interestingly, while waiting for the evening strafing, we saw something high in the sky reflecting sunlight and moving progressively across the sky. It was neither a plane nor a planet; it was a satellite.

At Fort Sam, by the cannons in front of headquarters, a bugler played Reveille in the morning as the flag was raised, and Retreat at 5 p.m. as the flag was lowered. All local traffic halted, and drivers and passengers exited and stood at attention. Our daughter Mary kept track of the cannons. Fig. 7. Brooke's main hospital, then the site of the burn unit, is above her head in the background (arrow).

Figure 7
Fig. 7. Mary checks the cannons. The burn unit was located at Brooke Main Hospital, arrow.

Class 3 Institution in a Class 3 Military Hospital

My initial orders (we wondered why I received 50 copies, but found out in time that we gave one to every place or person we dealt with) included assignment to Viet Nam for a year after basic training. This was changed during basic to the U.S. Army Burn Unit at Fort Sam Houston, due to the excessive amount of burn trauma and the need for experienced anesthesiologists.

I had finished residency in 1961 and been in practice for 6 years, a greater experience than virtually all drafted anesthesiologists. The Burn Unit was unique: Military facilities were one of three categories of classes. Class 3 was the most restrictive: a major care and teaching institution serving major needs. Brooke Army Medical Center on the grounds of Fort Sam Houston in San Antonio, Texas was a huge Class 3 facility with multiple large buildings and care for orthopedic problems, eye injuries, and other major specialty categories.

The Burn Unit, a Class 3 institute, rented space in the Class 3 Brooke Hospital, occupying a relatively small area – two wards, one operating room in the Brooke surgical suite, and a separate building for its recognized burn research. Two anesthesiologists were assigned to this class 3 facility and were independent of the anesthesia program at Brooke. Marvelous Max Mendenhall was chief of anesthesia at Brooke Army Hospital and was supportive and encouraging to all we did in anesthesia at the burn unit, even though he had no official responsibility or involvement with us. His wife Rita and he had anesthesia parties at his home on post for everyone in anesthesia, regardless of affiliation, particularly when there was a visiting professor, e.g., Art Keats.

Figure 8
Fig. 8. Colonel Jack Moncrief, Burn Unit Commander, pins my Captain's bars on Brian's fatigues.

The two anesthesiologists assigned to the burn unit did have occasional periodic temporary rotations of residents or nurse anesthesia students from the Brooke program as part of the teaching program, but, in general, we personally provided virtually all the burn anesthesia. When we had really tricky cases, Max had someone from his department check on us, just in case. We were never offended, as he was not ever a competitor.

Jack Moncrief was chief, a major person in burn care, and a formidable and respected leader. He had a deep measured voice, and our 9-year-old son Brian called him "Gunsmoke," for in that he resembled James Arness of the TV program. When I was promoted, he agreed to pin my Captain's bars on Brian. Fig. 8. The burn unit had its own dedicated medical personnel, including internists, nephrologists, general and thoracic surgeons, anesthesiologists, occupational and physical therapists, and various other specialty services. Unit capacity was perhaps 20 for acute burns, and 120 for ward patients.

Respiratory care as a specialty was in its infancy, and we in anesthesia provided some of the expertise. Since we worked with the airway in any anesthetic, we understood the early ventilators, because most were ward applications of equipment regularly used in the operating rooms. Each day, one of the anesthesiologists provided anesthesia for surgery, while the other made rounds with the surgeons and internists, and helped on those patients with respiratory problems, providing ventilator skills, and helping with tough intravenous or arterial lines.

Burn patients had constant severe pain, and regularly told us in anesthesia that the only pain-free experience they had was during anesthesia. For minor procedures in the Hubbard tank, e.g., superficial debridement and dressing changes, we provided added analgesia at times with the methoxyflurane plastic whistle. This was a cigar-shaped white plastic tube, much like a whistle, with an internal wick. We poured the recommended amount (can't remember how much) into it, and the burn patient inhaled on it, more vigorously as debridement progressed. Methoxyflurane (Penthrane®) is no longer in use due to renal toxicity. The Hubbard tank is a large curved 6 foot by 10 foot metal warm water structure for soaking a patient in warm water for comfort, easier debridement, and other care. Modest debridement could involve considerable pain and analgesia was important. The plastic whistle temporarily magnified the effect of parenteral analgesics.

Many patients had other serious injuries in addition to their burns, e.g., fractures, loss of a limb, or an eye. In 1968, the unit cared for 389 burn patients, most there for two to four months, with 259 receiving 794 anesthetics. The average burn was 30%, and 38 died (Annual Report of the Burn Unit, 1969). In 1969, there were 309 patients, with 189 receiving 662 anesthetics. The average burn was 36%, and 70 died (Annual Report of the Burn Unit, 1970). Part of our burn care was to sing happy birthday to recuperating patients. This added some solace and support during their terrible suffering. While the wish was that there would be many more, we realized at times that this was a happy last birthday party.

