It is impossible to convey to you 

the picture of human misery continually before my eye. . . . 

While I amputate one man’s thigh, there lay at one time thirteen, 

all beseeching to be taken next. . . . 

It was a strange thing to feel my clothes stiff with blood, 

and my arms powerless with the exertion of using the knife! . . . 

The view of the field, the gallant sorties, the charges, 

the individual instances of enterprise and valour 

recalled to me the sense the world has of victory and Waterloo. 

But this is transient. A gloomy uncomfortable view of 

human nature is the inevitable consequence of

looking upon the whole as I did—as I was forced to do.

 —Sir Charles Bell (1774–1842)
Office of The Surgeon General

United States Army, Falls Church, Virginia

Borden Institute

Walter Reed Army Medical Center, Washington, DC

Edited by

SHAWN CHRISTIAN NESSEN, DO, FACS

LTC, MC, US Army 

DAVE EDMOND LOUNSBURY, MD, FACP 

COL, MC, US Army (Retired)

STEPHEN P. HETZ, MD, FACS 

COL, MC, US Army (Retired)
A Specialty Volume of the 

TEXTBOOKS OF MILITARY MEDICINE

Published by the 

Office of The Surgeon General

Department of the Army, United States of America

US Army Medical Department Center and School

Fort Sam Houston, Texas

Telemedicine and Advanced Technology Research Center

US Army Medical Research and Materiel Command, Fort Detrick, Maryland

Editor in Chief

Martha K. Lenhart, MD, PhD

Colonel, MC, US Army

Director, Borden Institute

Assistant Professor of Medicine

F. Edward Hébert School of Medicine 

Uniformed Services University of the Health Sciences 

Developmental & Consulting Editor

Dave Edmond Lounsbury, MD, FACP

Colonel, MC, US Army (Retired)

Borden Institute

Assistant Professor of Medicine

F. Edward Hébert School of Medicine 

Uniformed Services University of the Health Sciences
 The Nation today needs men who think in terms of service to their

country and not in terms of their country’s debt to them.

 —General Omar N. Bradley, 1948

And so, my fellow Americans: ask not what your country can do for you—

ask what you can do for your country.

 —John F. Kennedy, 1961

H H H H H

TO SERVICE

To the Soldiers, Marines, Airmen, and Sailors

who have sacrificed so much 

for their country
Editorial Staff

Developmental Editor Dave Edmond Lounsbury, MD, FACP (COL, MC, US Army, Retired)

Creative Director/Production Manager Christine Gamboa-Onrubia, MBA, Fineline Graphics LLC

Senior Volume Editor Vivian Mason

Illustrator Aletta Frazier, MD

The purpose of this textbook is to provide concise supplemental material for military surgeons deploying or preparing to deploy to a combat theater. 

The information contained herein will foster discussion that may form the basis of policy and doctrine. Every effort has been made to ensure that 

information provided is consistent with official OTSG/MEDCOM policy and doctrine. This is not, however, an official Department of the Army publication. The views expressed are those of the editors and should not be construed necessarily to reflect the views of the Department of Defense, the 

Department of the Army, or the Army Medical Department.

Dosage Recommendations: The Editors and contributors have made every effort to ensure the efficacy of attributed medications and the accuracy of 

dosages provided. However, it is—and should be—the responsibility of every practitioner to consult appropriate information to confirm correct use 

and dosage for each clinical situation in which they are applied. The Editors, contributors, publisher, and the Department of Defense do not assume 

obligation for any errors found in this book.

Use of Trade or Brand Names: Use of trade or brand names in this publication does not imply endorsement by the Department of Defense.

Neutral Language: Unless the text states otherwise, use of masculine nouns and pronouns do not refer exclusively to men.

This work was created in part with the support of the United States Government under FedSource Contract No. TPD-03-C-002; United States Department of the Army Control Number WR1180. The Government has been granted a paid-up, royalty-free, world-wide, nonexclusive, irrevocable license 

to reproduce, prepare derivative works from, distribute, perform, or display, and to have or authorize others to do so, this work in any form or format 

in accordance with the terms of FAR 52.227-14 and ancillary instruments.

