Profiles in Combat Profiles in Combat CasualtiesCasualties

COL CLIFFORD C. CLOONAN, MD, FACEP

Interim Chair Dept. of Military and

Emergency Medicine

USUHS

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.

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

Dulce bellum inexpertis

(War is delightful to those who have no experience of it)

Erasmus

The Evolution of The Evolution of

Weapons of WarWeapons of War

Wounds of War

Historical

Background

The Inventionof Gunpowder

Encoded formulafor gunpowder and a depictionof its use

HISTORY OF WAR WOUNDS

CHANGING PATTERNS OF WOUNDING THROUGHOUT HISTORY

EFFECTS OF EVOLVING WEAPONS SYSTEMS

EFFECTS OF EVOLVING TACTICS

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

Combat Wounds Are Unique

High percentage of penetrating wounds

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

HighlyContaminated“Old”Wounds

Mechanisms of Combat Injury

Causes of Combat Wounds

(WWI, WWII, Korea, Vietnam, Middle East)

T y p e s o f C a s u a lt ie s

G U N S H O T W O U N D S5 2 %

F R A G M E N T2 9 %

B L U N T16 %

B U R N3 % Mogadishu Raid Casualties

Wounding Mechanism Distribution

Mogadishu Somalia Oct 3 1993

Shell Fragment Wound

Fragments from exploding anti-tank weapon

LandmineInjury

M-16 assault rifle 5.56mm GSW (exit)

Trans-Abdominal High Velocity GSW (fatal)

Facial Burns

Kosovo

Napalm Burns

Vietnam

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

Primary BlastInjury

USS Cole Terrorist Bombing

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

War Wound Distribution

Extremities

Extremities

Chest13%

Upper

21%

Lower

35%

Abdomen5%

Head & Neck17%

Other9%

Upper Extremities

Lower Extremities

Abdomen

Head & Neck

Chest

Other

H E A D & N E C K

1 7 %

C H E S T / B A C K

8 %

A B D O M E N

3 %

U P P E R E X T R E M I T I E S

3 1 %

L O W E R E X T R E M I T I E S

3 2 %

U N K N O W N / C O M B I N A T I O N

9 %

Mogadishu Raid Casualties Anatomic Wound Distribution

Time to death after initial wounding

Mechanisms of Injury Mechanisms of Injury and Distribution of and Distribution of

Injuries byInjuries byGeographic Environment Geographic Environment

and Type of Combatand Type of Combat

North Africa

Agent Percent

Shell fragments...................................…. 75

Bullets...................................................... 20

Mines........................................................ 2

Bombs....................................................... 1

Other......................................................... 2

_____

Total............100

SOUTH PACIFIC

AGENT PERCENT Shell Fragments 50 Bullets: Rifle 25 Machine gun 8 Grenade 12 Mines 2 Other 3

______

Total 100

Vietnam

Agent Percent

Shell Fragments 38.9

(Artillery, mortar, rocket)

Bullets (rifle and pistol) 23.8

Booby traps, mines, grenades 27.7

Wounding Agents in the Falklands

Gunshot Wounds - 38%

Fragment- Caused Wounds - 40%

Burns - 18%

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%)

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

Vietnam - Morbidity & Mortality

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

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%

War WoundsWar Wounds

Who is wounded / killed in war?

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

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

Desert Storm - Desert Storm - Cause of DeathCause of Death

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.

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

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

Mortality Rate of Extremity Wounds (%)

World War II Korea Vietnam

Upper 0.1 0.2 0.15

Lower 3.0 0.7 0.5

"BATTLE CASUALTIES, INCIDENCE, MORTALITY,

AND LOGISTIC CONSIDERATIONS"

By

Gilbert W. Beebe, Ph.D..

Michael E. De Bakey, MD

UNDERSTANDING UNDERSTANDING WAR, HISTORY WAR, HISTORY

AND THEORY OF AND THEORY OF COMBATCOMBAT

BY

T.N. Dupuy, 1987

Paragon House Publishers, N.Y.

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.

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

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

Casualty Rates

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

Attrition Rates

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

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".

QuotesQuotes

VICTORY IS THE

BEST MEDICINE

QuotesQuotes

...[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”

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

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)

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

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%

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 <5 minutes of wounding)

– Relatively few die once reaching a hospital