Page 86 - JSOM Fall 2025

and Prevention in Combat (JATPIC) and National Ground In- TABLE 2 Key Statistics
telligence Center, finding 11 Servicemembers shot in the side Notable mortality outcomes Mortality rate
plates, with zero complete penetrations and only one partial Overall 45%
penetration, resulting in a left-side flank contusion. From our
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limited sample size and adjacent studies, it appears axillary Four-plate system 38%
wounds to the side-plate region are associated with greater Two-plate system 50%
mortality when compared with those outside, but side plates Struck within side-plate region 67%
appear effective at mitigating injury from 7.62mm non–armor Struck in side-plate region with four-plate system 0%
piercing and below. Struck in side-plate region with two-plate system 100%
Struck outside side-plate region 25%
Injury Patterns Great vessel/cardiac injury 100%
With regards to injury patterns, there are multiple trends in Great vessel/cardiac injury from side-plate region 50%
this small series. All patients who sustained a great-vessel or Without great vessel injury 14%
cardiac injury died either on scene or during evacuation, with
two injured during CQC or room clearing operations, where
the axilla are particularly vulnerable. It is notable that side soldiers are forgoing the four-plate system is because of addi-
plates do not appear to be entirely protective from this in- tional weight, which is understandable in a trench warfare en-
jury, with only 50% of great-vessel/cardiac injuries presenting vironment requiring sprinting, repetitive climbing, and digging
from side-plate region injuries. This high mortality is also re- as essential tasks. This concern has also been highlighted by the
flected in civilian literature where, despite a lower occurrence Army and Marine Corps, recognizing that fighting loads had
of high-velocity rounds, mortality is still 88% and 100%, re- ballooned over the course of GWOT to concerning levels. In a
spectively, in two studies of patients presenting to a civilian 2017 study to “right size” the infantryman’s load, they found
trauma center. Additional injury patterns noted included the average combat load was 118 pounds, with 27 pounds
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near universal injuries violating the thoracic cavity, making the accounting for body armor and 5 pounds specifically for side
choice of empiric treatment for tension pneumothorax seem plates. This led the Marine Corps to reduce its plate protection
appropriate. ratings and forgo armor piercing protection to reduce fight
loads. With all levels of protection come trade-offs, specifi-
Superiority of the Four-Plate System and cally in the areas of weight and mobility that directly affect the
Appropriate Armor Coverage ability of the combatant to maneuver on the battlefield. Addi-
With the above data summarized in Table 1 and Table 2, it is tionally, combatant survivability is not just a matter of ballis-
reasonable to make two assumptions: (1) the four-plate system tic impermeability but is better thought of as a combination
should be the gold standard, and (2) current side plate cover- of equal parts lethality, maneuverability, and protection. The
age is inadequate; but as with most issues in war, the reality is Marine Corps claims reduction of armor weight by 25% led
more complicated. to an 8% increase in speed and agility testing. Much like the
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Ukrainians, the Marines understand the heavily armored com-
A recent article published by the Global Surgical and Med- batant who cannot maneuver fast enough to effectively en-
ical Support Group concerning their experiences in the gage the enemy is just as unlikely to survive as the unarmored
Ukrainian-Russian War highlights that “Use of standard cen- combatant and they must seek a middle ground. Furthermore,
ter mass front and rear plate armor that protect vital organs the relative importance of each of these combinations varies
within ‘The Box’ not be sufficient to save lives” and estimates greatly by mission: a turret gunner can favor protection over
60% of urgent surgical cases currently being received are due maneuverability as his platform inherently provides both ma-
to injuries lateral to the plates that could be mitigated by side neuverability and lethality. Contrast this with the dismounted
plates. While this statement is in line with our findings, the combatant on a long-range patrol who is likely to encounter
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authors proceed to explain that the reason so many Ukrainian the enemy after hours of prolonged exertion under a combat

TABLE 1 Injury Patterns and Outcomes
Struck in Thoracic
Side plates side-plate cavity Pneumothorax Cardiac Great-vessel
Case no. Entry wound worn coverage violated treated injury* injury* Disposition
1 † Right axilla (1–3 ICS) No No Yes Yes No No WIA
2 † Left axilla No No Yes Yes No No WIA
3 † Left 6th ICS No Yes Yes Yes Yes No KIA
4 † Right 7th ICS No Yes Yes Yes No Yes KIA
5 Right 3–5 ICS Yes No Yes Yes No Yes KIA
6 Lower edge of left side plate Yes Yes No No No No WIA
7 Right 1st rib/ICS Yes No Yes Yes No Yes KIA
8 Right 4th ICS Yes No Yes Yes No No KIA
9 Left axilla Yes No Yes Yes No No WIA
10 Left axilla Yes No Yes Yes No No WIA
11 Right axilla (1–3 ICS) Yes No Yes Yes No No WIA
*Cardiac and great vessel injuries were identified in review of radiologic studies, surgical documentation or autopsy.
† Injury sustained prior to the introduction of side plates.
ICS = intercostal space; KIA = killed in action; WIA = wounded in action.

84 | JSOM Volume 25, Edition 3 / Fall 2025