Copyright © 2008 by R. Paul Gauthier. 

No copyrighted parts of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical (including 

photocopy, recording, or any information storage and retrieval system), without permission in writing from the publisher or copyright owner.

Published by the Office of The Surgeon General 

Borden Institute, Walter Reed Army Medical Center, Washington, DC 20307-5001

Library of Congress Cataloging-in-Publication Data

War surgery in Afghanistan and Iraq : a series of cases, 2003–2007 /

edited by Shawn Christian Nessen, Dave Edmond Lounsbury, Stephen P. Hetz.

 p. ; cm.

 Includes bibliographical references and index.

 1. Surgery, Military—Afghanistan. 2. Surgery, Military—Iraq. 3. Afghan war, 2001—Medical care. 4. Iraq war, 2003—Medical care. 

I. Nessen, Shawn Christian. II. Lounsbury, Dave Edmond. III. Hetz, Stephen P. IV. United States. Dept. of the Army. Office of the Surgeon 

General. V. Borden Institute (U.S.) VI. Walter Reed Army Medical Center. [DNLM: 1. Military Medicine—Afghanistan. 2. Military

Medicine—Iraq. 3. Military Medicine—United States. 4. Wounds and Injuries—surgery—Afghanistan. 5. Wounds and Injuries—surgery—Iraq. 6. Wounds and Injuries—surgery—United States. 7. Emergency Medical Services—Afghanistan. 8. Emergency Medical 

Services—Iraq. 9. Emergency Medical Services—United States. 10. Iraq War, 2003—Afghanistan. 11. Iraq War, 2003—Iraq. 12. Iraq War, 

2003—United States. 13. Wars—Afghanistan. 14. Wars—Iraq. 15. Wars—United States. WO 800 W253 2008]

 RD476.A3W37 2008

 617.9’9—dc22

 2008011884

Classification: UNCLASSIFIED

Caveats: NONE

Printed in the United States of America

15 14 13 12 11 10 09 08 10 9 8 7 6 5 4 3 2

First Printing
contentS

Contributors ...............................................................................................................................................xii

Acknowledgments......................................................................................................................................xiii

Foreword by Bob Woodruff ........................................................................................................................ xv

Preface by The Surgeon General................................................................................................................ xvii

Introduction...............................................................................................................................................xix 

Prologue Trauma System Development and Medical Evacuation in the Combat Theater...................1 

Introduction .......................................................................................................................1

Trauma System ...................................................................................................................2

Military Health System Echelons of Care ............................................................................3

Aeromedical Evacuation .....................................................................................................6

Combat Trauma System Implementation ............................................................................7

Trauma Registry ...............................................................................................................10

Commentary: Are We Doing Better?: Assessing Combat Casualty Data ............................11 

Chapter I. Acute Resuscitation and Critical Care ...............................................................................17

1. Forward Resuscitative Surgery: An Introduction to Polytrauma .................................19 

2. Emergency Surgical Airway Management...................................................................24 

3. Devastating Burn, Blast, and Penetrating Injury..........................................................28 

4. To Shunt, Repair, or Amputate . . . ?...........................................................................31 

5. Extremity Trauma With Profound Shock ...................................................................33

6. Massive Blood Transfusion in a Patient With Hemoperitoneum .................................39

Commentary: Damage Control Resuscitation ...................................................................49 

Chapter II. Face, Neck, and Eye Trauma ............................................................................................53

1. Complex Facial Wounds.............................................................................................55 

2. Facial Lacerations.......................................................................................................58 

3. Corneal Perforation ....................................................................................................61 

4. Maxillofacial Reconstruction......................................................................................65 

5. Mandible Gunshot Wound .........................................................................................70 

Commentary: High-Energy Facial Injuries ........................................................................74
x | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Chapter III. Head and Spine Trauma ...................................................................................................83

1. Penetrating Head Injury With Subdural Hematoma ...................................................85 

2. Basilar Skull Fracture With Pneumocephaly................................................................90 

3. Right Hemisphere Fragment Wound...........................................................................93 

4. Manual Craniotomy for Penetrating Head Injury .....................................................101

5. Spinal Cord Injury Without Paralysis .......................................................................108 

Commentary: Hemicraniectomy .....................................................................................111 

