Page 16 - JSOM Summer 2024

FIGURE 1 Combat casualty care statistic hypothetical scenarios to are deemed to have either NS or PS injuries but NP death,
inform military and non-military investments to reduce death on the this highlights non-medical solutions and primary and second-
battlefield. ary prevention strategies that can potentially yield the largest
decrease in preventable combat deaths. It also allows for the
relatively limited medical research and training resources to
be directed to areas where military medicine might have the
largest impact. At this time, the full Military Trauma Mortality
Review process has only been applied to fatalities from U.S.
Special Operations Command, Operations New Dawn, Free-
dom’s Sentinel (OFS), and Inherent Resolve (OIR). Ideally, the
goal would be to use aggregate combat casualty care metrics
along with individual-level data to inform opportunities for
improvement in real time, which is a reasonable objective de-
not have optimal care delayed or prohibited by non-medical spite the potential limitations of small sample size among the
factors. That is, the graphs suggest that optimizing medical in- fatalities evaluated to date. The application of these statistics
terventions will have a meaningful impact in reducing prevent- to the two recent operations, OIR in Iraq and OFS in Afghan-
able deaths. An example might be ensuring that casualties with istan, supports scenario 3 (Figure 2) or specific investment
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PS injuries receive care in accordance with recommended pre- in non-medical solutions. It should be noted that this does
hospital and hospital guidelines, as there are few non- medical not suggest divesting from lessons learned during recent con-
factors either delaying or prohibiting implementation. flicts to improve Tactical Combat Casualty Care, transfusion
of blood products, and time to surgical and hospital capabili-
Hypothetical Scenario 2 ties (which includes a multitude of diagnostic and therapeutic
Military non-medical investment argues for an opportunity interventions).
to invest specifically in non-medical capabilities (i.e. TTPs;
logistics of supply and resupply; environmental factors; PPE; FIGURE 2 Battle-injured case fatality rate, potentially survivable
experienced leadership) to allow optimal care for survivable case fatality rate, and potentially preventable case fatality rate for
injuries and reduce preventable death. This is because the bat- Operation Inherent Resolve (OIR) in Iraq and Operation Freedom’s
Sentinel (OFS) in Afghanistan.
tle-injured CFR and PS-CFR are similar, but the battle-injured
PP-CFR statistic is meaningfully lower. This suggests that
non-medical interventions are required before optimal medical
care can be provided to casualties with PS injuries. That is, for
medical interventions to be successful in reducing preventable
deaths, the casualty must have the opportunity to receive op-
timal combat casualty care throughout the entire continuum
of care. An example might be ensuring that a casualty with PS
injuries in an austere environment (e.g., injured on the side of
the mountain at night in extreme weather conditions) still has
the opportunity via non-medical interventions to receive rapid
prehospital, en route, and hospital care.
It is for the complicated non-medical considerations high-
Hypothetical Scenario 3 lighted above that a focus on the %DOW rather than the CFR
Military non-medical investment is similar to scenario 2 and has been touted as a more suitable metric to evaluate hospital
also argues for an opportunity to invest specifically in non- care. While it may carry important descriptive value, some
3,6
medical capabilities to reduce preventable death, albeit with have suggested that using %DOW as a measure of success or
a different rationale. In this case, the battle-injured CFR is failure of hospital care is fundamentally flawed because con-
meaningfully higher than both the battle-injured PS-CFR and founding is not addressed. While these limitations are ac-
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PP-CFR. This means that the injuries sustained were highly knowledged, investigators may potentially over-reach when
lethal, resulting in catastrophic tissue destruction not amena- comparing inter- and intra-conflict differences. This is be-
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ble to current medical interventions. These fatalities are only cause a reliance on aggregate statistics fails to address criti-
amenable to primary and/or secondary interventions either cally important differences in anatomical wounding patterns,
preventing the battle injuries altogether or reducing the sever- mechanisms of injury, severity of injuries, medical capabilities,
ity of injuries to a level deemed PS and then amenable to con- weapon lethality, or tactical and operational differences. Addi-
temporary medical care. An example might be improved TTPs tionally, implementation of the Military Trauma Mortality Re-
which prevent injuries from occurring or improvements in PPE view process, 12–14 rigorously designed to make determinations
which reduces the severity of an injury from NS to PS and thus of injury survivability and death preventability, suggests that
amenable to medical intervention to prevent death. two-thirds of hospital combat fatalities from recent operations
are NP. This is because hospital deaths are not universally as-
Mortality Review Statistics from Combat Operations sociated with PS injuries and PP deaths (Figure 3). Two reasons
for these results are: (1) administrative misclassifications and
It is important to highlight that none of these scenarios argue (2) casualties with NS injuries who nonetheless survive long
for full investment in either strictly non-medical or medical im- enough to reach a military hospital. This may occur from rapid
provements. Nor do they argue that improvements in medical transport and/or heroic prehospital treatment. Administrative
care cannot be made among casualties with NS battle injuries. misclassifications in the DoD were reported to be more than
However, when a large proportion of battle injury fatalities 14%, with the overwhelming majority being prehospital
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14 | JSOM Volume 24, Edition 2 / Summer 2024