Profiles in Combat Casualties

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

2. 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.

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

28. Chest Other 13% 9% Head & Neck Upper 17% Extremities Abdomen 21% 5% Lower Extremities 35% War Wound Distribution 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 byGeographic Environment and Type of Combat

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

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

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

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