First, let me begin by stating that this article deals with a sensitive topic in that it discusses how U.S. military men and women die in battle, and it goes on to note that with improved care and faster evacuation times, a significant number of the combat fatalities in Iraq and Afghanistan could have been prevented.
The article addresses not just the mechanism of injury (for instance, a gunshot wound to the chest), but also the physiological result of that injury (for instance, a tension pneumothorax). And yet, so that we do not forget, each of these statistics corresponds to a fallen serviceman or woman, to someone’s father, mother, son, or daughter.
That is worth keeping in mind as we delve into the subject at hand.
Secondly, the title of this article is gender specific. Yes, women are also dying in battle—more so than ever before, in fact—and this author is all for opening up fully all combat units to women, as well as entering them in the Selective Service, for that matter, in the name of full equality. That is a whole other article, though, and for our purposes here, we shall leave the subject alone.
For the sake of this article, we are using in the title the gender-specific “men,” because the great majority of combat deaths (over 97 percent) are among males, and for the sake of brevity in the article’s title, the word simply fits better. Do not interpret this article as limited only to males, though. Women are being killed on the battlefield too these days, and are included in these statistics.
With that said, just how are men and women dying on the battlefield in the last 16-plus years of American war? Studies have been conducted on this topic, not to find fault, but to look for opportunities to improve combat casualty care. The largest and most significant study on combat fatalities from Iraq and Afghanistan was published in 2012 in the Journal of Trauma and Acute Care Surgery, and titled “Death on the Battlefield (2001-2011): Implications for the Future of Combat Casualty Care,” by Dr. Brian Eastridge, et al.
The Eastridge study focuses on the time period from October 2001 to June 2011. An autopsy conducted by the Armed Forces Medical Examiner System at their facility in Dover, Delaware, is conducted on all U.S. military fatalities resulting from trauma. The autopsy records for all trauma deaths that occurred in individuals deployed to Iraq or Afghanistan during the study period were identified. Of the 4,596 fatalities included in the study, it was noteworthy that 87 percent of the deaths in the study occurred before the wounded service member reached a medical treatment facility where surgical care could be provided. Furthermore, of that 87 percent of deaths that occurred pre-hospital, 24 percent had wounds that were judged to have been “potentially survivable.”
To clarify, consider a sample of 100 combat fatalities: 87 of them will have died before reaching a medical treatment facility (on the field of battle, or while being transported to a hospital). Out of those 87 pre-hospital fatalities, approximately 21 of them could have survived their wounds if their battlefield trauma care and transport time to the hospital had been optimized. The remaining 66 had devastating wounds that were not survivable no matter what care had been provided.
This leads one to ask, then, what injuries are proving fatal to American fighting men and women on the battlefield, and what is causing those injuries?
The answer to the question of how these men and women are being injured is pretty clear-cut and makes sense for battlefields where there is little actual force-on-force fighting, and more ambushes and IEDs. The primary causes of lethal injuries to American military personnel in combat in Afghanistan and Iraq are explosions (73.7 percent), gunshot wounds (22.1 percent), and other causes such as vehicle crashes, “industrial”-type accidents, crushing injuries, etc. (4.2 percent). There are no great surprises there, given the nature of warfare and the dangers associated with operations on the modern battlefield.
Of the fatalities, 35 percent involved instantaneous death, primarily caused by “physical dismemberment, catastrophic brain injury, and destructive cardiac and thoracic great vessel injury,” according to Eastridge. The term “great vessel injury” refers to massive and catastrophic injury to the very large arteries and veins in the chest, such as the aorta, the vena cava, and the pulmonary arteries and veins. Individuals with significant injury to these structures bleed to death very quickly.
Of the fatalities studied, approximately 52 percent of those who died did so within “minutes or hours” of the time of injury, before reaching a medical treatment facility. The non-survivable injuries suffered by this group included traumatic brain injury, injuries to the heart and thoracic blood vessels, high spinal cord injuries, and destructive injuries to the “abdominopelvic” area, per Eastridge.
Of those 52 percent of fatalities who died within minutes or hours, some could have survived given the availability of proper medical training and equipment and/or rapid transport to a surgical facility. These deaths were primarily (91 percent) caused by hemorrhage (bleeding to death) and airway obstruction (eight percent).
