title: Death on the battlefield (2001-2011): implications for the future of combat casualty care.
abstract: BACKGROUND
  Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre-medical treatment facility (pre-MTF) environment.
  
  
  METHODS
  The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.
  
  
  RESULTS
  For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.
  
  
  CONCLUSIONS
  Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.
authors.affiliation: US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA. eastridge@uthscsa.edu
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Eastridge
authors.forename: Robert L
authors.initials: RL
authors.lastname: Mabry
authors.forename: Peter
authors.initials: P
authors.lastname: Seguin
authors.forename: Joyce
authors.initials: J
authors.lastname: Cantrell
authors.forename: Terrill
authors.initials: T
authors.lastname: Tops
authors.forename: Paul
authors.initials: P
authors.lastname: Uribe
authors.forename: Olga
authors.initials: O
authors.lastname: Mallett
authors.forename: Tamara
authors.initials: T
authors.lastname: Zubko
authors.forename: Lynne
authors.initials: L
authors.lastname: Oetjen-Gerdes
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
authors.forename: Frank K
authors.initials: FK
authors.lastname: Butler
authors.forename: Russ S
authors.initials: RS
authors.lastname: Kotwal
authors.forename: Russell S
authors.initials: RS
authors.lastname: Kotwal
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Charles
authors.initials: C
authors.lastname: Wade
authors.forename: Howard
authors.initials: H
authors.lastname: Champion
authors.forename: Mimi
authors.initials: M
authors.lastname: Lawnick
authors.forename: Leon
authors.initials: L
authors.lastname: Moores
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
mesh_terms: D055826:Afghan Campaign 2001-; D002423:Cause of Death; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D005544:Forecasting; D006801:Humans; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008297:Male; D054527:Mass Casualty Incidents / Q000401:mortality* / Q000517:prevention & control; D008887:Military Medicine / Q000592:standards* / Q000639:trends; D008889:Military Personnel / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016019:Survival Analysis; D014857:Warfare; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy