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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