Death on the Battlefield Implications for Prevention, Training, and Medical Care

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PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH INSIUE OF SURGICAL RESEARCH Combat Casualty Care P R O E C P R O J E C S U S A I N Death on the Battlefield Implications for

1 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH INSIUE OF SURGICAL RESEARCH Combat Casualty Care P R O E C P R O J E C S U S A I N Death on the Battlefield Implications for Prevention, raining, and Medical Care US Army Institute of Surgical Research and Armed Forces Medical Examiner Service Brian Eastridge COL, MC, USA rauma Consultant US Army Surgeon General

2 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Disclaimer he opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

3 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH JS Vision hat every soldier, marine, sailor, or airman injured on the battlefield or in the theater of operations has the optimal chance for survival and maximal potential for functional recovery.

PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Joint heater rauma Registry (JR) Largest combat Injury database in existence All services injury data derived from level IIb, III, IV and

4 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Joint heater rauma Registry (JR) Largest combat Injury database in existence All services injury data derived from level IIb, III, IV and V medical charts Scoring of Injuries Diagnosis and Procedures Outcomes 60,000 US military injury patient records Maintaining the DoD Medical Mortality Registry. he registry component, which has the broader mission of analyzing all active duty deaths for trends and preventable or modifiable risk factors.

PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battle Injuries by Body Region Upper Extremities 22% Shoulder/Upper Arm 6% Forearm/Elbow 6% Wrist/Hand/Fingers 7% Other 3% Brain Injury

5 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battle Injuries by Body Region Upper Extremities 22% Shoulder/Upper Arm 6% Forearm/Elbow 6% Wrist/Hand/Fingers 7% Other 3% Brain Injury (BI) 12% Face 7% Eye 3% Head/Neck 2% Head/Neck 27% Spine/Back 3% 3% Head/Neck Unspec 3% orso 15% Chest 5% Abdomen 6% Pelvis/ Urogenital 3% Hip/Upper Leg/high 5% Knee/Lower Leg/Ankle 9% Foot/oes 5% Lower Extremities 31% runk/back/buttock 1% Other 12% Other 2% Source: JR September 2001 September 2011

6 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Dominant Mechanism of Injury 2/27/2014 Right Patient, Right Care, Right Place, Right ime 32

7 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Cause of Injury *Includes both battle and nonbattle injury 2/27/2014 Right Patient, Right Care, Right Place, Right ime 33

8 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Combat Casualty Care Statistics %KIA = Deaths before MF x 100 KIA + (WIA RD) %DOW = Died after reaching MF x 100 WIA RD CFR = KIA + DOW x 100 KIA + WIA

9 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH U.S. Combat Deaths (DOW+KIA) sustained during OIF, November 2003 September 2010 by month United States Army Institute of Surgical Research Nov 2003 Sept 2010 otal KIA: 2,486 otal DOW: 768 otal Deaths: 3, Nov03 Jan04 Mar04 May04 Jul04 Sep04 Nov04 Jan05 Mar05 May05 Jul05 Sep05 Nov05 Jan06 Mar06 May06 Jul06 Sep06 Nov06 Jan07 Mar07 May07 Jul07 Sep07 Nov07 Jan08 Mar08 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Jan10 Mar10 May10 Jul10 Sep10 DOW+KIA 2 month rolling avg Produced by the Joint heater rauma Registry Data Source: JR v.3 data extract supplemented by data provided by DMDC & US Pentagon

10 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH OIF Cumulative Rolling Monthly Averages 30.0% 25.0% OIF Cumulative Rolling Monthly Averages: %KIA, %DOW, CFR and Avg miss November 2003 September 2010 Cum KIA % Cum DOW % Cum CFR% Cum Avg miss % % % % % Month / Year Produced by the Joint heater rauma Registry Data Source: JR v.3 data extract supplemented by data provided by DMDC Statistical Analysis Division & US Pentagon OSD

11 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH U.S. Combat Deaths Sustained during OEF Nov Nov Mar Dec otal otal KIA: KIA: 1, otal otal DOW: DOW: otal otal Deaths: Deaths: 1,468 1,215 U.S. U.S. Combat Deaths (DOW+KIA) sustained during OEF, November March May by month 0 0 Nov03 Feb04 Nov03 May04 Feb04 Aug04 May04 Nov04 Aug04 Feb05 Nov04 May05 Feb05 Aug05 May05 Nov05 Aug05 Feb06 Nov05 May06 Feb06 Aug06 May06 Nov06 Aug06 Feb07 Nov06 May07 Feb07 Aug07 Nov07 May07 Feb08 Aug07 May08 Nov07 Aug08 Feb08 Nov08 May08 Feb09 Aug08 May09 Nov08 Aug09 Feb09 Nov09 May09 Feb10 Aug09 May10 Nov09 Aug10 Feb10 Nov10 May10 Feb11 May11 Aug10 Aug11 Nov10 Nov11 Feb11 Feb12 May11 DOW+KIA DOW+KIA 2 month rolling avg 2 month rolling avg Produced by the Joint heater rauma Registry Data Source: JR v.3 data extract supplemented by data provided by DMDC & US Pentagon

12 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH OEF Cumulative Rolling Monthly Averages OEF Cumulative Rolling Monthly Averages: %KIA, %DOW, CFR and Avg miss Nov 2003 Mar % % Cum KIA% Cum DOW% Cum CFR% Cum Avg miss % % % % % 0.00 Month / Year Produced by the Joint heater rauma Registry Data Source: JR v.3 data extract supplemented by data provided by DMDC Statistical Analysis Division & US Pentagon OSD

13 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Breakdown between WWII, Vietnam, and Iraq/Afghanistan roops.

OIF percentage of survivability, March 2003December 2010.

