Saving Lives on the Battlefield

Combat Casualty Care CourseFort Sam Houston, Texas

13 February 2013

COL Russ S. Kotwal, MD MPH FAAFP

• Epidemiology– Study of health and disease in human populations

• Biostatistics– Application of statistics in the health-related fields– Statistics = the process of analyzing data!

Battlefield Epidemiology and Biostatistics

• DataPOI → Tactical Evacuation (CASEVAC & MEDEVAC) → Role 2

→ Intratheather Evacuation→ Role 3 → Intertheater Evacuation → Role 4 → Intertheather Evacuation → Role 5

Battlefield Epidemiology and Biostatistics

“Accurate understanding of the epidemiology and outcome of battle injury is essential to improving combat casualty care.”

Definitions standardize numbers and allow comparisons and trends.

Holcomb JB, Stansbury LG, Champion HR, Wade C, Ballamy RF. Understanding combat casualty care statistics. Journal of Trauma 2006, 60(2):397-401.

Battlefield Epidemiology and Biostatistics

Holcomb JB, Stansbury LG, Champion HR, Wade C, Ballamy RF. Understanding combat casualty care statistics. Journal of Trauma 2006, 60(2):397-401.

%KIA – Potential measure of:1. weapon lethality2. effectiveness of prehospital medical care3. availability of tactical evacuation

%DOW – Potential measure of:1. precision of initial pre-hospital triage and care2. optimization of evacuation procedures3. application of a coordinated trauma system4. effectiveness of MTF care

CFR – Potential measure of overall battlefield lethality in a battlefield population

– TCCC is a contributing factor in reducing CFR and decreasing preventable death on the battlefield

– Tien, et al, and Kragh, et al, depict safety and lives saved through TCCC and use of pehospital tourniquets

Holcomb JB, Stansbury LG, Champion HR, Wade C, Ballamy RF. Understanding combat casualty care statistics. Journal of Trauma 2006, 60(2):397-401.Wilensky G, Holcomb JB. Tactical combat casualty care and minimizing preventable fatalities in combat. Defense Health Board Memorandum, 2009.Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evaluation of Tactical Combat Casualty Care interventions in a combat environment. Journal of the American College of Surgeons 2008, 207(2):174-8.Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery 2009, 249(1):1-7.

Battlefield Epidemiology and Biostatistics

WW II Vietnam OEF OIF OEF/OIF% KIA 20.2 20.0 14.7 16.4 14.5

% DOW 3.5 3.2 5.2 6.0 5.7CFR 19.1 15.8 10.3 10.0 10.2

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

OEF Cumulative Rolling Monthly Averages: %KIA, %DOW, CFR and Avg mISSNov 2003 - Mar 2012

Cum KIA% Cum DOW% Cum CFR% Cum Avg mISS

Produced by the Joint Theater Trauma RegistryData Source: JTTR v.3 data extract supplemented by data provided by DMDC Statistical Analysis Division & US Pentagon OSD

Month / Year

OEF Cumulative Rolling Monthly Averages:%KIA, %DOW, CFR and Avg mISS (Nov 2003 – Mar 2012)

Approved for public release by USAISR PAO and Operational Security Office on 7 August 2012.

Where Do Battlefield Casualties Die?Past = 88% Prehospital Present = 87.3% Prehospital

(4016/4596)

87.3%(n=4,016)

12.7%(n=580)

0102030405060708090

100

Pre-MTF DOWPe

rcent

Mortality Site

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: 431-7.

Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Military Medicine 1984, 149(2):55-62.

Eastridge 2012 Study:

• 4,596 U.S. deaths

• 87% pre-hospital deaths

• 24% of pre-hospital deaths were potentially survivable

Holcomb, et al, 2005 – US SOF Preventable Deaths = 15%Kelly, et al, 2008 – US Military Preventable Deaths = 24%

Eastridge, et al, 2011 & 2012 – US Military Preventable Deaths = 27.6%

Preventable Death Studies

Where Can We Save the Most Lives?

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: 431-7.

Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. Journal of Trauma 2011, 71(Suppl 1):4-8.

What is the Cause of Death?

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: 431-7.