Digging further into those deaths caused by hemorrhage, the lethal bleeding occurred in the torso (non-compressible hemorrhage) 67.3 percent of the time; in the so-called “junctional” areas where the arms, legs, and neck meet the torso 19.2 percent of the time; and in the extremities (arms and legs) 13.5 percent of the time.
The Eastridge study notes that deaths due to extremity bleeding decreased to 2.6 percent of the total combat fatalities (a reduction of 67 percent compared to earlier studies from Iraq and Afghanistan) after the widespread fielding and use of modern extremity tourniquets. This landmark change in battlefield trauma care was pioneered by Tactical Combat Casualty Care (TCCC) and was implemented thoughout U.S. combat forces during the years 2005-2007.
The dramatic reduction in deaths from extremity hemorrhage observed after this transition took place makes tourniquet use the signature success in battlefield trauma care in these two wars and is one of the most significant changes to U.S. military medicine in decades.
The Eastridge study also highlighted the need for better techniques to control junctional and truncal hemorrhage, noting that “there was no effective means to control or temporize junctional or truncal sources of hemorrhage on the battlefield.” This means that there is a “clear and persistent gap in medical treatment capability” when it comes to stopping torso bleeds.
With respect to the junctional hemorrhage deaths, this type of hemorrhage is external and theoretically compressible, that is, able to be controlled by a medic though the use of pressure. In the early years of the war, the U.S. military had not yet fielded combat gauze or other hemostatic dressings. Junctional tourniquets, capable of being applied in the groin area and controlling hemorrhage by compressing the large vessels to the legs as they cross the groin area, were not introduced in U.S. forces until 2011.
In the years since the Eastridge study, TCCC has recommended three junctional tourniquets for use (The Combat Ready Clamp, the Junctional Emergency Treatment Tool, and the SAM Junctional Tourniquet), but these devices are still not being used by all units in the U.S. military. The Eastridge study helped to document the need for this advance in battlefield trauma care.
It is more difficult to stop massive bleeds that occur in the torso, but TCCC measures such as the use of tranexamic acide (TXA), pelvic binders, prehospital use of blood products rather than crystalloid for fluid resuscitation, avoidance of conditions that decrease the blood’s ability to clot (coagulopathy), and avoidance of pain medications that worsen shock (opioids) through the use of ketamine in such casualties. All have the potential to reduce death from non-compressible hemorrhage. The only truly effective measure for this type of bleeding, however, has been and continues to be a skilled trauma surgeon.
Research and development is ongoing in the area of non-compressible hemorrhage, and promising new treatment options such as resuscitative endovascular occlusion of the aorta (REBOA), and injectible foams such as ResQFoam, may soon offer new hope for casualties with internal bleeding.
In summary, most deaths on the battlefield are caused by injuries that are non-survivable. Advances in medical care will not save service members whose airplane explodes in mid-air or who are hit by a direct strike from an artillery round. The Eastridge study found, however, that “the survivability of those injured on the battlefield is an unprecedented historical level of 90 percent, compared with 84 percent in Vietnam and 80 percent in World War II,” and notes further that “some of the likely factors influencing this improved survivability include advances in personal protective equipment, a deployed trauma system, and improved training of medics and corpsman based on the concepts of Tactical Combat Casualty Care (TCCC).”
Our deployed servicemen and women can take great comfort in knowing that casualty survival in the U.S. military is at an all-time high. But the military must remain vigilant for ways to continue to improve combat casualty care. It must also continue to turn the intent and methods of the Eastridge study into an ongoing process.
We should not wait until a decade of war has occurred to see how we are doing in combat casualty care. Every death sustained by U.S. forces should be carefully studied by the Armed Forces Medical Examiner System and the Joint Trauma System to determine what more, if anything, could have been done to save that serviceman or woman. Furthermore, we have to make sure that we do that for the next casualty, too.
Our nation’s combat casualties deserve the absolute best care we can possibly give them, and the ongoing effort to improve that care should never let up.
(U.S. Air Force photo by Airman Cory D. Payne).