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Kotwal RS, Janak JC, Howard JT, Rohrer AJ, Harcke HT, Holcomb JB, Eastridge BJ, Gurney JM, Shackelford SA, Mazuchowski EL. United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel. Mil Med 2023; 188:3045-3056. [PMID: 35544336 DOI: 10.1093/milmed/usac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/29/2022] [Accepted: 04/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. METHODS A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). CONCLUSIONS Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.
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Affiliation(s)
- Russ S Kotwal
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jud C Janak
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Jeffrey T Howard
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Public Health, College for Health Community and Policy, One UTSA Circle, University of Texas, San Antonio, TX 78249, USA
| | - Andrew J Rohrer
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
| | - Howard T Harcke
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama, Birmingham, AL 35294, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Jennifer M Gurney
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Burn Center and Research Directorate, United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Stacy A Shackelford
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Edward L Mazuchowski
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
- Forensic Pathology Associates, HNL Lab Medicine, Allentown, PA 18109, USA
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González-Alonso V, Usero-Pérez MDC, Seguido Chacón R, Gómez de la Fuente A, Cortés-Martín J, Rodríguez-Blanque R, Sánchez-García JC. Evaluation of the Impact of a Tourniquet Training Program: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2742. [PMID: 36768112 PMCID: PMC9914968 DOI: 10.3390/ijerph20032742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Among the main preventable causes of death in the area of operations is external exsanguinating hemorrhage in the extremities, hence the importance of the tourniquet as a therapeutic tool in this type of injury and, therefore, of the training of personnel participating in international missions. The main objective of this study is to determine the impact of training in the application of this device. This is a quasi-experimental, prospective, cross-sectional study, carried out with 97 healthy volunteers, military personnel who perform their work in the Royal Guard barracks of El Pardo. The study was conducted between June 2019 and July 2021. The correct determination of the device placement site and the times of correct device placement were evaluated by determining whether there was blood flow using Doppler ultrasound measurements. Statistically significant results were obtained for application time (76.68 s to 58.06 s; p < 0.001), correct device placement (p < 0.001), and achievement of complete ischemia in the upper extremity (23.7% pretest vs. 24.7% post-test; p < 0.001). In the lower extremity, after training, longer application duration (43.33 s to 47.30 s) and lower ischemia achievement (59.8% pretest vs. 37.8% post-test) were obtained. Standardized and regulated training improves device application. More intensive training is necessary to obtain better results.
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Affiliation(s)
- Valentín González-Alonso
- Departamento Simulación, Escuela Militar de Sanidad (EMISAN), Ministerio de Defensa, 28047 Madrid, Spain
| | | | | | | | - Jonathan Cortés-Martín
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
| | - Raquel Rodríguez-Blanque
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
- Hospital Clinico Universitario San Cecilio, 18016 Granada, Spain
| | - Juan Carlos Sánchez-García
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
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Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis. Sci Rep 2019; 9:13767. [PMID: 31551454 PMCID: PMC6760527 DOI: 10.1038/s41598-019-50272-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/30/2019] [Indexed: 11/12/2022] Open
Abstract
A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems.
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Harrison WY, Wardian JL, Sosnov JA, Kotwal RS, Butler FK, Stockinger ZT, Shackelford SA, Gurney JM, Spott MA, Finelli LN, Mazuchowski EL, Smith DJ, Janak JC. Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights. BMJ Mil Health 2019; 166:e47-e52. [DOI: 10.1136/jramc-2019-001193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 11/04/2022]
Abstract
IntroductionHistorically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care.MethodsThis qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology.ResultsMedical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care.ConclusionsIn the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.
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