91%(n=888)

7.9%(n=77) 1.1%

(n=11)0

102030405060708090

100

Hemorrhage Airway Obstruction Tension Pneumothorax

Perc

ent

Physiologic Cause

Extremity [119/888] = 13.5%Junctional [171/888] = 19.2%

Truncal [598/888] = 67.3%

Maughon – Mil Med 1970 – Vietnam:• 193 Extremity Hemorrhage Deaths / 2600 Battlefield Deaths = 7.4%Kelly – J Trauma 2008 – OEF and OIF:• 77 Extremity Hemorrhage Deaths / 982 Battlefield Deaths = 7.8%Progress...???

Extremity Hemorrhage Control

Kragh, et al – Tourniquet Study • Ibn Sina Hospital, Baghdad, 2006 • Tourniquets are saving lives on the battlefield • 31 lives saved in 6 months by use of prehospital tourniquets• Author estimated 3000 lives saved with tourniquets in this conflict as of 2012

Postscript: The U.S. military went to this war without tourniquets …TCCC helped to get this fixed…

Eastridge – J Trauma 2012 – OEF and OIF:• 119 Extremity Hemorrhage Deaths / 4596 Battlefield Deaths = 2.6%

Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 2009. 249(1):1-7.

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: 431-7.

Extremity Hemorrhage Control

How Can We Save More Lives?

*Key to Trauma Care Delivery: “Time to required [injury-dictated] capability [successfully performed]“

Trauma Care Delivery

Documentation

Data Abstraction

Trauma Registry

Data Analysis

Performance Improvement

Best Practice Guidelines

Personnel Training

Equipment

If…Strategy follows structure…

If…Culture follows structure…

Then…Performance improvement directed toward structure have the best opportunity to improve strategy and culture

Paradigm Shift and Primary Focus

Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Military Medicine, 1984. 149(2):55-62.

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press.

Paradigm Shift and Primary Focus

If…[After 30 years] “87.3% of all injury mortality [still] occur in the pre-MTF environment” – Eastridge, 2012

If…“[88%] of combat casualty deaths occur on the battlefield before the casualty ever reaches a medical treatment facility” – Bellamy, 1984

Then…Performance improvement directed toward primary prevention (TTPs); secondary prevention (PPE); pre-MTF care (Personnel, Training, Equipment); and Tactical Evacuation (MEDEVAC and CASEVAC Personnel, Training, Equipment) have the best opportunity to reduce preventable death on the battlefield

• Based on trauma courses NOT developed for combat• No emphasis for combining good medicine with good tactics• Medics taught NOT to use tourniquets• No hemostatic agents• Large volume crystalloid fluid resuscitation for shock• Two large bore IVs on all casualties with significant trauma• No focus on prevention of trauma-related coagulopathy• Civil War-vintage technology for battlefield analgesia (IM morphine)• Aggressive spinal immobilization for all neck and back trauma• No specific first responder resuscitation guidance for TBI

Butler FK, Blackbourne LH. Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. Journal of Trauma 2012, 73(6) Suppl 5: 395-402.

Battlefield Trauma Care: Then (2001) – “Civilian-Based Care”

• Phased “tactical” care in TCCC• Aggressive use of tourniquets• Combat Gauze as a hemostatic agent• Aggressive needle chest decompression• Improved non-surgical airway interventions• Surgical airways as needed for facial trauma• IVs only when needed, and IO access if required• Permissive hypotensive resuscitation with Hextend• Much improved analgesia (IV morphine, OTFC, ketamine)• Battlefield antibiotics; hypothermia prevention• First responder resuscitation guidance for TBI• Tranexamic acid (TXA) for torso hemorrhage• Junctional hemorrhage devices• Avoid NSAIDs (aspirin, motrin)

Battlefield Trauma Care: Now (2012) – “TCCC-Based Concepts”

Butler FK, Blackbourne LH. Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. Journal of Trauma 2012, 73(6) Suppl 5: 395-402.