Commentary: Traumatic Brain Injury .............................................................................113

Chapter IV. Thoracic Trauma.............................................................................................................117

1. Penetrating Thoracoabdominal Trauma, I ................................................................119 

2. Penetrating Thoracoabdominal Trauma, II ...............................................................125 

3. Thoracotomy for Massive Hemothorax....................................................................130 

4. Spinal Injury With Penetrating Thoracoabdominal Injuries ......................................134 

5. Traumatic Pericardial Tamponade ............................................................................138

6. Penetrating Right Chest Injury..................................................................................145

7. Transmediastinal Gunshot Wound............................................................................150

Commentary: Approaches to the Chest Cavity................................................................154

Chapter V. Abdominopelvic Trauma ................................................................................................157

1. Indirect Effects of Wounding ....................................................................................159 

2. Penetrating Trauma to the Stomach and Pancreas ....................................................163

3. Blunt Abdominal Trauma .........................................................................................169 

4. Missed Duodenal Injury............................................................................................172 

5. Traumatic Evisceration .............................................................................................176 

6. Penetrating Rectal Injury ..........................................................................................179 

7. Renal Trauma ...........................................................................................................185 

8. Penetrating Pelvic Trauma ........................................................................................188 

9. Penetrating Scrotal Trauma ......................................................................................192 

10. Genital Soft-Tissue Trauma ......................................................................................196 

Commentary: Damage Control .......................................................................................199 

 Commentary: Abdominopelvic Trauma, Cases Review ...................................................201

Chapter VI. Soft-Tissue Trauma and Burns ........................................................................................205

1. Lower Extremity Compartment Syndrome ...............................................................207 

2. Sciatic Nerve Laceration ...........................................................................................211 

3. Posttraumatic Necrotizing Fasciitis...........................................................................214 

4. Median Forehead Flap..............................................................................................219 

5. Soft-Tissue Coverage of Combat Wounds: A Series of Cases ....................................223 

6. 80% Body Burn........................................................................................................238 

Commentary: Soft-Tissue Trauma and Burns ..................................................................245

Chapter VII. Orthopaedic Trauma.......................................................................................................249

1. Gunshot Wound With Loss of the Elbow..................................................................251 

2. Hand and Face Blast Injuries; Polytrauma Management...........................................257 

3. Open Femur Fracture ...............................................................................................262 

4. Blast Injury of the Hand ...........................................................................................265 

5. Blast Injury of the Humerus .....................................................................................269 
6. Open Ulna Fracture ..................................................................................................272 

7. Gunshot Wound of the Hand ...................................................................................277 

8. Tibia Fracture With Compartment Syndrome ...........................................................281 

9. Traumatic Below-Knee Amputation .........................................................................286 

10. Umbrella Effect of a Landmine Blast ........................................................................292 

11. Penetrating Injury of the Left Foot ...........................................................................297 

12. High-Energy Gunshot Wound to the Forearm ..........................................................300 

13. High-Energy Orthopaedic Polytrauma .....................................................................306 

Commentary: Orthopaedic Trauma ................................................................................312

Chapter VIII. Vascular Trauma .............................................................................................................317

1. Innominate Vein Injury .............................................................................................319 

2. External Iliac Vein Injury, Exposure and Control .....................................................325 

3. Penetrating Subclavian Artery Injury ........................................................................329 

4. Shunts in Vascular Injuries........................................................................................332 

5. Arteriovenous Fistula, Delayed Effect of Blast ..........................................................337 

6. Brachial Artery Injury, Transection ...........................................................................340 

7. Femoral Vein Injury ..................................................................................................342 

8. Brachial Artery Injury, Blunt Trauma........................................................................346 

9. Left Subclavian Artery Gunshot Wound....................................................................350 

10. Gluteal Compartment Syndrome ..............................................................................353 

Commentary: Vascular Trauma; Cases Review................................................................359

Chapter IX. Special Scenarios .............................................................................................................363

