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load, and each additional ounce combines to reduce mobil- study should be replicated using the Department of Defense
ity and physiologic reserve. In short, what creates optimum Trauma Registry to compare data across various military com-
survivability depends radically on the nature of the mission munities with an increased sample size. Finally, further explo-
at hand. The Marines, understanding the challenges of mari- ration into trends in resuscitation and surgical requirements
time and jungle environments, are aggressively seeking weight for these patients after evacuation, such as total blood prod-
reductions at cost of protection to increase survivability. This uct requirement and common surgical repairs or procedures,
suggests that future efforts should aggressively focus on novel could help improve the triage and routing of these casualties
material development in efforts to increase the protection to from the point of injury or allow the receiving resuscitative
weight ratio. and surgical team to make standard preparation for reception
of casualties with penetrating axilla wounds.
Regardless of weight, our findings raised the question of in-
creasing the coverage area of the side plates, most specifically Conclusion
superiorly. Our British colleagues appeared also troubled by
this concern and conducted a study in 2019 looking to de- Decisions for mission personal protective equipment level is
termine the optimum coverage for body armor. For this, an operational decision for commanders who must consider
12
1,000 military-aged individuals underwent CT scans while the tradeoff of increased weight on the lethality, maneuver-
wearing Virtus armor, which is nearly identical to that of its ability, and protection of their force. With that, our findings
U.S. counterparts, to determine whether current systems pro- do provide reassurance that if appropriate for the mission, side
vided effective coverage. One hundred percent coverage was plates likely provide strong protection against catastrophic in-
defined as multidirectional ballistic protection of the heart, jury to critical anatomy such as the great vessels and the heart,
aorta from the arch to the bifurcation, vena cava, liver, and particularly during high-risk operations, such as close quarters
spleen. Current side plates generally covered from the iliac combat and other 360-degree threat environments, but show
crest to the 4th–5th intercostal space, providing 35% more that current armor is not a panacea and the ability to expand
coverage of vital areas than front and rear plates alone. They coverage with current material can create serious operational
noted, if they extended the side plates to cover above this re- limitations. This guides our recommendation that current ef-
gion, approximately 10cm to the armpit, they only gained an forts should be directed in finding new materials that can fill
additional 16% coverage at significant cost of mobility and the gaps in the armor, without sacrificing warfighter mobility.
comfort as reported by participants. The conclusion of their
study was that while the expanded coverage could provide Acknowledgments
significant protection, the cost in mobility made the tradeoff The authors would like to thank LtCol Matthew Newman and
inadvisable, and it recommended sustaining current plate sizes. Marine Gunner Alex Deykerhoff for their extensive assistance
This suggests that, to prevent 50% of the deaths associated in clarifying research and expert input.
with cardiac/great-vessel injury in this study, advances in ma-
terial rigidity, not just weight, will be required to attain further Author Contributions
gains in reducing mortality and morbidity. There should also RK, JA, DC, and AN designed the study. NW, RK, DC, and
be consideration of placement of armor over the shoulders or AN conducted a review of the case files. DC and AN drafted
deltoids to prevent lateral penetrating injuries to the axilla. the manuscript. JA, RK, CM, DC, and AN reviewed and edited
the draft.
Limitations
The retrospective case series design, limited sample size of a Disclosures
homogenous population consisting of members of a single The authors have nothing to disclose.
light infantry unit conducting patrolling or raid operations
against an inferior force, inherent recall bias of after action Funding
reports, ease of access to medical evacuation (GWOT Golden Funding for travel was provided by the Geneva Foundation
Hour) that is atypical in the current operating environment, U.S. Navy San Diego Emergency Medicine Alumni Educa-
vague documentation on many patients, and reports solely tional Fund.
based upon light infantry operations tempers the ability to ex-
trapolate these findings to other military communities (armor, References
artillery, flight) with differing mission sets during high-inten- 1. Joint Trauma System. “Clinical Practice Guidelines.” Joint Trauma
System. Published January 13, 2023. Accessed June 23, 2025. jts.
sity near-peer conflict. health.mil/index.cfm/PI_CPGs/cpgs
2. Cornett E, Downey A, Berwick D, eds. A National Trauma Care
Implications System: Integrating Military and Civilian Trauma Systems to
Findings in this study demonstrate the lethality of axilla injuries Achieve Zero Preventable Deaths After Injury. National Academies
and that side plates do reduce the occurrence of catastrophic Press; 2016.
injury. However, increased surface area can be covered with 3. Gooch W. Overview of the development of ceramic armor tech-
ceramic armor at the expense of mobility and agility. nology: past, present and the future. Paper presented at: 30th In-
ternational Conference on Advanced Ceramics and Composites;
January 22–27; Cocoa Beach, FL.
Areas for Future Research 4. Armed Forces Institute of Pathology (AFIP). Marine Lethal Torso
Future armor development should look for soft armor technol- Injury: Preliminary Findings. Technical Report to Congress. Ma-
ogies to offset the anatomic limitations of hard armor designs. rine Corps System Command; August 29, 2005. Accessed June 24,
The case series, along with the numerous cited studies, point 2025. https://apps.dtic.mil/sti/pdfs/ADA442169.pdf
to the “gaps in the armor” as being the limiting factor to fur- 5. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
(2001–2011): implications for the future of combat casualty care.
ther decreasing fatalities in the four-plate era. An alternative J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–S437. doi:
or innovation to hard armor must be found. Additionally, this 10.1097/TA.0b013e3182755dcc

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