Military Medicine Supplement, August 1996

Best-practice pre-hospital trauma care guidelines

customized for the battlefield

Tactical Combat Casualty Care

TCCC: A Brief History• Original paper published in 1996• First used by SEALs & Rangers in 1997• Updates have been published in the

authoritative Pre-Hospital Trauma Life Support manual since 1999– Endorsed by American College of Surgeons and

National Association of Emergency Medical Technicians

• Now used throughout U.S. military, Allied nations, and civilian EMS

• TCCC currently under the Defense Health Board, but needs to be aligned under the Joint Trauma System for optimal function

Circulation – Hemorrhage Control Extremity Junctional Truncal

Airway Breathing Circulation – Resuscitation

Permissive Hypotension Forward Damage Control Resuscitation

Hypothermia Prevention Infection Control Pain Control Documentation – Casualty Card, AAR, Registry Tiered evacuation (both MEDEVAC and CASEVAC) Reduce time to

required capability, “Damage Control Resuscitation” & “Damage Control Surgery”

TCCC = Prehospital BattlefieldTrauma Care Clinical Practice Guidelines

Case Fatality RateEMT-B Flight Medic + Provider (RC-E before and after) = 6.6%EMT-P Flight Medic Pure = 15.6%EMT-B Flight Medic Pure (RC-S before and after) = 23.2%

Rates Before

Flight Paramedic

Rates After

RC-East(Flight Medic with Provider

[MD/RN])

Patients 73 170 155

Deaths 6 11 9

CFR 8.2% 6.5% 5.8%

RC-South(Flight Medic Pure)

Patients 53 32 188

Deaths 15 5 41

CFR 28.3% 15.6% 21.8%

Total

Patients 126 202 346

Deaths 21 16 50

CFR 16.7% 7.9% 14.5%

Performance Improvement:MEDEVAC Flight Medic

Mabry RL, Apodaca A, Penrod J. Impact of critical care-trained paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma 2012. 73(2) Suppl 1: 32-7.

U.S. military preventable deaths: pre-hospital = 24%, total = 27%

U.S. Ranger preventable deaths: pre-hospital = 0%, total = 3%Ranger success = command-directed Casualty Response System and a mastery of the basics through rehearsals, repetition, and conditioning1) All Rangers and Docs trained in TCCC – initial and refresher training2) Casualty scenarios integrated into small unit tactics, battle drills, exercises3) Unit registry used for performance improvement and directed procurement

The Ranger Model “Eliminating Preventable Death on the Battlefield”

Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Archives of Surgery 2011, 146(12): 1350-8.

“The Big Four”(1)Marksmanship

(2)Physical training

(3)Small unit tactics

(4)Medical training

(5)MobilityCOL Stanley A. McChrystal, 75th Ranger Regiment, Regimental Commander, 1998.

Casualty Response System

…Preventive Medicine(Human Performance/Rehabilitation)

…Preventive Medicine

…includes Casualty Battle Drills

…includes Casualty Evacuation

CASUALTY RESPONSE SYSTEM

5Physicians

8Physician Assistants

1 : 30Medic (SOCM)

1 : 10Non-Medic EMT-B/Is

All Other Personnel (> 3000)Non-Medic First Responders

Personnel – Training – Equipment

Tactical Leader Ownership & Responsibility for the

Casualty Response System!

CASUALTY RESPONSE SYSTEM• CRTRL – Casualty Response Training for Ranger Leaders

– Line Command Ownership is key, as they control the time and resources for personnel, training, and equipment

– Contingency planning, tactical response, CCP Ops, CASEVAC

• SOCM – Special Operations Combat Medic– Pre-SOCM Training (Med Fundamentals, Sick Call)– SOCM Course (28 wks – Fort Bragg, NC)– Post-SOCM Training (CTM, TCR, RMAV, SOFMSSC)

• Non-Medic EMT-B/I

• RFR – Ranger First Responder– All personnel, initial and annual refresher training– TCCC-based, focus on hemorrhage control

Personnel – Training – Equipment

CASUALTY RESPONSE SYSTEM

Personnel – Training – Equipment

CASUALTY RESPONSE SYSTEM

Preventable Combat Death

CTMTCR

RMAVSOFMSSC

• CRTRLTactical Leaders

• SOCMMEDICS

• RFR & EMTNon-MedicsVeliz CE, Montgomery HR, Kotwal RS. Ranger First Responder and the evolution of Tactical Combat Casualty Care. J Spec Oper Med 2010;10(3):90-1.

