1. Establishing a US Military Mortality Surveillance System: Recommendations for Preventable Death Reviews – Forensic Pathology
2017 AMSUS Meeting
30 NOV 2017
Washington, DC
Alice J. Briones, DO, Lt Col, USAF, MC
Edward L. Mazuchowski, MD, PhD, Lt Col, USAF, MC
Louis N. Finelli, DO, COL, MC, USA

2. Disclaimer
The opinions or assertions presented hereafter are the private views of the speaker and should not be construed as official or as reflecting the views of the Department of Defense, its branches, the Defense Health Agency or the Armed Forces Medical Examiner System. The authors have no financial disclosures.

3. AFMES
Mission: Investigate deaths, Identify the fallen, Improve readiness. Vision: Be the global leader in comprehensive and innovative medicolegal services enhancing the readiness, sustainability, and survivability of those we serve.

4. Section1471, Title 10, U.S.C. (1999)
Under regulations prescribed by SECDEF, grants the Armed Forces Medical Examiner the authority to conduct forensic pathology (medicolegal death) investigations
Decedent on exclusive federal jurisdiction
Service Members on active duty or inactive duty for training
Any authorized DoD investigation
Any authorized investigation conducted by FBI, NTSB, or any other Federal Agency

5. DoD Instruction
Armed Forces Medical Examiner System Operations (December 29, 2015)
Subordinate element to the DHA
Perform forensic pathology investigations in accordance with Section 1471 of Title 10, U.S.C.
DoD maintains expertise and capabilities in current and emerging forensic medicine disciplines, including but not limited to, forensic pathology, forensic anthropology, forensic odontology, DNA sciences, forensic toxicology, and mortality surveillance.

6. National Association of Medical Examiners Performance Standards
Forensic autopsy necessary to determine cause or manner of death, document injury/disease or collect evidence
Forensic pathologists determines extent of examination
External examination, radiographs, ancillary studies

7. Post 9/11/01
AFME directs complete forensic pathology investigation on all individuals that die in support of an overseas contingency operation
Scientific identification of all individuals and dissociated remains
Fingerprint, dental, and/or DNA analysis
Postmortem examination (complete autopsy) to determine cause and manner of death
Results of investigation provided to families, investigative agencies, and commanders

8. U.S. Military Fatalities
Operation Enduring Freedom – 2,351
Combat related – 1,843
Non-hostile – 508
Operation Iraqi Freedom – 4,411
Combat related – 3,481
Non-hostile – 930
Operation New Dawn – 66
Combat related – 38
Non-hostile - 28
Source: DMDC

10. Advanced Radiology Techniques
Increased documentation and characterization of injuries sustained
Precise location of foreign bodies, including ballistic projectiles
Visualization of resuscitative devices such as airway devices, intraosseous devices, needle decompression devices and tourniquets

13. Mortality Studies
Holcomb JB et al. Causes of Death in U.S. Special Operations Forces in the Global War on Terrorism (2007)
Kelly JF et al. Injury Severity and Causes of Death From Operation Iraqi Freedom and Operation Enduring Freedom: Versus 2006 (2008)
Eastridge BJ et al. Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care (2011)
Kotwal RS et al. Eliminating Preventable Death on the Battlefield (2011)
Eastridge BJ et al. Death on the Battlefield ( ): Implications for the future of combat casualty care (2012)

14. Mortality Conferences
Established in 2009, bi-weekly conferences with deployed physicians and medical providers
Formal AFMES-JTS monthly conference
Emphasis on injuries sustained and treatment observed
Identify any process improvements
Survivability or potential survivability based on injuries sustained

18. Abbreviated Injury Scale
Near complete transection of the aorta
Left hemothorax and hemopericardium
vs.
Left hemothorax due to near complete transection of the aorta

19. Abbreviated Injury Scale (2008)
– Aortic laceration, perforation, puncture
– Thoracic injury, hemothorax >1000cc in at least one chest cavity
vs.
– Aorta, thoracic, laceration, perforation, puncture, major; transection with hemorrhage not confined to mediastinum
NISS and ISS = 75

21. Conclusions
Complete forensic pathology investigations to include advance radiologic techniques and photography of major injuries sustained
Collaboration with trauma physicians and medical providers
Evidence-based determination of lethal injuries
Incorporation of poly-trauma

22. “Make Good from the Bad” - Harcke 2005
Questions?
“Make Good from the Bad” - Harcke 2005