Page 84 - JSOM Fall 2025

the inferior border of the clavicle, superior border of the to the forward surgical team. There, arterial injury was con-
scapula. These areas correspond to the superior edge of the firmed, a left-sided tube thoracostomy was performed, and,
thoracic cavity, the lateral edges of properly fitted front and following a blood transfusion, the patient was transferred to
rear ceramic plates, and the aortic distal bifurcation within the Role 3 for definitive exploration and vascular repair. The pa-
pelvis. A total of 786 casualty medical records were screened. tient returned to full duty after repair. Only front and rear
These cases were from Operation Enduring Freedom (OEF) plates had been worn at the time of injury. Final Disposition:
and Operation Iraqi Freedom (OIF), from 2001 through 2018, Wounded in Action
consisting of casualties that occurred under the unit’s opera-
tional command, to include attachments. This data did not in- Case 3
clude foreign partner forces or contractors. Additionally, each The patient was wounded conducting close quarter combat
file included at a minimum, a tactical combat casualty care (CQC) operations, shot in the left 6th ICS during room clearing,
card or a variant thereof along with documentation stating the through soft armor where side ceramic plates would typically
final disposition of the casualty. Many files included enroute be. Pulled from the target and given needle decompression by
care documents, after-action reports by medical providers, and medics, the patient lost pulses at the scene and did not respond
follow-on surgical and medical notes from the patient’s ongo- to decompression. CPR was performed en route to the forward
ing care, but this was not standardized. surgical team where he was found without cardiac activity and
declared dead on arrival (DOA). The autopsy was significant
The inclusion criteria included axilla injury secondary to small for trans-mediastinal gunshot wound with penetration of the
arms fire, documentation of patient body armor level, and final left liver lobe, left ventricle, left lower lobe of the lung, and
disposition. Exclusion criteria included wounds from weap- fundus of stomach. Only front and rear plates had been worn
ons with caliber >7.62mm, explosive injuries or catastrophic at the time of injury. Final disposition: Killed in Action.
polytrauma (>1 limb amputation, penetrating head trauma, or
complex blast wounding), wounds outside of defined axilla Case 4
(supraclavicular, etc.), operational classification unsuitable The patient was wounded during CQC, shot in the left 7th
for disclosure, or documentation with inadequate details to ICS during room clearing, through soft armor where side plate
determine location or extent of injuries and final disposition. would be. Extracted from the house by first responder, chest
Charts were prescreened by one emergency medicine physician seals were immediately placed, and the patient lost conscious-
and one Army medic for injury patterns with axilla trauma. ness once pulled from cover. A medic reevaluated and needle
They were then reviewed by two emergency physicians for the decompressed on scene followed by two intubation attempts
following data: type of injuries, type of body armor worn, ini- without success due to blood in the airway. A cricothyrotomy
tial vital signs, interventions completed, surgical reports, and was then attempted, which also failed. Intubation was reat-
autopsy reports, as indicated. Of the 40 cases identified after tempted a third time with success after suctioning. The pa-
first screening, following additional chart queries through De- tient lost pulses during transit to the forward surgical team.
partment of Defense electronic health records for missing or Resuscitative thoracotomy by the forward surgical team was
additional information, 29 were removed because of exclusion unsuccessful; there was documented significant injury to the
criteria or insufficient documentation to determine injury lo- great vessels as well as a large hemothorax. Autopsy was also
cation, pattern, or disposition. The remaining 11 cases were significant for fractures of 7th and 8th thoracic vertebral bod-
examined. ies and penetration of the right lower lobe of the lung. Only
front and rear plates had been worn at the time of injury. Final
disposition: Killed in Action.
Case Series
Case 1 Case 5
The patient was conducting dismounted patrol when they The patient was conducting dismounted patrolling in opera-
were wounded by small arms fire between the 1st and 3rd tions when he was wounded between the right 3rd and 5th
intercostal space (ICS) of the right axilla. A first responder ICS by small arms fire, superior to the side plate. A medic re-
placed an occlusive dressing. The patient was then moved to a ported that the patient was initially alert and tachypneic with
vehicle where a medic reevaluated and completed two needle tracheal deviation and three puncture wounds to right chest
decompressions of the right 2nd intercostal space due to respi- wall. Occlusive dressing was placed and needle decompression
ratory distress. Right-sided tube thoracostomy was performed completed without a rush of air. The medic then performed
in a vehicle with no documented output. The patient was then tube thoracostomy with >1000cc immediate output and un-
transferred to Role 3 facility and evacuated from the theater. documented ongoing flow. The patient remained unconscious
Only front and rear plates had been worn at the time of injury. with no pulse. Return of spontaneous circulation (ROSC)
Final disposition: Wounded in Action. was achieved with CPR, and the patient was transferred to
MEDEVAC. The patient died at the receiving hospital without
Case 2 further documentation available. Autopsy was significant for
The patient was conducting dismounted operations when he aortic arch tear with bullet lodged in the mediastinum. Front,
was struck by a combination of fragmentation grenades and rear, and side plates had been worn at the time of injury. Final
penetrating small arms fire to the left axilla. The patient was Disposition: Killed in Action.
alert and oriented on presentation, the medic placed an occlu-
sive dressing over suspected sucking chest wound, but upon Case 6
reevaluation there was concern for axillary artery injury. The The patient was wounded during dismounted patrol when a
dressing was removed, the wound packed with hemostatic small arms round clipped the bottom left side plate and en-
gauze and wrapped with an Israeli pressure bandage. The pa- tered the left abdomen above the iliac crest. The patient was
tient received intramuscular analgesia and was transported found alert and oriented, with a pulse of 90 beats per minute,

82 | JSOM Volume 25, Edition 3 / Fall 2025