CASUALTY RESPONSE SYSTEM

ELIMINATE POTENTIALLY SURVIVABLE CAUSES OF DEATH!

3. Prehospital Trauma Registry(Refine TTPs, PPE, TCCC [Personnel, Training, Equipment])

2. TCCC Training for All Personnel(Conditioning through Repetition, Become Masters of the Basics)

1. Tactical Leader Ownership of System

THREE KEY PRINCIPLES…ONE GOAL

CASUALTY RESPONSE SYSTEM

CSM Michael T. Hall, 75th Ranger Regiment, Regimental Sergeant Major, 1999.

As all have the potential to be a casualty, and all have the potential to be a first responder:

1. All will carry a Bleeder Control Kit

2. All will carry a Casualty Card to document care…

Documentation Requirements1. Usable in the “Tactical” environment

Cannot detract from the combat mission Cannot hinder combat casualty care Cannot put Task Force at risk Must be durable and redundant

2. Supports, and is driven by, “First Responder” TCCC tasks and scope of practice

3. Must be “Soldier-centric,” not medic-centric, thus ubiquitous, simple to use, durable, and readily identifiable with the casualty

DD Form 1380 FMC1999:

Ranger Casualty Card2008:

CoTCCC-TCCC Card2009:

DA Form 7656 TCCC Card

Why Document?PATIENT Improve care, continuity of care, historical record of

event, and support for entitlements

PROVIDER

Provider-to-provider communication of patient status, injuries, and treatment Use data, statistical analysis, and epidemiologic study to reduce morbidity and mortality through:

1. Preventive Medicine: force protection modifications2. Good Medicine: evidence-based treatment protocols3. Standardized Medicine: global policy application

COMMANDER

Use data, statistics, trends, and analysis to:1. Improve command visibility of casualties2. Augment decision-making process3. Validate and refine casualty response system and TCCC4. Refine personnel, training, & equipment requirements5. Refine force protection requirements and procurement

Casualty Card and AAR collection of point-of-injury data at near-real time for timely unit-based PHTR command-level reports and feedback in order to: 1. Improve Command visibility of casualties2. Augment Commander’s decision-making process3. Validate and refine casualty response system and TCCC treatment strategies4. Refine medical & non-medical personnel, training, and equipment requirements5. Reduce morbidity/mortality,force protection modifications, directed procurement

Medic Enters Casualty Data Data Populates Graphs, Shows Trends, Depicts Wounding Patterns

PREHOSPITAL TRAUMA REGISTRY

PHTR RESEARCH – Example 1ARMY RANGER CASUALTY, ATTRITION, AND SURGERY RATES

FOR AIRBORNE OPERATIONS IN AFGHANISTAN AND IRAQKotwal RS, Meyer DE, O’Connor KC, Shahbaz BA, Johnson TR, Sterling RA, Wenzel RB

Aviation, Space, and Environmental Medicine. October 2004; 75(10):833-40.

INTRODUCTION: Examined airborne casualty, attrition, and surgery rates in U.S. Army Rangers during combat operations in order to identify risk factors attributed to static-line parachute injuries and provide a comparison to estimated attrition rates.METHODS: Data were recorded on standardized manual casualty cards during two missions into Afghanistan during Operation Enduring Freedom and two missions into Iraq during Operation Iraqi Freedom, and then consolidated onto an electronic database for further analysis.RESULTS: 4 airborne missions totaling 634 jumpers resulted in 83 injuries sustained by 76 Rangers (12%). 27 Rangers (4%) were unable to continue the mission and were evacuated. 11 Rangers (2%) required surgery. The overall observed attrition rate differed from the estimated rate (p = 0.04). Although observed attrition rates did not differ from estimations in Afghanistan (p = 0.75), attrition rates in Iraq were greater than estimated rates (p = 0.02) and observed rates in Afghanistan (p = 0.05).

CONCLUSION: Many factors impact casualty, attrition, and injury patterns. Terrain and equipment load were notable associations.