1. Penetrating Pediatric Trauma, I ................................................................................365 

2. Penetrating Pediatric Trauma, II ...............................................................................369

3. Removal of an Unexploded Ordnance ......................................................................373 

4. Ectopic Pregnancy.....................................................................................................377 

5. Continuous Peripheral Nerve Block..........................................................................380

6. Pediatric Popliteal Artery Trauma.............................................................................385 

7. Tetanus.....................................................................................................................389 

8. Penetrating Abdominal Trauma in the Pregnant Patient............................................392 

Commentary: Management of Pediatric Trauma.............................................................399

Afterword .................................................................................................................................................403 

Appendices A. Abbreviations and Acronyms ...................................................................................405

B. Product Manufacturers.............................................................................................407

C. Glasgow Coma Scale ................................................................................................408

D. Clinical Practice Guidelines ......................................................................................409

	 • Burn Care ..............................................................................................................409

	 • Management of Patients With Severe Head Trauma...............................................425

	 • Damage Control Resuscitation at Levels IIb and III ...............................................429

	 • Military Acute Concussion Evaluation (MACE) ....................................................431

	 • Urologic Trauma ...................................................................................................434

Index ........................................................................................................................................................437

About the Editors .....................................................................................................................................442

contents | xi
xii | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

contributors

Original Case Contributors

Todd S. Albright, DO, MPH, LTC, MC, US Army 

Kenneth Azarow, MD, COL, MC, US Army

Scott D. Barnes, MD, LTC, MC, US Army

Douglas M. Bowley, FRCS(Eng), FRCS(Gen Surg), 

 Lt Col, RAMC

Matthew L. Brengman, MD, MAJ, MC, US Army

William A. Brock, CRNA, LTC, AN, US Army

Chester Buckenmaier, MD, LTC, MC, US Army 

Jeffrey S. Bui, MD, Maj, MC, US Air Force

Brennan Carmody, MD, LTC, MC, US Army

Paul R. Cordts, MD, COL, MC, US Army

Steven J. Cyr, MD, Maj, MC, FS, US Air Force

Louis A. Dainty, MD, LTC, MC, US Army

David Danielson, MD, MAJ, MC, US Army

Dennis P. Eastman, MD, COL, MC, US Army

James M. Ecklund, MD, COL, MC, US Army

Mark T. Edney, MD, MAJ, MC, US Army

Jonathan Eliason, MD, Maj, MC, US Air Force

Richard Ellison, MD, COL, MC, US Army

Dion L. Franga, MD, MAJ, MC, US Army

Kirby Gross, MD, LTC, MC, US Army 

Marty Harnisch, MD, MAJ, MC, US Army 

Stephen P. Hetz, MD, COL, MC, US Army (Retired)

Linda C. Hird, MD, CPT, MC, US Army

Patrick J. Houde, MD, Capt, MC, US Air Force

Ronald A. Hyde, DO, MAJ, MC, US Army

James R. Jezior, MD, COL, MC, US Army

Karen M. Keith, DDS, MD, COL, DC, US Army

Kevin L. Kirk, MD, MAJ, MC, US Army

Kevin J. Kulwicki, MD, MAJ, MC, US Army

Geoffrey S. Ling, MD, PhD, COL, MC, US Army

Juan M. Lopez-Gonzalez, MD, LTC, MC, US Army

Dave Edmond Lounsbury, MD, COL, MC, US Army (Retired)

John D. Lowry, MD, LTC, MC, US Army

Kevin J. Mork, MD, COL, MC, US Army

Shawn Christian Nessen, DO, LTC, MC, US Army

Peter E. Nielsen, MD, COL, MC, US Army 

Joel B. Nilsson, MD, Lt Col, MC, US Air Force

John S. Oh, MD, MAJ, MC, US Army

Mary F. Parker, MD, LTC, MC, US Army

George E. Peoples, MD, COL, MC, US Army

Kimberley L. Perkins, DDS, LTC, DC, US Army 

Donald W. Robinson, DO, LTC, MC, US Army

Nelson Rosen, MD, MAJ, MC, US Army

Paul J. Schenarts, MD, MAJ, MC, US Army 

Brian S. Schultz, DO, MAJ, MC, US Army

Jody Schultz, MD, MAJ, MC, US Army

Niten N. Singh, MD, MAJ, MC, US Army

Richard J. Teff, MD, LTC, MC, US Army

Andrew Wargo, DDS, LTC, DC, US Army 

Harry Warren, MD, COL, MC, US Army 

Glenn W. Wortmann, MD, COL, MC, US Army 

Mark Ziemba, MD, COL, MC, US Army

Joseph J. Zubak, MD, LTC, MC, US Army 

Other Contributors

Rocco A. Armonda, MD, LTC, MC, US Army 

Ronald F. Bellamy, MD, COL, MC, US Army (Retired)

Francis M. Chiricosta, MD, LTC, MC, US Army 

James R. Ficke, MD, COL, MC, US Army 

Katherine M. Helmick, MS, CNRN, CRNP 

John B. Holcomb, MD, COL, MC, US Army 

Donald H. Jenkins, MD, Col, MC, US Air Force

John F. Kragh, MD, COL, MC, US Army 

Charles R. Mulligan, MD, MAJ, MC, US Army

Clinton K. Murray, MD, MAJ, MC, US Army 

Jeremy G. Perkins, MD, MAJ, MC, US Army 

Benjamin Potter, MD, CPT, MC, US Army 

Evan M. Renz, MD, LTC, MC, US Army

Stephen L. Rouse, DDS, LTC, DC, US Army (Retired)

Deborah L. Warden, MD 
acknowledgments

An edited work such as this is only as good as the efforts of its contributors and 

production staff. The Editors are deeply grateful to all those who participated in 

and supported this project.

This textbook would not have been possible without the unflagging support of 

the Borden Institute under the Directorship of Colonel Martha K. Lenhart. 

Ms. Vivian Mason worked tirelessly—often in real time—to interpret and translate 

innumerable twists and turns in the development of this book.

Ms. Chris Onrubia grasped early the intent of this project and captured that 

purpose in the design and layout of the final product.

Dr. Aletta Frazier not only provided expert medical illustration, but also her generous 

time and effort to assist with graphics. We appreciate this more than she knows.

Mr. David Leeson of The Dallas Morning News has generously provided stunning 

nonclinical photographs. Today soldiers unknowingly circulate many of his OIF-1 

(2003) photographs, unattributed, and wrongly assumed to be amateur snapshots 

unprotected by copyright.

The Editors are grateful to all case contributors. We wish to especially acknowledge, 

however, the generosity of MAJ Kevin J. Kulwicki, LTC Richard J. Teff, LTC Mary 

F. Parker, LTC Kimberley L. Perkins, MAJ Mark T. Edney, and MAJ Jeffrey S. Bui.

Special tribute is extended to SFC John C. Thomas, SGT (Retired) Brian Wilhelm, 

SFC (Retired) Joseph M. Mosner, SSG (Retired) Brian E. Wells (all US Army), and 

Sr A (Retired) Brian G. Kolfage for their permissions to reveal personal images. 

Others whose efforts, advice, and contributions warrant mention include the 

following: Dr Paul J. Dougherty (formerly LTC, MC, US Army); Dr James E. 

Cox (COL, MC, USAF, Retired); Mr Douglas Wise; Mr Bruce Maston; COL Leo 

Tucker, MC, US Army; and COL Peter Nielsen, MC, US Army.

Photo Credits: Digital cameras are ubiquitous today in both theaters of combat operations. Electronic sharing of snapshots, both 

clinical and recreational, is widespread. As a consequence, however, it becomes difficult, if not impossible, to accurately attribute 

each photo. For this and other reasons, we have not attempted to provide photo-by-photo attribution. With few exceptions, clinical 

photographs were taken and provided by the surgical team attending the case with which they are attached. We are particularly 

indebted for the large files of nonclinical material provided by the Editors and the following individuals: COL Martha Lenhart, 

LTC Kenneth L. Ferster, LTC Tommy Brown, and MAJ Adam Hamawy—all MC, US Army. We also thank Dr (PhD) Sanders 