Transport of Burn Patients from Viet Nam and Japan

Our patient sources were active duty military, dependents, and Native Americans, including Alaskan Inuits and Aleuts. At that time, we could not properly distinguish Alaskan tribes, and, furthermore, nomenclature varies. They are now described as three distinct racial groups: Aleut, Indian, and Eskimo – now Inupiat and Yupik. They do not like being confused with one another. These distinctions exist because they are alike with one exception – their languages are mutually unintelligible. Recently, an Inupiat visited Greenland and was amazed that he could talk to people there – Yupik are Siberian (Longenbaugh 2007).

Most of our patients were from Viet Nam. After they were stabilized there, usually within several days, they were transferred to the 106th General Hospital at Kishine Barracks, Yokahama, Japan. Averaging twice per month, we sent a burn team (one physician, two medical corpsmen) for the purpose of safe evacuation on a military jet of some 30-40 patients with thermal injury, back to Fort Sam, with re-fueling at Travis Air Force Base, southwest of Davis, CA. We never had a fatality on these prolonged evacuation flights. I never flew on these nor did I go to Viet Nam.

One source of patients was ‘friendly napalm.' Planes targeting the enemy lines dropped napalm, prematurely, on our own troops. They were saturated with this clinging combination of gasoline and a jelly-like substance that burned deep and couldn't be wiped or scraped off. Phosphorous grenades were another terrible weapon. Phosphorous burns under water or in tissue because it combines with oxygen to combust in solution, so the grenades were particularly damaging to deep structures. Both of these produced horrible wounds with prolonged convalescence and deep scarring.

Scars due to thermal injury gradually contract over the years and restrict movement, so burn patients repeatedly return for plastic surgery to open these scars and add in new skin grafts, so-called ‘scar swapping.'

For drafted military personnel sent to Viet Nam, the experience was crippling to their ego and sense of well being, with immense frustration. As a result, many became pre-occupied with drugs or alcohol. In part due to this, half of the casualties in Viet Nam (military records) were related to non-hostile action, e.g., drunk or drugged and disorderly conduct, or such things as unsuccessful attempts to fly a plane under a bridge. Some became our burn patients.

At this time, the Viet Nam military budget was $2.5 billion/month. Some of the funds were richly spent at Fort Sam. We had marvelous entertainment on the Parade Ground on the Fourth of July, with bands, sophisticated marching units, parachutists, and horses. At Thanksgiving, the hospital mess prepared a complete meal for all military and families, charging about $1.50/person. The Officers' Club and Non-commissioned Officer's Clubs were prosperous and tastily decorated throughout the year, with excellent food at reasonable prices. This benefited those who needed a quiet relaxing break from tensions.

Thermal Trauma in Families of Conservative Religion

One disturbing aspect of the burn unit population was the attitude of seriously burned children from families of some conservative and/or fundamentalist religions. These children were extremely depressed, with no desire to live, even though the causes of their burns were accidental. It took a major effort of many personnel to help them see that it was worth it to survive.

Finally, one of them described what was wrong: they had been told since their earliest years that, whenever they were hurt, it was God punishing them for misbehavior, and that, the more serious the injury, the more serious had been their misbehavior. A serious burn indelibly etched them with the idea that they were terrible human beings and that they shouldn't survive. Some of these parents even had difficulty supporting such a ‘terrible' child.

Lyndon Baines Johnson and Brooke Army Medical Center

We lived on post among other officers' homes about ¾ mile from the hospital, at 125 Lang Road, with close contact to army activities, people, rules, and regulations. Many of our burn patients were draftees, primarily young men who lacked much education. As infantry, 'grunt' soldiers, and point men, they were more subject to injury or death. They had an almost child-like attitude while recuperating, with a teen's preoccupation with comic books.

Pat and I had supported the war effort until I was drafted, but now became anti-war. Hostility to the war was fairly widely seen at Fort Sam and toward our president, Lyndon Baines Johnson. This hostility occurred in some regular army personnel, draftees, inpatients, recuperating ambulant patients, and post personnel. LBJ would come by helicopter from his ranch for checkups at Brooke's Main hospital. Pat could tell when he was about to arrive, although it was never announced. Military Police would start searching our neighborhood, lifting sewer covers, checking on who was around. The helicopter would land at varying locations, never the same, and LBJ would be driven to Brooke. On those days, we saw sharpshooters posted on the roofs of the buildings around the semicircular drive approaching Brooke Main.

Pat would phone to tell me he was coming, and, if I was not in the operating room, I would watch him enter the hospital from my second floor office overlooking the entrance.

We officers were periodically ordered to attend receptions at the Officers' Club or elsewhere, with a relaxed review by high ranking officers. Most interesting was how seriously their wives regarded their station in the military. The women introduced themselves, either by card, or directly, as "Mrs. Colonel Jones" or "Mrs. General Smith." They avoided any chance that their status might be missed. I entered as a Captain, was promoted to Major in nine months, based on my time out of college, and to Lieutenant Colonel six months after that, based upon my time out of medical school (by order of W.C. Westmoreland, Chief of Staff). I was now the ranking junior officer in the burn unit, second in command to the burn unit chief surgeon.