Profiles in Combat Casualties

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Profiles in Combat Casualties

• COL CLIFFORD C. CLOONAN, MD, FACEP
• Interim Chair Dept. of Military and
• Emergency Medicine
• USUHS

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WAR WOUNDSHistory, Wound Description, Mechanisms
and Wounding Agents, Distribution of
Wounds/Wounding By Anatomical Location and by
Demography,

• Following this lecture the participant will be
  able to
• Discuss why military medical personnel should
  know something about weapons and the effects they
  produce
• State which wounds are most commonly associated
  with death.

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WAR WOUNDS

• Following this lecture the participant will be
  able to (cont.)
• State the frequency with which the various type
  of combat wounds occur and the impact that type
  of combat, geography, and weapons available have
  on the relative percentages of each type.
• List the various wounding patterns associated
  with different types of weapons and different
  types of combat
• State who primarily gets wounded/killed in combat
• State where in the echeloned combat health care
  system the deaths occur

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Dulce bellum inexpertis(War is delightful to
those who have no experience of it)Erasmus
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The Evolution of Weapons of War
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Wounds of War Historical Background
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The Invention of Gunpowder
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Encoded formula for gunpowder and a depiction of
its use
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HISTORY OF WAR WOUNDS

• CHANGING PATTERNS OF WOUNDING THROUGHOUT HISTORY
• EFFECTS OF EVOLVING WEAPONS SYSTEMS
• EFFECTS OF EVOLVING TACTICS

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The Modern BattlefieldMore Dangerous and
Violent Than Ever

• Smart Weapons, Improved conventional munitions
• Increased probability of multiple hits
• Automatic Weapons - Multiple hits
• Decreased proportion of surviving wounded
• Fragments will cause 80-90 of living wounded
• More extremity wounds - effects of protective
  equipment

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Combat Wounds Are Unique

• High percentage of penetrating wounds
• Multi-System injury
• Multi-Etiologic
• High degree of wound contamination
• Old (delayed initial care)

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Highly Contaminated Old Wounds
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Mechanisms of Combat Injury
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Causes of Combat Wounds
(WWI, WWII, Korea, Vietnam, Middle East)
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Mogadishu Somalia Oct 3 1993
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Shell Fragment Wound
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Fragments from exploding anti-tank weapon
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Landmine Injury
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M-16 assault rifle 5.56mm GSW (exit)
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Trans-Abdominal High Velocity GSW (fatal)
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Facial Burns Kosovo
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Napalm Burns Vietnam
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Burns - The Israeli Experience

• Six Day War 1967 - 4.6 Burn Injuries
• October War 1973 - 8.1 Burn Injuries
• Lebanon War 1982 - 7.6 Burn Injuries

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Primary Blast Injury
USS Cole Terrorist Bombing
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Primary Blast Injury

• Primary Blast Injury is uncommon in most combat
  casualties but
• In an armored vehicle that has been penetrated by
  a large warhead,1-20 of the survivors will have
  some degree of 1o blast injury in addition to
  other wounds.
• Primary blast injury is considerably more common
  in casualties due to naval combat

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War Wound Distribution
Upper Extremities
Lower Extremities
Abdomen
Head Neck
Chest
Other
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Mogadishu Raid Casualties Anatomic Wound
Distribution
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Time to death after initial wounding
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Mechanisms of Injury and Distribution of
Injuries byGeographic Environment and Type of
Combat
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North Africa

• Agent Percent
• Shell fragments...................................
  . 75
• Bullets...........................................
  ........... 20
• Mines.............................................
  ........... 2
• Bombs.............................................
  .......... 1
• Other.............................................
  ............ 2
• _____
• Total............100

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SOUTH PACIFIC

• AGENT PERCENT
• Shell Fragments 50
• Bullets
• Rifle 25
• Machine gun 8
• Grenade 12
• Mines 2
• Other 3 ______
• Total 100

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Vietnam

• Agent Percent
• Shell Fragments 38.9
• (Artillery, mortar, rocket)
• Bullets (rifle and pistol) 23.8
• Booby traps, mines, grenades 27.7

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Wounding Agents in the Falklands

• Gunshot Wounds - 38
• Fragment- Caused Wounds - 40
• Burns - 18

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Sites of Wounding - Falklands

• Head and Neck - 30/133 (23)
• Upper Limb - 42/133 (31)
• Lower Limb - 88/133 (68)
• Intra-thoracic - 11/133 (8)
• Intra-peritoneal - 12/133 (8)
• Multiple Wounding Sites - 59/133 (41)

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Falklands British Killed Wounded

• WIA - 783 (75)
• KIA - 255 (24.5)
• DOW - 3 (0.3)
• High percentage of KIAs is probably related to
  high of GSWs and prolonged evacuation times
  (this also probably contributed to a low DOW rate

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Vietnam - Morbidity Mortality

• KIA - 11
• WIA - 87.5 (45.5 CRO)
• DOW - 1.5

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Distribution of Wounds By Anatomic Group - Viet
Nam

• Head and Neck - 16.5
• Thorax - 7.3
• Abdomen - 8.0
• Upper Extremities - 27.7
• Lower Extremities - 40.5

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War Wounds

• Who is wounded / killed in war?

