Profiles in Combat
Casualties
COL CLIFFORD C. CLOONAN,
MD, FACEP
Interim Chair Dept. of Military and
Emergency Medicine
USUHS
WAR WOUNDS
History, 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.
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
Dulce bellum inexpertis
(War is delightful to those who
have no experience of it)
Erasmus
The Evolution of
Weapons of War
Wounds of War
Historical
Background
The Invention
of Gunpowder
Encoded formula
for gunpowder
and a depiction
of its use
HISTORY OF WAR WOUNDS
 CHANGING PATTERNS OF
WOUNDING THROUGHOUT HISTORY
 EFFECTS OF EVOLVING WEAPONS
SYSTEMS
 EFFECTS OF EVOLVING TACTICS
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
Combat Wounds Are Unique
 High percentage of penetrating
wounds
 Multi-System injury
 Multi-Etiologic
 High degree of wound contamination
 Old (delayed initial care)
Highly
Contaminated
“Old”
Wounds
Mechanisms of
Combat Injury
Causes of Combat Wounds
Bullets
23%
Burns Blast
6% 3%Other
6%
Fragments
62%
(WWI, WWII, Korea, Vietnam, Middle East)
Fragments
Bullets
Burns
Blast
Other
BLUNT
16%
BURN
3%
Types of Casualties
Mogadishu Raid Casualties
Wounding Mechanism
Distribution
GUN SHOT WOUNDS
52%
FRAGMENT
29%
Mogadishu Somalia Oct 3 1993
Shell Fragment Wound
Fragments from exploding anti-tank weapon
Landmine
Injury
M-16 assault rifle 5.56mm GSW (exit)
Trans-Abdominal High Velocity GSW (fatal)
Facial
Burns
Kosovo
Napalm Burns
Vietnam
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
Primary Blast
Injury
USS Cole Terrorist Bombing
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
War Wound Distribution
Chest
13%
Other
9%
Head & Neck
17%
Abdomen
5%
Upper
Extremities
21%
Lower
Extremities
35%
Upper Extremities
Lower Extremities
Abdomen
Head & Neck
Chest
Other
Mogadishu Raid Casualties
Anatomic Wound Distribution
HE AD & NE C K
17%
UNKNOWN/ C OM B INAT ION
9%
C HE ST / B AC K
8%
LOWE R E XT R E M IT IE S
AB DOM E N
32%
3%
UP P E R E XT R E M IT IE S
31%
Time to death after initial wounding
Mechanisms of Injury
and Distribution of
Injuries by
Geographic Environment
and Type of Combat
North Africa
Agent
Percent
Shell fragments...................................…. 75
Bullets...................................................... 20
Mines........................................................ 2
Bombs....................................................... 1
Other......................................................... 2
_____
Total............100
SOUTH PACIFIC








AGENT
Shell Fragments
Bullets:
Rifle
Machine gun
Grenade
Mines
Other
PERCENT
50
Total
25
8
12
2
3
______
100
Vietnam
Agent
Shell Fragments
(Artillery, mortar, rocket)
Bullets (rifle and pistol)
Booby traps, mines, grenades
Percent
38.9
23.8
27.7
Wounding Agents in the
Falklands
 Gunshot Wounds - 38%
 Fragment- Caused Wounds - 40%
 Burns - 18%
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%)
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
Vietnam - Morbidity &
Mortality
KIA - 11%
WIA - 87.5% (45.5% CRO)
DOW - 1.5%
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%
War Wounds
Who is wounded /
killed in war?
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
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
Desert Storm Cause of Death
When only ground troops
are studied, the ratio of
WIA/KIA, which was
4.2/1 in WW II, has
remained essentially
unchanged for the past 200
years.
SITE OF EXSANGUINATION IN
98 VIET NAM COMBAT DEATHS





16 - Heart/Ascending Aorta
13 - Lung/Pulmonary Artery
10 - Liver
10 - Multiple Abdominal Sites
9 - Great Vessels of the Thorax (Principally the
Aorta)
 *9 - Arteries in the Lower Extremity
 8 - Great Vessels of the Abdomen (especially the
Aorta/Vena Cava
SITE OF EXSANGUINATION
IN 98 DEATHS (CONT)




