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underlying epidemiology of disease burden requiring evacua- TABLE 1 Casualties Requiring Prolonged Field Care by Percentage
tion from the anticipated battlefield of tomorrow. 6 Casualty Type
(Number) Description Percentage
Methods Disease Non-Battle Personnel whose injuries were 45.29
not caused by direct enemy
Injury (DNBI)
This study is predicated on the critical hypothesis that any (226/499) action
patient who requires a higher level of care, and is unable to Disease (35/499) Individuals with a medical illness
access that care due to operational constraints, becomes a PFC that excludes the musculoskeletal (7.01)
patient from the perspective of medical personnel within a system
Special Operations task force (SOTF). In an attempt to find Orthopedic Injury Individuals with a (38.28)
(191/499)
musculoskeletal injury
a representative patient population where information was
available regarding all illness and injury incurred while de- Dental Patients Patients requiring significant 17.03
dental work that precludes
(85/499)
ployed, the research of Murray et al. noting epidemiologic effective service (e.g., root canal)
trends within a Role II medical facility in Iraq from 2003 to Wounded in Action Injuries caused by direct enemy
2004 appeared the most applicable. Specifically, this research (WIA) (150/499) action and the individual survives 30.06
7
reflected intense ground combat operations, concurrent stabil- Psychiatric Patients Personnel with a behavioral
ity operations, the effects of a diverse patient pool (i.e., female (38/499) health condition requiring 7.62
Soldiers), and an austere environment with little supporting treatment that is not supportable
host nation medical infrastructure. in theater
Murray et al. reported 341 total evacuations, 35 inpatients, and FIGURE 1 PFC casualty estimation.
84 dental patients (i.e., root canal patients) who would have
likely required additional care that would exceed the organic
capabilities of a SOTF. In examining this literature further, it is
7
shown that 150 patients were wounded in action (WIA) from
the 341 total evacuations. Of the remaining evacuations, 191
were due to orthopedic injuries. Notably, this study excluded
behavioral health cases, as these were exclusively seen by a
neighboring combat stress control team. However, reports from
World War II cite approximately 20% of all “battle casualties”
were the result of neuropsychiatric causes. The authors posit
8
that the World War II “battle casualty” statistic correlates most
closely to today’s WIA definition. Therefore, if we assume that
a future MDO battlefield will be inherently stressful, then ap-
plying a 20% metric to compensate for this missed pathology TABLE 2 Estimated Prolonged Field Care Casualties by Type
would reflect 38 patients (as calculated by (150/0.8) – 150) re- Per 100,000 Per SOTF Per AOB
quiring evacuation for a behavioral health concern. In total, this Casualty Type per Year per Year per Year
represents 499 serious medical cases that would have been PFC WIA (30.06%) 2,796 14 4
patients had the necessary ancillary services or evacuation not Disease (7.01%) 652 4 1
been available. The complete breakdown of patients by type al-
lows for an overall percentage calculation that can then be ap- Orthopedic (38.28%) 3,561 18 5
plied to different populations in a hypothetical future scenario. Dental (17.03%) 1,584 8 2
This information is shown in Table 1. Graphically, this would Psychiatric (7.62%) 709 4 1
appear as the distribution shown in Figure 1. Total (100%) 9,302 48 13

Although these percentages are useful, they remain difficult to presented during an anticipated MDO, a balanced approach
apply unless an underlying casualty rate is known. According that encompasses the expected disease burden involved in PFC
to Belmont et al., 6,990 WIAs were observed for each 100,000 must be pursued.
troop years for an Army Brigade combat team during the Op-
eration Iraqi Freedom “surge.” Per Murray et al., 40% of all Discussion
9
WIAs seen at the Role II were evacuated. Therefore, 40% of
6,990 total WIAs is 2,796 patients. If this number, in turn, re- Foremost, do the aforementioned estimations make sense?
flects 30.06% of the total PFC casualty estimation, then for a From the collective authors’ experience, we believe they do.
population of 100,000 soldiers deployed for 1 year, we would Additionally, the diversity in the types of cases included in
expect to see 9,302 total PFC cases within this hypothetical these estimations speaks to the benefit of the broad and inten-
population. Adjusting accordingly for unit size using 500 per- sive training SFMSs receive. By approximating which catego-
sonnel SOTF and 120 personnel Special Forces Operational ries of disease are likely to occur, and in what quantities, this
Detachment–Bravo (SFOD-B) approximations, the following knowledge will assist in making crucial decisions regarding
allocation of PFC cases would arise (see Table 2). training and preparation. Acknowledging the 380 skill tasks
represented in the STP, revised to 313 tasks in the SFMS criti-
Given these extrapolations, it is clear that PFC is not simply cal task list in July 2008, it becomes apparent that some may
the extension of Tactical Combat Casualty Care (TCCC) stan- be far more useful to prioritize in a PFC training program.
dards for a protracted duration. On the contrary, because SOF However, although PFC is a pressing issue, it cannot eclipse
will be required to manage the entirety of the health concerns all of the necessary training required for SFMS proficiency.

118 | JSOM Volume 20, Edition 3 / Fall 2020