Injury and Illness Casualty Distributions among U.S. Army and Marine Corps Personnel during Operation Iraqi Freedom

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1 MILITARY MEDICINE, 173, 3:247, 2008 Injury nd Illness Csulty Distriutions mong U.S. Army nd Mrine Corps Personnel during Opertion Irqi Freedom Jmes M. Zouris, BS*; Amer L. Wde, MPH ; Cheryl P. Mgno, MPH ABSTRACT The ojetive of this study ws to evlute the distriutions of U.S. Mrine Corps nd Army wounded in tion (WIA) nd disese nd nonttle injury (DNBI) sulties during Opertion Irqi Freedom Mjor Comt Phse (OIF-1) nd Support nd Stility Phse (OIF-2). A retrospetive review of hospitliztion dt ws onduted. 2 tests were used to ssess the Primry Interntionl Clssifition of Diseses, 9th Revision (ICD-9), dignosti tegory distriutions y phse of opertion, sulty type, nd gender. Of the 13,071 sulties identified for nlysis, 3,263 were WIA nd 9,808 were DNBI. Overll, the proportion of WIA ws higher during OIF-1 (36.6%) thn OIF-2 (23.6%). Mrines hd higher proportion of WIA nd nonttle injuries thn soldiers. Although overll DNBI distriutions for men nd women were sttistilly different, their distriutions of types of nonttle injuries were similr. Identifying differenes in injury nd illness distriutions y hrteristis of the sulty popultion is neessry for militry medil rediness plnning. *Nvl Helth Reserh Center, 271 Ctlin Boulevrd, Sn Diego, CA Siene Applitions Interntionl Corportion, In., Cmpus Point Drive, Sn Diego, CA Sn Diego Stte University Reserh Foundtion, 5250 Cmpnile Drive, Sn Diego, CA The views expressed in this rtile re those of the uthors nd do not reflet the offiil poliy or position of the Nvy, Deprtment of Defense nor the U.S. government. Approved for puli relese; distriution is unlimited. This reserh hs een onduted in ompline with ll pplile federl regultions governing the protetion of humn sujets. No humn sujets were diretly involved in this reserh. This mnusript ws reeived for review in Ferury The revised mnusript ws epted for pulition in Novemer INTRODUCTION Exmining nd understnding the distriution of omt sulty illnesses nd injuries is essentil to improving militry medil plnning. Relile estimtes of sulties nd threts to the Helth Servie Support (HSS) system, suh s mss sulty situtions, re neessry to forest medil resoure requirements for militry opertions. Csulty estimtes onsist of solute numers, surges in sulty dmissions, evution ptterns, nd the distriution of types of injuries nd illnesses. Hospitliztion estimtes nd other support requirements re derived from these dt nd re then inorported into HSS plnning tools, suh s the Medil Anlysis Tool (MAT), 1 Estimting Supplies Progrm, 2 nd Ttil Medil Logistis Plnning Tool. 3 MAT is joint medil resoure plnning tool tht provides theter-wide medil nd linil deision support during plnning, progrmming, nd deployment. MAT lso provides medil plnners with the level nd sope of medil support needed for joint opertion, nd the pility of evluting prole ourses of tion for vriety of senrios. The Estimting Supplies Progrm nd the Ttil Medil Logistis Plnning Tool re the plnning tools used y the Mrines nd Nvy to estimte nd onfigure the uthorized medil llowne lists, provide overll medil system nlysis, nd ssist in risk ssessment nd pility-sed plnning. The purpose of the present study ws to desrie the distriution of evuted wounded in tion (WIA) nd disese nd nonttle injury (DNBI) sulties sustined during the Mjor Comt Phse (OIF-1) nd the Support nd Stility Phse (OIF-2) of Opertion Irqi Freedom (OIF) involving the U.S. Army nd Mrines. This study uses dt from the TRANSCOM Regulting nd Commnd nd Control Evution System (TRAC2ES) nd the Joint Ptient Trking Applition (JPTA). TRAC2ES is World Wide We-sed system tht provides doumenttion on ptient regultion nd movement for ll rnhes of the U.S. Armed Fores in the theter of opertions. The JPTA is World Wide We-sed ptient trking nd mngement tool tht ollets, mnges, nlyzes, nd reports dt on ptient trnsfers, nd provides informtion out trnsporttion, tretment, nd disposition of ptients from Opertions Irqi nd Enduring Freedom. The dt from the JPTA eme ville fter Jnury Both systems re prt of the Theter Medil Informtion Progrm Joint (TMIP-J). 4 TMIP-J is fmily of systems designed to id deployed medil personnel in ll levels of re in theter, inluding omplete linil re doumenttion, medil supply nd equipment trking, ptient movement visiility, nd helth surveillne. METHODS A retrospetive review of hospitliztion ICD-9 (Primry Interntionl Clssifition of Diseses, 9th Revision) dt from OIF ws performed. Dt from OIF-1 (Mrh 21 April 30, 2003) were otined from TRAC2ES. Dt from OIF-2 (Mrh 1, 2004 April 30, 2005) were otined from JPTA. 5 Primry ICD-9 6 dignoses, gender, nd servie were extrted from the respetive dtses for eh ptient. Csu- MILITARY MEDICINE, Vol. 173, Mrh

2 lties were tegorized s WIA or DNBI nd were ssigned to n ICD-9 dignosti tegory (or injury sutegory) sed on their primry dignosis on dmission. Sine the mjority of WIA nd nonttle injury uslities were from the injury nd poisoning tegory (ICD-9 odes ), these dignoses were lssified into the injury nd poisoning sutegories (i.e., frtures ( ), dislotions ( ), sprins nd strins ( ), urns ( ), intrrnil injury ( ), open wounds ( )) sed on the sulty trum desription. In ddition, mputtions were inluded s unique tegory to prllel previous studies tht exmined injury distriutions. 7 9 Furthermore, two ICD-9 disese tegories, nervous system nd musuloskeletl, were dded to the injury distriution to pture: (1) injuries oded s disese in ICD-9 (e.g., ICD-9 ode , ousti trum (explosive) to er); (2) injuries misoded s diseses (e.g., injuries to the eye); nd (3) future onditions resulting from injury (e.g., Mrine whose k ws injured in omt nd ontinues to seek medil re for k pin). Exluding these situtions would eliminte signifint portion of injury-relted uslities. WIA sulties were defined s tive duty militry personnel who were injured during hostile tion nd required hospitliztion. Csulties who were killed in tion (i.e., died s result of hostile tion efore rehing medil tretment fility), died of wounds (i.e., died s result of wounds reeived during hostile tion fter rehing medil tretment fility), or returned to duty were exluded from nlysis. Sutegories within the injury ICD-9 tegory (e.g., frtures, mputtions) were used to ompre WIA sulties. DNBI sulties were defined s tive duty militry personnel who required hospitliztion due to disese or injury unrelted to hostile event. DNBI sulties were ompred ross 17 ICD-9 dignosti groups. 2 tests of independene were used to ompre the dignosti distriutions (using the ICD-9 dignosti tegories) of WIA nd DNBI sulties y phse of opertion, rnh of servie, nd gender. Sttistil nlyses were performed using SPSS softwre version (SPSS In., Chigo, Illinois); tests were two-tiled nd p 0.05 ws used to determine sttistil signifine. Adjusted stndrdized residuls were used to identify ells tht hd the gretest impt on the 2 sttisti. Critil vlues for stndrdized residuls were 2.0. RESULTS Of the 13,071 sulties identified for nlysis, 1,368 (10.5%) were from OIF-1 nd 11,703 (89.5%) were from OIF-2. As shown in Tle I, the mjority of sulties were DNBI (75.0%), were Army personnel (83.5%), nd were mle (90.0%). Phse of Opertion The overll injury distriutions mong WIA sulties from OIF-1 were sttistilly different from tht of OIF-2 ( , df 9, p 0.001). There were higher proportion of WIA sulties during OIF-1 thn OIF-2 (36.6% vs. 23.6%). TABLE