title: Causes of death in US Special Operations Forces in the global war on terrorism: 2001-2004.
abstract: BACKGROUND
  Effective combat trauma management strategies depend on an understanding of the epidemiology of death on the battlefield, resulting in evidence-based equipment, training, and research requirements.
  
  
  METHODS
  All Special Operations Forces (SOF) fatalities (combat and noncombat) in Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) from October 2001 until November 2004 were reviewed. All available autopsy and treatment records and photographs were used. In most cases, the immediate tactical situation was unknown. The review was performed by a multidisciplinary group including forensic pathologists, an SOF combat medic, and trauma surgeons. Fatalities were classified as having wounds that were either nonsurvivable or potentially survivable with existing training, equipment, and expertise on the battlefield. A structured review was performed evaluating the need for new equipment, training, or research requirements. Results were compared to autopsy data from Vietnam and modern civilian trauma center data. The study was approved by the Institutional Review Boards of the Armed Forces Institute of Pathology and the US Army Institute of Surgical Research.
  
  
  RESULTS
  During the study period, 82 SOF fatalities were identified. Autopsies were performed on 77 Soldiers. Five casualties died secondary to aircraft crash, their bodies were not recovered from the ocean. For the purposes of this study they were considered nonsurvivable. Eighty-five percent (n = 70) of the fatalities sustained wounds that were nonsurvivable, while the remaining 15% (n = 12) had wounds that were potentially survivable. Injury Severity Score (ISS) was higher in the nonsurvivable group (p < 0.05). Truncal hemorrhage accounted for 47% of deaths while extremity hemorrhage accounted for 33%. One casualty was noted at autopsy to have a tension pneumothorax as well as multiple sources of internal hemorrhage, one suffered an airway death, while another died of sepsis 56 days after injury. Of those casualties deemed to be nonsurvivable, there were 31 patients with 40 Abbreviated Injury Score (AIS) 6 injuries (p = .0011), and 53 patients with 104 AIS 5 injuries. Among the 12 deaths deemed to be potentially survivable, there were only 8 AIS 5 injuries. Deaths were largely caused by explosions (n = 35), gunshot wounds (n = 23), and aircraft accidents (n = 19). No new training or equipment needs were identified for 53% of the potentially survivable deaths while improved methods of truncal hemorrhage control need to be developed for the remainder. The review panel concluded that 85% of the deaths would not have been prevented at a civilian Level I facility. Available records, in most cases, did not contain information about the use of body armor, time to death after injury, or the ongoing tactical situation.
  
  
  CONCLUSIONS
  The majority of deaths on the modern battlefield are nonsurvivable. Current results are not different from previous conflicts. In Vietnam, reported potentially preventable death rates range from 5% to 35% and civilian data reports potentially preventable death rates ranging from 12% to 22%. Military munitions cause multiple lethal injuries. Current trauma training and equipment is sufficient to care for 53% of the potentially survivable deaths. Improved methods of intravenous or intracavitary noncompressible hemostasis combined with rapid surgery are required for the remaining 47% of the decedents.
authors.affiliation: US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
authors.forename: John
authors.initials: J
authors.lastname: Holcomb
authors.forename: James
authors.initials: J
authors.lastname: Caruso
authors.forename: Neil
authors.initials: N
authors.lastname: McMullin
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: Lisa
authors.initials: L
authors.lastname: Pearse
authors.forename: Lynne
authors.initials: L
authors.lastname: Oetjen-Gerdes
authors.forename: Howard R
authors.initials: HR
authors.lastname: Champion
authors.forename: Mary
authors.initials: M
authors.lastname: Lawnick
authors.forename: Warner
authors.initials: W
authors.lastname: Farr
authors.forename: Sammy
authors.initials: S
authors.lastname: Rodriguez
authors.forename: Frank
authors.initials: F
authors.lastname: Butler
mesh_terms: D015998:Abbreviated Injury Scale; D055826:Afghan Campaign 2001-; D001344:Autopsy; D002423:Cause of Death; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008887:Military Medicine / Q000706:statistics & numerical data*; D008889:Military Personnel / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D023481:Terrorism; D014481:United States; D014947:Wounds and Injuries / Q000401:mortality*