Marble, Mr Dimitri Doganis, Mr Stefan Radtke, Keith S. Albertson, MD (COL, MC, US Army, Retired), SGT Heather Denman, 

and Polaris Images Corporation for permission to use Sungsu Cho’s photograph that appears on page 403. Where they appear, 

unblocked facial images are used with permission. All photographs are retained on file at the Borden Institute.

acknowledgments | xiii

foreword | xv

foreword

On January 29, 2006, I was riding on top of an Iraqi APC (armored personal 

carrier), heading down a road in Taji, Iraq, that was supposed to represent a 

success story of the war: a collaboration between US and Iraqi forces against the 

insurgents. As the newly named co-anchor of ABC World News Tonight, I was 

in Iraq to cover President Bush’s State of the Union address and to report on the 

positive stories of the war—the hard work of the military to train and empower 

local forces on the ground. 

In an instant, an improvised explosive device (IED) exploded about 20 yards from 

the vehicle, and my life was changed forever, as well as that of my cameraman, 

Doug Vogt. The force of the blast, a 155-mm shell, shattered my skull over the left 

temporal lobe. Hundreds of rocks, packed around the IED, were blasted into the 

side of my face. One rock, the size of a child’s marble, sheared my helmet chinstrap 

in half and traveled through the left side of my neck, coming to rest on the carotid 

artery on the other side of my head. 

For the next 36 days, I would remain in a medically induced coma; but the quick 

actions and amazing skills of the medics, military doctors, nurses, and assistants 

would not only save my life, but also save my brain function following this lifethreatening injury. Their experiences with such large numbers of those wounded 

by IEDs, most of whom would not have survived in previous wars, gave them the 

confidence to make split-second decisions. In the medical barracks of Balad, the 

doctors did not hesitate, giving me the chance for the best possible outcome. 

One of the most amazing stories I heard later, which speaks to me of the dedication 

of our men and women in uniform, is a story about the MEDEVAC pilots. After 

the IED exploded, a gunfight ensued and the helicopter pilots were instructed not 

to land. Unaware of who was on the ground and only knowing that someone 

needed help, these pilots turned down the radio, ignored the order, and landed. I 

was then taken to Baghdad, assessed, and then sent to Balad, where—within the 

hour—my skull flap was removed and my brain began swelling. From Balad, I 

was sent to Landstuhl Regional Medical Center in Germany, a major way station 

for wounded soldiers en route to the United States. Just 60 hours after my family 

arrived there, I was ready to be transported again to neurosurgical care at the 

National Naval Medical Center (also known as Bethesda Naval Hospital) outside 

of Washington, DC. 
xvi | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

It was there that I received top-notch medical care from an expert team of dedicated 

military specialists. It was their skill, perseverance, team approach, and kindness 

that created a platform from which to heal. In writing this foreword, I want to 

applaud the efforts, bravery, and dedication of the American military. It is well 

known that much of cutting edge medicine in civilian life comes from the valiant 

efforts, ingenuity, and pure guts of the battlefield physicians in an effort to save 

lives under extreme conditions. I am not a hero. I leave that to the men and women 

serving their country in uniform who put their lives on the line every day for our 

freedoms. After their wounds, their lives (like mine) are changed forever. What do 

we owe these men and women? How do we measure our debt to them and their 

families? What will be our legacy of how we treat those with long-term injuries—

such as traumatic brain injury, posttraumatic stress disorder, depression, and other 

mental illnesses—that can require years of appropriate therapy as the brain heals 

and the body regenerates? 

George Washington, our nation’s first Commander in Chief, said, “The willingness 

with which our young people are likely to serve in any war, no matter how 

justified, shall be directly proportional to how they perceive the Veterans of earlier 

wars were treated and appreciated by their nation.” Today, in the face of so many 

injured returning from the wars in Iraq and Afghanistan, we are faced with a wave 

of wounded, many of them young, all of them returning to a life vastly different 

than what they left, and families who must learn to deal with a new reality. Are we 

adequately meeting that charge from our founding father? 

