1. Profiles in Combat Casualties COL CLIFFORD C. CLOONAN, MD, FACEP Interim Chair Dept. of Military and Emergency Medicine USUHS

2. WAR WOUNDS History, 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.

3. 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

4. Dulce bellum inexpertis (War is delightful to those who have no experience of it) Erasmus

5. The Evolution of Weapons of War

6. Wounds of War Historical Background

7. The Invention of Gunpowder

8. Encoded formula for gunpowder and a depiction of its use

9. HISTORY OF WAR WOUNDS  CHANGING PATTERNS OF WOUNDING THROUGHOUT HISTORY  EFFECTS OF EVOLVING WEAPONS SYSTEMS  EFFECTS OF EVOLVING TACTICS

10. The Modern Battlefield: More 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

11. Combat Wounds Are Unique  High percentage of penetrating wounds  Multi-System injury  Multi-Etiologic  High degree of wound contamination  Old (delayed initial care)

12. Highly Contaminated “Old” Wounds

13. Mechanisms of Combat Injury

15. Causes of Combat Wounds (WWI, WWII, Korea, Vietnam, Middle East)

16. Mogadishu Raid Casualties Wounding Mechanism Distribution Mogadishu Somalia Oct 3 1993

17. Shell Fragment Wound

18. Fragments from exploding anti-tank weapon

19. Landmine Injury

21. M-16 assault rifle 5.56mm GSW (exit)

22. Trans-Abdominal High Velocity GSW (fatal)

23. Facial Burns Kosovo

24. Napalm Burns Vietnam

25. 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

26. Primary Blast Injury USS Cole Terrorist Bombing

27. 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 1 o blast injury in addition to other wounds. – Primary blast injury is considerably more common in casualties due to naval combat

28. War Wound Distribution Extremities Chest 13% Upper 21% Lower 35% Abdomen 5% Head & Neck 17% Other 9% Upper Extremities Lower Extremities Abdomen Head & Neck Chest Other

30. Mogadishu Raid Casualties Anatomic Wound Distribution

31. Time to death after initial wounding

34. Mechanisms of Injury and Distribution of Injuries by Geographic Environment and Type of Combat

35. North Africa AgentPercent Shell fragments...................................…. 75 Bullets...................................................... 20 Mines........................................................ 2 Bombs....................................................... 1 Other......................................................... 2 _____ Total............100

36. SOUTH PACIFIC  AGENTPERCENT  Shell Fragments50  Bullets:  Rifle25  Machine gun 8  Grenade12  Mines 2  Other 3 ______ Total100

37. Vietnam AgentPercent Shell Fragments38.9 (Artillery, mortar, rocket) Bullets (rifle and pistol)23.8 Booby traps, mines, grenades27.7

38. Wounding Agents in the Falklands  Gunshot Wounds - 38%  Fragment- Caused Wounds - 40%  Burns - 18%

39. 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%)

40. Falklands – British Killed & Wounded  WIA - 783 (75%)  KIA - 255 (24.5%)*  DOW - 3 (0.3%) * High percentage of KIA’s is probably related to high % of GSW’s and prolonged evacuation times (this also probably contributed to a low DOW rate

41. Vietnam - Morbidity & Mortality  KIA - 11%  WIA - 87.5% (45.5% CRO)  DOW - 1.5%

42. 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%

43. War Wounds Who is wounded / killed in war?

44. 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

45. 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

46. Desert Storm - Cause of Death

51. 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.

52. 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

53. 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

54. Mortality Rate of Extremity Wounds (%) World War II Korea Vietnam Upper 0.10.20.15 Lower 3.00.70.5

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

56. UNDERSTANDING WAR, HISTORY AND THEORY OF COMBAT BY T.N. Dupuy, 1987 Paragon House Publishers, N.Y.

57. 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.

58. 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

59. The site of death for 90% of fatally wounded combat casualties is the battlefield.

60. Casualty Rates  AVERAGE WORLD WAR II DIVISION ENGAGEMENT – Casualty rates were 1-3% per day

61. Attrition Rates  Attrition Rates in the 1973 Arab-Israeli October War Were Comparable to World War II

62. 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".

63. Quotes VICTORY IS THE BEST MEDICINE

64. Quotes...[M]edicine 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”

65. 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

66. Summary – The most common combat wounding mechanisms are Fragments 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)

67. 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 <10% - 50% Primary Blast – generally <5% Burn (all types) – generally <5

68. 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%

69. Summary  Who primarily gets wounded/killed in combat – Young men ages 18 – 24 – Predominantly infantrymen – Almost entirely enlisted men with 2 nd 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 <5 minutes of wounding) – Relatively few die once reaching a hospital