14 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH OEF percentage of survivability, October 2001December 2010 and OIF percentage of survivability, March 2003December % Survivability Equipment Doctrine acticsechniques Procedures raining

15 Casualty Combat Care E O PR C C E J O R P U S S A I N OF SURGICAL INSIUE RESEARCH Battlefield Mortality Mechanism and Causation

16 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Empiric Probability Combat Death Bellamy, J rauma, 1984

17 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Mortality Penetrating rauma 100% 80% Instantaneous Death Breathing complications 70% 60% 50% PPE and good tactics Hemorrhag e Airway obstruction Self aid Buddy aid EMB Shoc k ALS level skills Surgery interventions And Antibiotics Infections 6min 1hr 6hr 24hr 72hr

18 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH How People Die in Ground Combat

Injury severity and causes of death from Operation Iraqi

19 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Where can we save the most lives? Kelly JF, et.al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: versus J rauma

PS deaths, 79% secondary to hemorrhage Extremity 31% orso 48%

20 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Potentially Survivable Hemorrhagic Deaths on the Battlefield Of PS deaths, 79% secondary to hemorrhage Extremity 31% orso 48% Axilla/Groin 21% Nearly 50% of deaths not amenable to field control

21 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield Killers

22 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH 100% iming of rauma Death 80% 80% Civilian* Baghdad 60% 40% 45% 34% 20% 17% 20% 3% 0% Acute (<1 hour) Early (14 hrs) Late (>7 days) Martin et al., J rauma 2009

23 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Combat Hospital Killers Martin et al., J rauma 2009

24 Casualty Combat Care E O PR C C E J O R P U S S A I N OF SURGICAL INSIUE RESEARCH Died of Wounds Analysis

25 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW Analysis Review died of wounds (DOW)deaths n=558 Variables Demographics Mechanism and cause Injury severity Expert panel trauma surgeons, emergency physiscian, neurosurgeon, and forensic parthologist graded deaths as non survivable or potentially survivable. Goal: Identify areas for improved training, medical care, material, research and development

26 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW Analysis DOW rate 4.6% NS in 271 (48.6%) and PS in 287 (51.4%) 51% presented in extremis with CPR on admission

27 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW ISS

28 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW Cause

100 90 80 70 60 50 40 30 20 10 0 83 % 16 % 1 raumatic

29 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW NonSurvivable Etiology Percent of Patients % 16 % 1 raumatic Brain Injury Hemorrhage Other Eastridge et al, J rauma 2011

30 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW Potentially Survivable Etiology Percent of Patients % 9 % 8 % 3 % Hemorrhage raumatic Brain Injury Multiple Organ Failure Other (Airway, PX, ) Eastridge et al, J rauma 2011

31 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH DOW (Potentially Survivable) Hemorrhage Focus 21% 31% 48% runcal Extremity Junctional Eastridge et al, J rauma 2011

32 Casualty Combat Care E O PR C C E J O R P U S S A I N OF SURGICAL INSIUE RESEARCH Killed in Action Analysis

33 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH KIA Analysis Review battlefield deaths (n=4,596) Variables Demographics Mechanism and cause Injury severity Expert panel trauma surgeons, emergency physiscian, neurosurgeon, and forensic parthologist graded deaths as non survivable or potentially survivable. Goal: Identify areas for improved training, medical care, material, research and development

34 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH KIA Analysis Nonsurvivable Dismemberment raumatic brain injury Cervical cord transection (above C3) Airway transection within thorax Cardiac injury (>1/2 ), thoracic aorta injury, pulmonary artery Hepatic avulsion Junctional lower extremity amputations with open pelvis with soft tissue loss

35 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH KIA Analysis Potentially survivable All other injuries

36 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Where Battlefield Casualties Die n=4,596

37 Casualty bat Ca re IU PRO INS CH EC N RO C S U S AR P JE E SE om AI C OF SURGICAL RE Putting it in Perspective DOW KIA

38 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Distribution of Battlefield Death n=4,596

39 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield PreMF Death Analysis n=4,090 (DOW excluded)

40 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Potentially Survivable PreMF Death Analysis (n=1,075)

41 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield PreMF Mortality Cause n=4,090

42 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield Instantaneous Lethality n=1,391

43 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield Acute Lethality Non Survivable (n=1,624)

44 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Battlefield Acute Lethality Potentially Survivable n=1,075

45 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Hemorrhage Focus (n=984)

46 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Can We Have An Impact?

47 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Conclusion Most battlefield casualties (88.9 %) die on the battlefield Majority of battlefield deaths (73.7%) are nonsurvivable Mitigation strategy: prevention Hemorrhage is the major mechanism of death in (91.5 %) of PS combat injuries. Mitigation strategy: hemorrhage control ourniquets Junctional hemorrhage control Intracorporeal hemostasis Freeze dried plasma XA Novel therapeutics Extending the survival time window from POI to MF

48 PR O E C P R O J E C S U S A I N INSIUE OF SURGICAL RESEARCH Conclusion Understanding battlefield mortality is a vital component of the trauma system rauma system optimization CCC improvements Data driven research and development focus Command emphasis raining & tactical perspective Kotwal et al, Arch Surg, 2011 Equipment and materiel

49 Casualty Combat Care E O PR C C E J O R P U S S A I N OF SURGICAL INSIUE RESEARCH Questions?

Modern Military Trauma. from 16 Years of Conflict. Care: Lessons Learned. Joe DuBose MD, FACS FCCM

Modern Military Trauma. from 16 Years of Conflict. Care: Lessons Learned. Joe DuBose MD, FACS FCCM Modern Military Trauma Care: Lessons Learned from 16 Years of Conflict Joe DuBose MD, FACS FCCM Associate Professor of Surgery Uniformed Services University of the Health Sciences Lt Col USAF MC Director