I. Chrteristis of U.S. Mrine nd Soldier Csulties during OIF-1 nd OIF-2 OIF-1 OIF-2 Totl Chrteristi No. % No. % No. % Csulty type DNBI , , WIA , , Brnh of servie Army , , Mrine Corps , , Gender Mle 1, , , Femle , , Totl 1, , , TABLE II. Distriution of WIA Csulties y Injury Ctegory during OIF-1 nd OIF-2 OIF-1 OIF-2 Totl Injury Ctegory No. % No. % No. % Amputtions Burns Dislotions Frtures Intrrnil Nervous system d Sprins/strins Musuloskeletl Open wounds e , , Other Totl , , , df 9, p Adjusted stndrdized residul ws less thn 2.0. Adjusted stndrdized residul ws more thn 2.0. d Hering nd visul impirment. e Exludes mputtions. As indited y the djusted stndrdized residuls (see Tle II), sprins nd strins, open wounds, nd dislotions were signifintly higher during OIF-1, wheres urns, frtures, nd trumti mputtions were higher during OIF-2. As demonstrted in Tle III, ICD-9 tegory distriutions for DNBI sulties lso differed signifintly y phse of opertion ( , df 16, p 0.001). Injuries nd mentl disorders were notly higher during OIF-1. During OIF-2, infetious nd prsiti diseses nd diseses of the musuloskeletl, digestive, nd nervous systems were more ommon. Brnh of Servie Mrines sustined proportionlly more WIA injuries thn Army personnel during OIF-1 (51.9% vs. 29.1%) nd OIF-2 (54.1% vs. 18.4%). In ddition, distriutions of injury tegories mong WIA sulties differed signifintly etween Army nd Mrines during OIF-1 ( , df 9, p 0.01) nd during OIF-2 ( , df 9, p 0.01) (Tle IV). 248 MILITARY MEDICINE, Vol. 173, Mrh 2008

3 TABLE III. Distriution of DNBI Csulties y ICD-9 Dignosti Ctegory during OIF-1 nd OIF-2 OIF-1 OIF-2 Totl ICD-9 Ctegory No. % No. % No. % Infetious Neoplsms Endorine Blood Mentl disorders Nervous system Cirultory Respirtory Digestive , , Genitourinry Pregnny Skin Musuloskeletl , , Congenitl Ill-defined , Injury , , Supplementry Totl , , , df 16, p Adjusted stndrdized residul ws less thn 2.0. Adjusted stndrdized residul ws more thn 2.0. The distriutions of DNBI ICD-9 tegories y servie nd phse of opertion re shown in Tle V. Mrines hd the highest proportions of nonttle injuries during OIF-1 nd OIF-2, nd the lowest proportions of ill-defined onditions, mentl disorders, nd diseses of the musuloskeletl system. However, 2 tests were not performed on the DNBI distriutions y phse nd servie due to the lk of ell ounts in severl of the ICD-9 tegories. Gender Disese nd nonttle injury ICD-9 sulty distriutions lso differed y gender ( , df 15, p 0.001) TABLE IV. (Tle VI). The proportion of nonttle injuries ws signifintly higher mong men thn women (25.2% vs. 16.4%). However, mong the ICD-9 mjor tegories, neoplsms, mentl disorders, diseses of the lood nd lood-forming orgns, respirtory, nd genitourinry systems were more ommon mong women thn men. As shown in Tle VII, the gender distriutions within eh phse were onsistent with the overll findings for gender. Although mle nd femle DNBI distriutions were different, similr trends existed mong them. Restriting our nlysis to just the ICD-9 injury nd poisoning group demonstrted tht the distriutions of nonttle injuries mong men nd women were similr ( , df 6, p 0.47) (Tle VIII). DISCUSSION This study evluted the dignosti distriutions of WIA nd DNBI sulties from the Mjor Comt nd Support nd Stility Phses of OIF otined from the reporting tools of the TMIP-J progrm. As in previous militry opertions, DNBI sulties were muh more prevlent thn WIA sulties overll. 10 However, during oth phses of OIF, Mrines sustined signifintly higher proportion of WIA sulties thn the Army; pproximtely one in two Mrine sulties ws WIA ompred with only one in five Army sulties. This differene my e ttriuted to the distint dotrinl missions nd pilities of the Mrines Corps nd the Army. The disrepny in wounding ptterns mong ttle sulties in the present nlysis more trumti mputtions, frtures, nd urns during OIF-2 is likely the result of hnging weponry preferenes of the enemy. During OIF-2, improvised explosive devies emerged s the primry mehnism of injury mong WIA sulties. 