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Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System., (2024.)

The Afghan National Army Special Operations Command (ANASOC) uses several documents for casualty reporting. By analyzing these documents from a period of March to December 2018, the authors demonstrate the predominance of gunshot fatalities within ANASOC at approximately 63% of combat deaths and a high rate of prehospital death at approximately 97% of combat deaths. The data also demonstrate relatively few cases of long-term disability from ANASOC soldiers wounded in action. The authors used these conclusions to create a Combined Joint Special Operations Task Force-Afghanistan (CJSOTF-A) working group that recommended changes to the medical curriculum at the ANASOC School of Excellence. These recommendations centered on an increased emphasis on bleeding control to prevent death from hemorrhagic shock., (2019.)

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare survival of causalities undergoing cricothyrotomy versus SGA placement., Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a subanalysis of that dataset., Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019) a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar upon arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios (ORs) for survival were not significantly different between the two groups., Conclusion: We found no difference in short-term outcomes between combat casualties who received an SGA vs cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq., (2019.)

Introduction: The military working dog (MWD) has been essential in military operations such as Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). MWDs sustain traumatic injuries that require point of injury and en route clinical interventions. The objective of this study was to describe the injuries and treatment military working dogs received on the battlefield and report their final disposition., Methods: This was a convenience sample of 11 injury and treatment reports of US MWDs from February 2008 to December 2014. We obtained clinical data regarding battlefield treatment from the 160th Special Operations Aviation Regiment (SOAR) database and supplemental operational sources. A single individual collected the data and maintained the dataset. The data collected included mechanism of injury, clinical interventions, and outcomes. We reported findings as frequencies., Results: Of the 11 MWD casualties identified in this dataset, 10 reports had documented injuries secondary to trauma. Eighty percent of the cases sustained gunshot wounds. The hindlegs were the most common site of injury (50%); however, 80% sustained injuries at more than one anatomical location. Seventy percent of cases received at least one clinical intervention before arrival at their first treatment facility. The most common interventions included trauma dressing (30%), gauze (30%), chest seal (30%), and pain medication (30%). The survival rate was 50%., Conclusion: The majority of the MWD cases in this dataset sustained traumatic injuries, with gunshot being the most common mechanism of injury. Most MWDs received at least one clinical intervention. Fifty percent did not survive their traumatic injuries., (2019.)

Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation., Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome., Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82)., Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders., (2019.)

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement., Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set., Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups., Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq., (2019.)

Technology has become a necessity in modern society, providing capabilities that have never been experienced before. The integration of such capabilities arms today's Special Operations medic with abilities that can make a vast difference to the survivability rate of an ill or injured patient. Taking advantage of new technological capabilities such as advanced monitoring and diagnostics and portable ultrasound also plays a key role; together with the evolution in modern communication., (2019.)

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome., (2018.)