*6
*3
*2
*2
Amputations of the lower extremity
Carotid Artery
Upper Extremity Amputations
Arteries of the Upper Extremity (Esp.
Axillary/Brachial)
 10 Mult. Sites in the Chest, Abdomen, and
Extremities
*Possibility For Temporary Control of Bleeding with First
Aid
Mortality Rate of
Extremity Wounds (%)
World War II Korea Vietnam
Upper
0.1
0.2
0.15
Lower
3.0
0.7
0.5
"BATTLE CASUALTIES,
INCIDENCE, MORTALITY,
AND LOGISTIC
CONSIDERATIONS"
By
Gilbert W. Beebe, Ph.D..
Michael E. De Bakey, MD
UNDERSTANDING
WAR, HISTORY
AND THEORY OF
COMBAT
BY
T.N. Dupuy, 1987
Paragon House Publishers,
N.Y.
FACTORS WHICH INFLUENCE
WOUNDING RATES ON THE
BATTLEFIELD
 Ratio of enemy to U.S. strength.
 Type of weapons employed and ratio of
enemy to U.S. firepower
 The experience and training of the troops
 Terrain
 Tactical advantage and the excellence of the
plan.
FACTORS WHICH INFLUENCE
WOUNDING RATES ON THE
BATTLEFIELD (cont)
 Availability of prepared positions (enemy
vs. U.S.)
 Possession of key terrain (enemy vs. U.S.)
 Quality of available intelligence
 Tactical and strategic support
 Logistic support
The site of death for 90% of fatally wounded
combat casualties is the battlefield.
Casualty Rates
 AVERAGE WORLD WAR II DIVISION
ENGAGEMENT
– Casualty rates were 1-3% per day
Attrition Rates
Attrition Rates in the 1973
Arab-Israeli October War
Were Comparable to World
War II
It is vital that the medical
officer "...be in a position to
check the tactical situation
estimates with other staff
officers so that his plans may
be more securely grounded".
Quotes
VICTORY IS THE
BEST MEDICINE
Quotes
...[M]edicine has...[an] indirect
influence on war which is not
negligible. there seems little doubt
that some of the reckless courage
of...American troops...[is]
stimulated by the knowledge that
in front of them [is] only
the...[enemy], but behind
them...[are] the assembled
surgeons of America, with sleeves
rolled up.”
Hans Zinsser, “Rats, Lice and History”
Summary
 Following this lecture the participant will be able
to:
– Military medical personnel should know something
about weapons and the effects they produce because
such knowledge is useful
• for medical planning purposes
• to aid in developing or improving wounding prevention
methods
• in helping to estimate the number and types of casualties that
might be generated
• To improve communication with the line
Summary
– The most common combat wounding mechanisms are
•
•
•
•
•
•
•
Fragments
Fragments
Fragments
Fragments
Bullets
Bullets
Blast and burns and all other (unless you are in the navy
AND you are assigned to a ship in which case blast and burn
make up a larger percent)
Summary
– The frequency with which the various type of
combat wounds occur (see above) – all of
these depend upon type of combat (geography,
weapons available, type of combat etc.)
•
•
•
•
Fragments (all types) 50 – 90%
Bullets <10% - 50%
Primary Blast – generally <5%
Burn (all types) – generally <5
Summary
– Wounding patterns associated with different types of
weapons
• For most weapons wounding location is random and thus
primarily based upon body surface area therefore – Extremities which make up roughly 55% of BSA account from
roughly 55% of sites of wounding
– Landmines clearly primarily affect the lower extremities
– Some bullets are aimed so there is a slightly higher percent of
wounds in torso and head
– Head and neck are injured somewhat disproportionate to their
BSA because these body parts are more commonly exposed
(have to be able to see to shoot!) -roughly 17% instead of 10%
Summary
 Who primarily gets wounded/killed in combat
– Young men ages 18 – 24
– Predominantly infantrymen
– Almost entirely enlisted men with 2nd Lieutenants
being at highest risk of death among officers
 Which wounds most commonly cause death?
– Head and Chest Wounds
 Where do most deaths occur?
– On the battlefield (mostly at the point of wounding
and within <5 minutes of wounding)
– Relatively few die once reaching a hospital