11 In previous onflits, inluding OIF-1, however, injuries due to smll rms wepons were more ommon. 12,13 Distriution of U.S. Army nd Mrine Corps WIA Csulties y Injury Ctegory during OIF-1 nd OIF-2 OIF-1 Injury Ctegory No. % No. % No. % No. % Amputtions d 3.6 Burns d 4.6 Dislotions Frtures Intrrnil 1 d Nervous system d 2.3 Sprins/strins Musuloskeletl Open wounds 113 d Other d d 6.6 Totl , OIF-2 Army Mrine Corps Army Mrine Corps , df 9, p , df 9, p Adjusted stndrdized residul ws more thn 2.0. d Adjusted stndrdized residul ws less thn 2.0. MILITARY MEDICINE, Vol. 173, Mrh

4 TABLE V. Distriution of DNBI Csulties y ICD-9 Dignosti Ctegory nd Brnh of Servie during OIF-1 nd OIF-2 ICD-9 Ctegory No. % No. % No. % No. % Infetious Neoplsms Endorine Blood Mentl disorders Nervous system Cirultory Respirtory Digestive Genitourinry Pregnny Skin Musuloskeletl , Congenitl Ill-defined Injury , Supplementry Totl , tests were exluded due to insuffiient ell ounts. TABLE VI. Distriution of DNBI Csulties y Gender nd ICD-9 Dignosti Ctegory during OIF Men Women Totl ICD-9 Ctegory No. % No. % No. % Infetious Neoplsms Endorine Blood Mentl disorders Nervous system Cirultory Respirtory Digestive , Genitourinry Skin Musuloskeletl 1, , Congenitl Ill defined , Injury 2, , Supplementry Totl 8, , , ICD-9 dignoses ssoited with hildirth, diseses of the mle genitl orgns, inflmmtory disese of femle pelvi orgns, nd other disorders of the femle genitl trt were exluded , df 15, p Adjusted stndrdized residul ws more thn 2.0. Adjusted stndrdized residul ws less thn 2.0. DNBI distriutions lso differed etween the phses of OIF. The initil, intense omt experiene, s well s the onstnt movement of onvoys, my hve ontriuted to the higher proportion of mentl disorders nd nonttle injuries during OIF-1. However, diseses of the musuloskeletl system, suh s injuries due to overuse nd hroni pin, were OIF-1 OIF-2 Army Mrine Corps Army Mrine Corps expetedly more prevlent during OIF-2. In ft, musuloskeletl prolems ounted for one in five DNBI hospitliztions during this time period. Although this nlysis provides importnt informtion regrding opertionl, gender, nd servie-speifi differenes in injury nd illness distriutions, there re limittions. Only hospitliztion dt were represented in this study, whih inlude sulties who required medil re t level III tretment fility due to more serious injury or illness. As suh, these dt my not reflet distriutions of sik ll or surveillne reporting systems from forwrd-deployed medil tretment filities. The reporting tools used in this study (i.e., TRAC2ES nd JPTA) re primrily used for trking sulties nd do not provide denomintor or popultion t risk. Furthermore, the reliility nd vlidity of the dignosti methodology nd hrteristis of medil providers in theter is unknown, nd determining the ury of the ICD-9 dt ws outside the sope of this study. However, s the only dignosti informtion provided y these reporting tools, ICD-9 dt my serve s the est proxy mesure to inorporte into urrent nd future HSS modeling nd simultion pplitions. Despite these limittions, the findings demonstrte tht sulty medil re resoure plnners should evlute the differenes in ICD-9 distriutions for oth WIA nd DNBI sulties y opertionl phse, rnh of servie, nd gender. Furthermore, methodologies tht estimte senrio-speifi ptient strems should e modified to ount for these distintions to eliminte medil resoure shortflls suh s the numer of eds needed or the proper mix of medil speilists to tret the sulties. Together 250 MILITARY MEDICINE, Vol. 173, Mrh 2008

