Page 13 - JSOM Summer 2024

Advancing Combat Casualty Care Statistics

and Other Battlefield Care Metrics

Jud C. Janak, PhD *; Russ S. Kotwal, MD, MPH ;
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Jeffrey T. Howard, PhD ; Jennifer M. Gurney, MD ; Brian J. Eastridge, MD ;
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John B. Holcomb, MD ; Stacy A. Shackelford, MD ; Robert A. De Lorenzo, MD ;
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Ian J. Stewart, MD ; Edward L. Mazuchowski, MD, PhD 10
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ABSTRACT
Aggregate statistics can provide intra-conflict and inter-conflict Introduction
mortality comparisons and trends within and between U.S.
combat operations. However, capturing individual-level data to The seminal article entitled “Understanding Combat Casualty
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evaluate medical and non-medical factors that influence com- Care Statistics” was published by Holcomb et al. in 2006. Sub-
bat casualty mortality has historically proven difficult. The De- sequent application and interpretation of statistics outlined by
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partment of Defense (DoD) Trauma Registry, developed as an this article have varied between studies through time. This
integral component of the Joint Trauma System during recent well-described heterogeneity includes the variable presence of
conflicts in Afghanistan and Iraq, has amassed individual-level medical and non-medical confounders (e.g., injury survivabil-
data that have afforded greater opportunity for a variety of ity, death preventability, environmental considerations), and
analyses and comparisons. Although aggregate statistics are these confounders are important when interpreting the effec-
4,5,7
easily calculated and commonly used across the DoD, other is- tiveness of medical interventions in reducing death. Addi-
sues that require consideration include the impact of individual tionally, of 7,076 U.S. military fatalities from recent conflicts in
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medical interventions, non-medical factors, non-battle-injured Afghanistan and Iraq, nearly a quarter (1,601; 23%) resulted
casualties, and incomplete or missing medical data, especially from non-battle injury, and these are, by definition, excluded
for prehospital care and forward surgical team care. Needed from traditional combat casualty care statistics. Although op-
are novel methods to address these issues in order to provide portunities for improvement and prevention may differ, disease
a clearer interpretation of aggregate statistics and to highlight non-battle-injured fatalities (DNBI) also need ongoing surveil-
solutions that will ultimately increase survival and eliminate lance and review. There are three main objectives of this article:
preventable death on the battlefield. Although many U.S. mil-
itary combat fatalities sustain injuries deemed non-survivable, 1. Review use of traditional combat casualty care statistics;
survival among these casualties might be improved using pri- 2. Discuss how traditional combat casualty care statistics can
mary and secondary prevention strategies that prevent injury be integrated with mortality review statistics to better un-
or reduce injury severity. The current commentary proposes derstand medical and non-medical solutions to reduce pre-
adjustments to traditional aggregate combat casualty care sta- ventable death; and
tistics by integrating statistics from the DoD Military Trauma 3. Reiterate the importance of reducing DNBI death.
Mortality Review process as conducted by the Joint Trauma
System and Armed Forces Medical Examiner System. Traditional Combat Casualty Care Statistics
Holcomb et al. delineated three combat casualty care statis-
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Keywords: combat casualty care statics; injury survivability
mortality; trauma; battle injury; disease, non-battle injury tics specific to battle-injured casualties: case fatality rate (CFR),
percentage killed in action (%KIA; battle-injured prehospital
deaths), and percent died of wounds (%DOW; battle- injured
*Correspondence to judjanak@bexardata.org
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1 Dr. Jud C. Janak is affiliated with Bexar Data LLC, San Antonio, TX. COL Russ S. Kotwal is affiliated with the Department of Military and
Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, and Joint Trauma System, Defense Health Agency,
Joint Base San Antonio-Fort Sam Houston, San Antonio, TX. Dr. Jeffrey T. Howard is affiliated with the Department of Public Health, College
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for Health Community and Policy, One UTSA Circle, University of Texas, San Antonio, TX. COL Jennifer M. Gurney is affiliated with the De-
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partment of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, and the Joint Trauma System, Defense Health Agency
and the Burn Center and Research Directorate, United States Army Institute of Surgical Research, JBSA – Fort Sam Houston, San Antonio, TX.
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5 COL Brian J. Eastridge is affiliated with the Department of Surgery, University of Texas Health Science Center, San Antonio, TX. COL John
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B. Holcomb is affiliated with the Department of Surgery, University of Alabama at Birmingham, Birmingham AL. COL Stacy A. Shackelford is
Trauma Medical Director, Defense Health Agency, Air Force Academy, Colorado Springs, CO, and is affiliated with the Department of Surgery,
Uniformed Services University of the Health Sciences, Bethesda, MD. COL Robert A. De Lorenzo is affiliated with the Department of Emergency
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Medicine, University of Texas Health Science Center, San Antonio, TX. Lt Col Ian J. Stewart is affiliated with the Department of Medicine, Uni-
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formed Services University of the Health Sciences, Bethesda, MD. Lt Col Edward L. Mazuchowski is affiliated with the Department of Pathol-
ogy, Uniformed Services University of the Health Sciences, Bethesda, MD and Forensic Pathology Associates, HNL Lab Medicine, Allentown, PA.
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