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Vietnam - Marine Corps Wounded

• Mean Age - 20.7 years old
• Distribution by Pay Grade
• E1 - E3 - 71.2 of those wounded
• E4 - E6 - 25.6 of those wounded
• Officers - 2.7 of those wounded

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Distribution of Wounding in Vietnam by Occupation

• Infantry - 71.8 of those wounded
• Artillery - 2.2 of those wounded
• Direct Correlation between a Lack of Combat
  Experience and Increased Wounding

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Desert Storm - Cause of Death
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• When only ground troops are studied, the ratio of
  WIA/KIA, which was 4.2/1 in WW II, has remained
  essentially unchanged for the past 200 years.

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SITE OF EXSANGUINATION IN 98 VIET NAM COMBAT
DEATHS

• 16 - Heart/Ascending Aorta
• 13 - Lung/Pulmonary Artery
• 10 - Liver
• 10 - Multiple Abdominal Sites
• 9 - Great Vessels of the Thorax (Principally the
  Aorta)
• 9 - Arteries in the Lower Extremity
• 8 - Great Vessels of the Abdomen (especially the
  Aorta/Vena Cava

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SITE OF EXSANGUINATION IN 98 DEATHS (CONT)

• 6 Amputations of the lower extremity
• 3 Carotid Artery
• 2 Upper Extremity Amputations
• 2 Arteries of the Upper Extremity (Esp.
  Axillary/Brachial)
• 10 Mult. Sites in the Chest, Abdomen, and
  Extremities
• Possibility For Temporary Control of Bleeding
  with First Aid

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Mortality Rate of Extremity Wounds ()

• World War II Korea Vietnam
• Upper 0.1 0.2 0.15
• Lower 3.0 0.7 0.5

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• "BATTLE CASUALTIES, INCIDENCE, MORTALITY, AND
  LOGISTIC CONSIDERATIONS"
  
• By
• Gilbert W. Beebe, Ph.D..
• Michael E. De Bakey, MD

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UNDERSTANDING WAR, HISTORY AND THEORY OF COMBAT

• BY
• T.N. Dupuy, 1987
• Paragon House Publishers, N.Y.

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FACTORS WHICH INFLUENCE WOUNDING RATES ON THE
BATTLEFIELD

• Ratio of enemy to U.S. strength.
• Type of weapons employed and ratio of enemy to
  U.S. firepower
• The experience and training of the troops
• Terrain
• Tactical advantage and the excellence of the
  plan.

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FACTORS WHICH INFLUENCE WOUNDING RATES ON THE
BATTLEFIELD (cont)

• Availability of prepared positions (enemy vs.
  U.S.)
• Possession of key terrain (enemy vs. U.S.)
• Quality of available intelligence
• Tactical and strategic support
• Logistic support

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The site of death for 90 of fatally wounded
combat casualties is the battlefield.
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Casualty Rates

• AVERAGE WORLD WAR II DIVISION ENGAGEMENT
• Casualty rates were 1-3 per day

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Attrition Rates

• Attrition Rates in the 1973 Arab-Israeli October
  War Were Comparable to World War II

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• It is vital that the medical officer "...be in a
  position to check the tactical situation
  estimates with other staff officers so that his
  plans may be more securely grounded".

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Quotes

• VICTORY IS THE
• BEST MEDICINE

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Quotes

• ...Medicine has...an indirect influence on
  war which is not negligible. there seems little
  doubt that some of the reckless courage
  of...American troops...is stimulated by the
  knowledge that in front of them is only
  the...enemy, but behind them...are the
  assembled surgeons of America, with sleeves
  rolled up.
• Hans Zinsser, Rats, Lice and History

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Summary

• Following this lecture the participant will be
  able to
• Military medical personnel should know something
  about weapons and the effects they produce
  because such knowledge is useful
• for medical planning purposes
• to aid in developing or improving wounding
  prevention methods
• in helping to estimate the number and types of
  casualties that might be generated
• To improve communication with the line

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Summary

• The most common combat wounding mechanisms are
• Fragments
• Fragments
• Fragments
• Fragments
• Bullets
• Bullets
• Blast and burns and all other (unless you are in
  the navy AND you are assigned to a ship in which
  case blast and burn make up a larger percent)

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Summary

• The frequency with which the various type of
  combat wounds occur (see above) all of these
  depend upon type of combat (geography, weapons
  available, type of combat etc.)
• Fragments (all types) 50 90
• Bullets lt10 - 50
• Primary Blast generally lt5
• Burn (all types) generally lt5

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Summary

• Wounding patterns associated with different types
  of weapons
• For most weapons wounding location is random and
  thus primarily based upon body surface area
  therefore -
• Extremities which make up roughly 55 of BSA
  account from roughly 55 of sites of wounding
• Landmines clearly primarily affect the lower
  extremities
• Some bullets are aimed so there is a slightly
  higher percent of wounds in torso and head
• Head and neck are injured somewhat
  disproportionate to their BSA because these body
  parts are more commonly exposed (have to be able
  to see to shoot!) -roughly 17 instead of 10

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Summary

• Who primarily gets wounded/killed in combat
• Young men ages 18 24
• Predominantly infantrymen
• Almost entirely enlisted men with 2nd Lieutenants
  being at highest risk of death among officers
• Which wounds most commonly cause death?
• Head and Chest Wounds
• Where do most deaths occur?
• On the battlefield (mostly at the point of
  wounding and within lt5 minutes of wounding)
• Relatively few die once reaching a hospital