ENVIRONMENTAL FACTORS

MISSION 1 MISSION 2 MISSION 3 MISSION 4

Location Afghanistan Afghanistan Iraq Iraq

Time of Year October 2001 November 2001 March 2003 March 2003

Time of Day, % Illum* Night, <5% Illum† Night, <5% Illum Night, 47% Illum Night, <5% Illum‡

Ground Elevation§ 3300 ft 3300 ft 500 ft 500 ft

Ground Wind Speed¶ 1 knot 5 knots 8 knots 5 knots

Temperature¶ 60o F 50o F 56o F 40o F

Aircraft C130 C130 C130 C17

Exits Used 2 Side Doors 2 Side Doors 2 Side Doors, Tailgate 2 Side Doors

Jump Altitude (AGL)** 800 ft 800 ft 800 ft 800 ft

Average Equip Load 47 lb. 43 lb. 90 lb. 85 lb.

Drop Zone Hard/Even(Landing Strip)

Hard/Even(Landing Strip)

Hard/Even(Landing Strip)

Hard/Even/Hazards(Paved Runway)

* Value obtained from assigned Air Force Staff Weather Officer (SWO) immediately prior to each mission.† Pre-assault fires on the objective provided additional ambient light.‡ Targets engaged on adjacent objectives provided an additional visual cue of the horizon.§ Approximation in feet above mean sea level obtained from topographical maps of each location.¶ Approximate value obtained from environmental data specialist at each location.** Above ground level.

Parachutists Casualties Attrition Surgeries Ruck Weight

Mission 1 199 14.07% 2.01% 1.01% 47 lbs

Mission 2 45 13.33% 2.22% 0.00% 43 lbs

Mission 3 175 13.71% 5.71% 2.29% 90 lbs

Mission 4 215 8.37% 5.58% 2.33% 85 lbs

PHTR RESEARCH – Example 2A NOVEL PAIN MANAGEMENT STRATEGY

FOR COMBAT CASUALTY CAREKotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB

Annals of Emergency Medicine. August 2004; 44(2):121-7.

OBJECTIVE: Evaluate the effectiveness of a novel application of a pain control medication in the reduction of acute pain for wounded Special Operations soldiers in an austere combat environment.

METHODS: Oral transmucosal fentanyl citrate was administered during missions in support of Operation Iraqi Freedom from March 3, 2003, to May 3, 2003. Pretreatment, 15-minute posttreatment, and 5-hour posttreatment pain intensities were quantified by the verbal 0-to-10 numeric rating scale.

RESULTS: A total of 22 patients. The mean difference in verbal pain scores (5.77; 95% confidence interval [CI] 5.18 to 6.37) was found to be statistically significant between the mean pain rating at 0 minutes and the rating at 15 minutes. However, the mean difference (0.39; 95% CI -0.18 to 0.96) was not statistically significant between 15 minutes and 5 hours, indicating sustained action without need for redosing.

CONCLUSION: Oral transmucosal fentanyl citrate can provide an alternative means of delivering effective, rapid-onset, and noninvasive pain management in an out-of-hospital, combat, or austere environment.

The median pain rating at initial presentation was 7.0 (Mean 7.18, SD 1.26, 95% confidence interval [CI] 6.62 to 7.74, N=22). The median pain rating at 15 minutes following medication administration was 1.0 (Mean 1.41, SD 1.74, 95% CI 0.64 to 2.18, N=22), and the median pain rating at 5 hours following medication administration was 0.5 (Mean 1.00, SD 1.37, 95% CI 0.32 to 1.68, N=18).* Data was not obtained for four casualties (1, 2, 3, 14) at the 5-hour mark. Three casualties (13, 14, 22) received additional pain medication prior to this time.

Figure 2. Casualty Number Plot of Effect of 1600 mcg OTFC on Subjective Pain

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0 Min 15 Min 5 Hrs*

Time

Su

bje

ctiv

e P

ain

13 14

5

18 19 21 22

4 6 8 7 11 12 20

1 2 3 9 10 15 16 17

14

13 18 22

20

19 18 19

20

11 11

131210 15

1 - 10 12 15 - 17 21 4 - 9 16 17 21 22

PHTR RESEARCH – Example 3EFFICACY OF POINT-OF-INJURY COMBAT ANTIMICROBIALS

Murray CK, Hospenthal DR, Kotwal RS, Butler FKJournal of Trauma. August 2011; 71(Suppl 2):307-13.

