Page 17 - JSOM Summer 2024

FIGURE 3 Non-suicide hospital trauma fatalities for Operation equivalents (CFR, %prehospital deaths, %hospital deaths, PS,
Inherent Resolve (OIR) in Iraq and Operation Freedom’s Sentinel PP, PS-CFR, PP-CFR). Because survivability and prevention of
(OFS) in Afghanistan. fatalities resulting from non- homicide manners of death (ac-
cident, natural causes, suicide) are inherently different from
battle injury and homicide manner of death, we also recom-
mend tracking the proportionate mortality from accident,
natural causes, and suicide along with combat casualty care
statistics. If the proportionate mortality from accident, natu-
ral causes, and suicide increases dramatically, as was the case
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during OIR, then this warrants strategies to reduce mortality
from these DNBI manners of death.
Summary and Conclusion

The majority of U.S. military combat fatalities have injuries
deaths (KIA) misclassified as in-hospital deaths (DOW), thus deemed non-survivable. In addition to promoting advance-
artificially inflating the %DOW. This was caused by patients ments in all aspects of medical care, medical and non-medical
dead on arrival and patients with no return of spontaneous leaders should strongly advocate for improving survival us-
circulation after hospital arrival being classified as DOW when ing primary and secondary prevention strategies that prevent
they were in fact KIA. Furthermore, 42% of hospital fatali- injury or reduce injury severity. This may be especially ap-
ties in OFS and OIR were deemed to have PS injuries after propriate during a conflict that lasts decades, requires Service-
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the Military Trauma Mortality Review process was completed members to deploy multiple times, and places them at higher
(Figure 3). risk for chronic disease and premature mortality.
Not surprisingly, compared with prehospital combat deaths Accurate and complete data capture, from the point of injury
(where a casualty dies rapidly from a likely NS injury), a dis- through hospitalization and rehabilitation must be a priority
proportionate number of fatalities with PS battle injuries and in any future conflict. This includes collecting and analyzing
PP deaths occurred in hospital. 12–14 In our opinion, when the data on all deaths using timely and comprehensive autopsies
%DOW is compared longitudinally (e.g., over time, between that incorporate advanced radiologic techniques. In addi-
subgroups of interest, etc.), a fair comparison requires inclu- tion to using these data for performance improvement, data
sion of only casualties with PS battle injuries. Otherwise, it is along with recommendations should be shared with medical
not possible to determine whether an increase in %DOW is and non-medical leadership in near real time to inform deci-
due to an increase in fatalities with PS battle injuries or sim- sion-making. The integration of mortality review statistics can
ply an increase in the number of casualties arriving with NS elucidate injury survivability and death preventability. This
battle injuries, systematic administrative misclassifications of revised framework, alongside continuous mortality surveil-
KIAs as DOWs, etc. Therefore, while specific focus on an in- lance, may lead to an improved understanding of medical and
crease in %DOW is worthwhile to identify opportunities to non-medical solutions to save lives and eliminate preventable
improve hospital trauma care, this statistic must be supple- death.
mented with accompanying timely mortality reviews. In terms
of mass casualty events and large-scale combat operations, any Acknowledgments
significant increase in the number of casualties or delays in The authors would like to acknowledge past and present per-
casualty transport to a surgical capability can affect %DOW. sonnel from the Armed Forces Medical Examiner System and
For example, if prehospital casualty transport is significantly Joint Trauma System for their efforts to improve morbidity
delayed, the hospital %DOW may actually improve as more and mortality in military casualties, and thus “Make Good
critical casualties die before arriving at a hospital. Yet, such an from the Bad.”
improvement in %DOW would have nothing to do with any
changes to hospital care. Author Contributions
JCJ, RSK, JTH, and ELM conceived the concept and design
of the commentary. All authors assisted in the acquisition,
Disease and Non-Battle Injury Death
analysis, and interpretation of data. JCJ, RSK, JTH, and ELM
These aggregate statistics (e.g., CFR, %DOW, %KIA) by contributed to the initial draft of the manuscript. All authors
definition exclude non-battle injuries and deaths. A separate revised the manuscript for critically important intellectual con-
statistic, DNBI has long been used to describe the important tent. All authors read and approved the final version of the
role of military medicine in reducing preventable deaths for all manuscript to be published.
deployed Servicemembers. Non-battle injuries account for 1
in 3 injuries sustained in the deployed setting. Further, these Disclaimer
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non-battle injuries along with disease from natural causes and The views, opinions, and findings contained in this article are
suicide account for approximately 1 in 5 deaths of Servicemem- those of the authors and should not be construed as official or
bers deployed in the theater of conflict. DNBI has historically reflecting views of the Department of Defense unless otherwise
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been a leading cause of death on the battlefield but has gener- stated.
ally declined in more recent conflicts. As the goal of military
medicine is to reduce death from all causes, metrics and mortal- Disclosures
ity reviews for DNBI should receive renewed attention. It is for Dr. John Holcomb is on the board of directors of Decisio
this reason we also recommend the use of the non-battle injury Health, CCJ Medical Devices, QinFlow, Hemostatics, Zibrio

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