Who is Hawkeye?

Last year, America lost one of its foremost surgeons with the death of Keith Reemstma. Dr Reemstma was a pioneer in the field of solid organ transplantation and an academic leader who served as Professor and Chair of Surgery at both the University of Utah and the Columbia University College of Physicians and Surgeons. Among the many tributes paid to him in his obituary was the statement that he had been a prototype for the character of Hawkeye Pierce. Hawkeye Pierce is the surgically skilled, courageous, altruistic, and irreverent character in Richard Hooker's novel MASH. The book details the tragi-comic experiences and antics of surgeons, nurses, chaplains, injured soldiers, displaced Koreans, and others thrown together at a mobile army surgical hospital near the combat zone in Korea during the long and costly battles after the Chinese entered the conflict. Hawkeye Pierce was later immortalized by Donald Sutherland in Robert Altman's film M*A*S*H and still later by Alan Alda in the long-running television comedy-drama of the same name. Other surgeons who served in Korea have also been identified as models for Hawkeye Pierce: John Davis of Vt; John Howard of Ohio; Frank Spencer of NY; and Alvin Bronwell of Tex are a few known to me.

Otto F. Apel, Jr, a surgeon who practiced in Portsmouth, Ohio, collaborated with his son and produced a book entitled MASH: An Army Surgeon in Korea. Dr Apel's book details his experiences which, in many ways, resemble events described in Hooker's novel, the motion picture, and the television series. Dr Apel and other surgeons in Korea pioneered advances in the care of the injured patient. One example is the development of helicopter evacuation of the injured, which shortened the interval between injury and definitive surgical care of the injuries. Also, they challenged the military doctrine of ligation of interrupted arteries and used direct arterial repair and interposition vein grafts to restore arterial continuity. Vascular repairs and interposition graft insertions are reported in detail in Dr Apel's book, with descriptions drawn from his personal operative notes.

The Mobile Army Surgical Hospital passed in military history and has now been replaced with a new doctrine of combat injury care thought to be more suitable for warfare in the 21st century. The 43rd MASH Hospital, the last MASH unit in Korea, closed on June 11, 1997. Doug Mellgren, reporting for Nando Media and the Associated Press, described the deployment of the US Army's last MASH unit in Albania in April of 1999.

Have the surgical personalities become, simply, historical footnotes as well? What were the characteristics of surgeons who served in Korea? Many were thrust into a combat surgery situation with very little formal surgical training. Dr Apel's book describes the shortages of surgeons and nurses that faced the military in Korea. The initial resources tapped for this need were recent medical graduates whose education had been supported by the government near the end of World War II in programs such as the V-12 medical education support plan. Many of the surgeons selected for duty in Korea had barely started their careers and were understandably frustrated by the disruption of their lives. The military had few career surgeons, and those available were poorly suited as mentors for these young surgeons. On-the-job training was the order of the day. Shortages of equipment and the many injured soldiers needing care produced remarkable feats of surgical accomplishment against staggering odds. Despite meager training, these surgeons brought knowledge of the latest techniques, such as arterial repair, to the care of the injured in Korea. Given the chronic fatigue and stress facing these surgeons, it is easy to understand the intolerance they displayed in the face of rigid military bureaucracy. Nincompoops Frank Burns and “Hotlips” Houlihan are the fictional portrayals of the idiocy that war reveals in stark relief. They are the butts of every joke and the targets of continuous ridicule. The real target of the surgeons' wrath is the world view that war happens simply because the Army needs it; injured patients are merely an inconvenient by-product of this reality. This interpretation is obviously an exaggeration and a huge oversimplification of what happens in real life. Doctors and nurses who commit to military careers are not imbeciles, psychopaths, or uncaring people. The technical skill, compassion, endurance, and success rates of the surgeons are, in Hooker's enormously popular work of fiction, exaggerated as well. However, the central personality traits of the surgeons are real and recognizable in several generations of bright, committed people whose training was interrupted for temporary stints as military surgeons.

As a young surgical resident who left training to serve in Vietnam, I saw the intellectual riches and spectacular humor which were generated by putting a group of surgeons together to care for large numbers of soldiers who were hurt during the 1968 Tet offensive. The memories remain vivid now more than 3 decades later. More than 200 operations in one 24-hour period. Five-hundred units of blood drawn from the soldiers and airmen of the Pleiku Air Base and processed for transfusion in less than 6 hours. The unbelievable fatigue followed by relentless boredom. Nurses and medics who grabbed mattresses to cover and protect 42 patients in an orthopedic ward in the seconds between the first rocket explosion and the second, which was a direct hit that demolished the ward building. Miraculously, there were no patient or staff injuries that day.

The deaths and the successes were palpable and the loneliness profound. Were there military bureaucrats? Certainly. More commonly, though, the committed career officers and enlisted personnel were wonderfully understanding, capable, and always helpful. Did we complain? Of course! Were we irreverent? Yes! Outspoken? Yes! Skilled? Absolutely! Willing to challenge military dogma? Anytime! Arrogant? Not really. Unpatriotic? Never.

The military has never had enough surgeons when the shooting starts. Partially trained and newly trained surgeons have always supplied the talent necessary, and the understanding of the pathophysiology of injury has leaped ahead in the aftermath of every war. It was my observation that nothing in civilian residency prepared me for the carnage that was combat trauma. Take a group of bright, young surgeons and nurses faced with soldiers who have incredibly severe injuries and who desperately need help, and the result is predictable. The surgeons operate and then misbehave but offer no excuses. Some patients die but most recover, many times against all odds. New diseases (adult respiratory distress syndrome, multiple systems organ failure) are described. New treatments are developed (fluid resuscitation of shock) and new specialties (surgical critical care) are born. Because surgeons are committed to “keeping score,” the operations and treatments that work come to the fore, and future patients are spared suffering because of the war experience.

Who is Hawkeye? Any surgeon who rises to the occasion to treat patients under desperate circumstances in combat, at the mission outpost, in the urban, indigent care hospital. There is not one Hawkeye, there are thousands. Within every surgeon burns the glimmering spark of Hawkeye Pierce. Thank goodness for this; life would be pretty dull without him or her.