Once I passed through the acute stage of my injury, the real work began with 

my long journey to heal during rehabilitation. Time, energy, commitment, and 

dedicated professionals supplied the framework to help my brain heal. The love 

and encouragement of family and friends provided my personal motivation to “get 

my brain back.” 

I hope that this book instructs deployed physicians in aspects of the care of initial 

injuries. But may it also serve as a stepping-off point to focus on continuing that 

quality of care in the long road to rehabilitation following the injury. My family 

and I are so appreciative and forever grateful for the medical care that I received 

from the military. It is our dream that the attention to the wounded remains as 

focused in the long journey to heal as it is in those white-hot moments in the 

surgical theater when nothing is spared to save a life. 

Bob Woodruff

July 2007

“The willingness 

with which our 

young people 

are likely to 

serve in any 

war, no matter 

how justified, 

shall be directly 

proportional 

to how they 

perceive the 

Veterans of 

earlier wars 

were treated and 

appreciated by 

their nation.”
preface | xvii

preface

It is not uncommon for editors of multiauthored textbooks, and for reviewers of 

these books, to comment apologetically—or critically—on the inherent bumpiness 

of such works. We make no such apology here. Indeed, we maintain that the 

individual nuance and variation among this series of cases are a testament to the 

collective dedication of the many surgeons, deployed in Southwest Asia, who 

volunteered their experiences to the effort that produced this textbook.

The photographs were taken mostly in the field by handheld digital cameras. 

The surgical accounts were typed into e-mails dispatched to the Borden Institute 

from overseas Forward Surgical Teams (FSTs), combat support hospitals (CSHs), 

and their equivalent sister Service deployable surgical facilities, or collected from 

surgeons on their return from these deployments. End-of-chapter peer review 

commentary has been provided, but the editors have been careful to maintain 

the individual character of each case as it was presented, as it evolved, as it was 

managed, and as it was concluded . . . not in every case successfully.

The result of this extraordinary frankness, included in such a broad spectrum of 

acute trauma surgical presentations, is a textbook unlike any other in the surgical 

literature. Paired, as it is intended to be, with the 2004 edition of Emergency War 

Surgery, Third United States Revision, this text provides the deploying surgeon, as 

well as surgical housestaff, with the fundamental principles and priorities critical 

in managing the trauma of modern warfare; and all medical professionals with 

insights into the extraordinary technical, clinical, and ethical challenges of their 

colleagues.

The US Army Medical Department applauds the diligent work of the editors in 

collecting these cases and providing the necessary instruction and discussion in 

order to provide optimal forward surgical care—care that is the duty of a great 

nation to those who serve.

 Eric B. Schoomaker, MD, PhD, FACP

Lieutenant General, Medical Corps, US Army

The Surgeon General

Washington, DC, December 2007

Introduction | xix

introduction

. . . he who would become a surgeon, 

therefore, should join the army and follow it.

 —Hippocrates

Following terrorist attacks of September 11, 2001 on the United States, US military 

forces were mobilized and deployed to Afghanistan (Operation Enduring Freedom 

[OEF]) in 2001 and to Iraq (Operation Iraqi Freedom [OIF]) in 2003. Deployed 

forces were accompanied by Army field medical assets (eg, the Mobile Army 

Surgical Hospital [MASH], the Combat Support Hospital [CSH], and the Forward 

Surgical Team [FST]), as well as their Air Force and Navy equivalents. Almost 

immediately, these medical units were presented with the casualties, both military 

and civilian, of insurgent guerilla warfare.

When Emergency War Surgery, Third United States Revision (EWS) was published 

in 2004, it was the intention of the Borden Institute to present this handbook 

in an electronic version, as well as in a printed format. Although EWS is widely 

available today, including on the World Wide Web (http://bordeninstitute.army.

mil) and as a CD-ROM, plans to incorporate instructional video links proved 

technically infeasible. Nonetheless, the Borden Institute continued to solicit case 

reports related to the resuscitation and management of acute trauma in the field. 

These requests were extended in an ad hoc fashion predominantly to US Army 

medical units as they rotated in and out of operations in Iraq and Afghanistan.