5 TABLE VII. Distriution of DNBI Csulties y Gender nd ICD-9 Dignosti Ctegory during OIF-1 nd OIF-2 ICD-9 Ctegory No. % No. % No. % No. % Infetious Neoplsms Endorine Blood Mentl disorders Nervous system Cirultory Respirtory Digestive Genitourinry Pregnny Skin Musuloskeletl , Congenitl Ill-defined Injury , Supplementry Totl , , Note: 2 tests were exluded due to insuffiient ell ounts. TABLE VIII. with the estimted ounts of sulties, ptient strems re the impetus of projeting the resoures needed to sustin the HSS. Future reserh should ompre vrious ommnd elements, whih will provide more insight on the differenes etween ICD-9 tegory distriutions. Future studies should lso ttempt to exmine the ury of the ICD-9 dt from TRAC2ES nd JPTA y ompring it with dt olleted nd oded y registries suh s the Nvy-Mrine Corps Comt Trum Registry. 14 The Nvy-Mrine Corps Comt Trum Registry, lthough primrily onsisting of Mrine sulties nd inluding only ptients initilly treted t level I nd II Nvy-Mrine Corps filities, uses professionl nurse oders to ode injuries nd illnesses whih llows for the identifition of possile systemti ises nd ssessments of reliility nd vlidity. Dignosti reporting proedures nd guidelines my need to e OIF-1 OIF-2 Men Women Men Women Distriution of Nonttle Injuries mong DNBI Csulties y Gender during OIF Nonttle Injury Men Women Totl Ctegory No. % No. % No. % Burns Dislotions Frtures Het Sprins/strins Open wounds Other Totl 2, , , df 6, p dopted y TMIP-J to ddress these issues in their reporting tools. More work is needed to identify wounding ptterns ssoited with speifi ustive gents nd to identify the popultions t risk, whih re neessry for lulting inidene nd prevlene of the disese or injury entities. ACKNOWLEDGMENTS Report No ws supported y the Offie of Nvl Reserh, Arlington, VA, nd the Mrine Corps Wrfighting Lortory under Work Unit No N.M ,511. REFERENCES 1. Medil Anlysis Tool, version 0.5. Tehnil Referene Mnul. MLen, VA, Booz Allen & Hmilton, In., Tropeno A: Estimting Supplies Progrm. Tehnil Doument 00-4D. Sn Diego, CA, Nvl Helth Reserh Center, Tropeno A, Konoske P, Glrneu M, Mithell R, Brok J: The Development of the Ttil Medil Logistis Plnning Tool (TML ). Tehnil Doument 03-03C. Sn Diego, CA, Nvl Helth Reserh Center, The Militry Helth System. Wshington, DC, The Pentgon. Aville t essed My 20, Frvell M: Fore Helth Protetion Review: Keeping Trk of Injured nd Ill Servie Memers Is All out the Detils. Militry Medil Tehnology Online Arhives, Vol 9(8), Aville t essed July 20, World Helth Orgniztion: Interntionl Clssifition of Diseses, 9th Revision. Genev, Switzerlnd, WHO, Plinks LA, Coen P: Comt Csulties mong U.S. Mrine Corps Personnel in Vietnm: Tehnil Report Sn Diego, CA, Nvl Helth Reserh Center, Reister FA: Medil Sttistis in World Wr II, p 21. Wshington, DC, Deprtment of the Army, Offie of the Surgeon Generl, MILITARY MEDICINE, Vol. 173, Mrh

6 9. Reister FA: Bttle Csulties nd Medil Sttistis: U.S. Army Experiene in the Koren Wr, Chp 3. Wshington, DC, Deprtment of the Army, Offie of the Surgeon Generl, Plinks LA, Coen P: Disese nd non-ttle injuries mong U.S. Mrines in Vietnm. Milit Med 1988; 153: Gondusky JS, Reiter MP: Proteting militry onvoys in Irq: n exmintion of ttle injuries sustined y mehnized ttlion during Opertion Irqi Freedom II. Milit Med 2005; 170: Mry RL, Holom JB, Bker AM, et l: United Sttes Army Rngers in Somli: n nlysis of omt sulties on n urn ttlefield. J Trum 2000; 49: Zouris JM, Wlker GJ, Dye J, Glrneu M: Wounding ptterns of U.S. Mrines nd Silors during Opertion Irqi Freedom, mjor omt phse. Milit Med 2006; 171: Glrneu MR, Hnok W, Konoske P, et l: U.S. Nvy-Mrine Corps omt trum registry. Milit Med 2006; 171: MILITARY MEDICINE, Vol. 173, Mrh 2008