INTRODUCTION: One strategy to decrease infections is immediate delivery of antimicrobials at or near the point-of-injury by the casualty or the first medical responder. We review infectious complications and colonization rates associated with delivery of point-of-injury antimicrobial therapy.METHODS: Reviewed casualty treatment data from the 75th Ranger Regiment prehospital trauma registry on patients injured between March 2003 and March 2010 and linked this to electronic medical record data in order to look for presence of bacterial infection or colonization within 30 days of injury. RESULTS: Of 405 total casualties, 28 (6.9%) were infected with gram-negative bacteria, primarily A. baumannii. The only identified risk factor for infection was higher military Injury Severity Score. Prehospital administration of antimicrobials to 113 of 405 casualties (27.9%), including 8 of the 28 infected casualties, did not affect infection or colonization rates.

CONCLUSION: A significant difference in infection rates and MDR pathogen colonization was not seen in those casualties who received single-dose broad spectrum antimicrobials at the point-of-injury, confirming neither benefit nor harm.

PHTR RESEARCH – Example 4ELIMINATING PREVENTABLE DEATH ON THE BATTLEFIELD

Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB Archives of Surgery, 2011. 146(12): 1350-8.

INTRODUCTION: The 75th Ranger Regiment comprehensively integrated TCCC training with a prehospital trauma registry (PHTR) through a command-directed casualty response system. This system is evaluated in terms of battlefield survival.METHODS: Battle injury data were analyzed for combat missions conducted by the 75th Ranger Regiment in Afghanistan and Iraq over 8.5 years, from October 2001 through March 2010. Each casualty was scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made to official Department of Defense (DoD) casualty data for the military as a whole.RESULTS: 419 battle injury casualties. Regiment’s 10.7% KIA, 1.7% DOW, and 7.6 CFR rates were lower than the 16.4%, 5.8%, and 10.3 rates for U.S. military as a whole. Of 32 fatalities, 0 were DOW from infection, 0 were potentially survivable through additional prehospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial prehospital care was provided by non-medical personnel.

CONCLUSION: Tactical leader management of a casualty response system that trains all personnel in TCCC and receives continuous feedback from PHTR data resulted in unprecedented reduction of KIA, DOW, and preventable combat death.

aGSW Fatalities: 44% coronal trajectory transthoracic wounds, 31% sagittal trajectory transcranial wounds, 13% coronal trajectory transthoracic and neck wounds, and 6% sagittal trajectory extremity wounds.bIED Fatalities: all had massive head and extremity wounds and 90% also had massive torso wounds.cNon-IED Explosive Fatalities: all had massive torso and extremity wounds and 33% also had massive head wounds.dBlunt Trauma Fatalities: all had massive head, torso, and extremity wounds with a crush component.

Figure 2. The 75th Ranger Regiment casualties (n = 419) (A) and fatalities (n = 32) (B) by MOI between October 1, 2001, and March 31, 2010.

DoDTR Prehospital Documentation:Point of Injury

1 OCT 2011 – 30 SEP 2012 1 JUL 2012 – 30 SEP 2012

Yes91

15%

No52785%

Total N = 618

Yes47

20%

No19480%

N = 241

Data Source: DoDTR as provided by Ms Sheralyn Wright, Joint Trauma System, USAISR

DoDTR Prehospital Documentation:TACEVAC

1 OCT 2011 – 30 SEP 2012 1 JUL 2012 – 30 SEP 2012

Yes177756%

No137144%

N = 3148

Yes57272%

No22128%

N = 793

Data Source: DoDTR as provided by Ms Sheralyn Wright, Joint Trauma System, USAISR

QUESTIONS?

COL Russ S. Kotwal, MD MPH FAAFPJoint Trauma System, USAISR

russ.kotwal@us.army.mil