Today, it is common for deployed physicians to have ready access to personal 

digital cameras, and to use these to capture presentations and operative stages of 

their surgical cases. We are grateful for the generous response to our requests. In 

2005, with almost 50 cases on file, we decided to collect these into a single series 

for publication and distribution to surgeons deploying to overseas theaters of war. 

Our goal was to select cases such that, when paired with the pertinent section of 

EWS, they would provide important insight and guidance on one or more aspects 

of the management of acute combat trauma. We believe we have succeeded in 

this endeavor. Over 80 cases are now captured and presented in identical format 

with “Teaching Points” describing key aspects that the attending surgeon took 

away from his or her case. “Clinical Implications” follow. Largely developed by 

the editors, these points are intended to address the broader issues of all cases 

similar to the one presented. Due to multiple considerations, the editors decided 

not to identify contributors at the case level, a reluctant decision not intended to 

diminish the debt due these dedicated individuals. A single photo without legend 
xx | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

at the opening of each case is a deployment scene from Iraq or Afghanistan and is 

usually unrelated to the case. Nearly all subsequent clinical photos, however, were 

taken by staff attending the case presented.

It is important to clarify what this book is not. It is not a comprehensive textbook of 

surgery. Nor does it substitute for a preparation grounded in the principles of surgery, 

patient management, or the experience that comes with years at the bedside. We 

do believe, however, that we have captured the comprehensive spectrum of trauma 

that characterizes war today, as well as the military medical interventions that have 

evolved to deliver the wounded from the ferocious destruction of modern warfare. 

As the history of mankind has been regrettably punctuated in its largest part by 

the history of war, so have numerous leaps in the advancement of medicine been 

attributed to lessons learned in war. The present conflicts in Iraq and Afghanistan 

have proved no exception.

Indeed, the pace of clinical adjustment and improvement in this war is startling 

and unprecedented. Due to the present availability of high-speed communication, 

practiced command and control, rapid air evacuation, routine teleconferencing 

between in-theater level III medical assets and level IV and V facilities (in Germany 

and the United States, respectively), and (increasingly) computer-based patient 

tracking, refinement of medical-surgical practice is ongoing rather than gleaned 

decades after the conflict ends, as was the case in previous wars. A change in 

the technique for field decompression of suspected pneumothorax and revised 

thresholds for suspicion of extremity compartment syndromes are two examples 

of midcourse theater medical corrections.

Broader changes in treatment are also evident. These often began when anecdotal 

notice was extended to wider practice if not controlled trials. To be sure, emergency 

surgical resuscitation in combat does not readily lend itself to placebo-controlled 

or blinded trials. However, an improving computerized database does permit 

intratheater outcomes comparisons, as well as theater comparisons to civilian 

and/or historical norms. As a result, hemorrhage control—the most preventable 

cause of death on the battlefield—has significantly improved in OIF and OEF, 

given the introduction of field-applied topical hemostatics (QuikClot and the 

HemCon Bandage), improved use of prefashioned tourniquets, low-volume and 

hypertonic resuscitation, newer ratios of packed red cell-to-plasma transfusions, 

recent (limited) theater availability of apheresis platelets, early resort to fresh whole 

blood, and perhaps the timely use of human recombinant Factor VIIa.

As important as these interventions, however, has been a wider understanding of 

the need to recognize early, treat prophylactically, and thereby avoid what has been 

familiarly called a “triad,” but which is, in fact, a relentless vortex of hypothermia, 

metabolic acidosis, and (hypo)coagulopathy in the severely injured. This approach, 

known as damage control resuscitation, is transforming the priorities and mechanics 

of forward acute trauma management fraught with wide practitioner variation to 

an applied science based on sound physiological principles and with measurable 

goals and outcomes.

“. . . refinement 

of medicalsurgical 

practice is 

ongoing 

rather than 

gleaned 

decades 

after the 

conflict 

ends, . . . .”
Introduction | xxi

The major precepts of damage control resuscitation are to stop bleeding, minimize 

contamination, and restore blood flow in order to establish near-normal physiology 

prior to embarking on definitive repair of injuries. Damage control surgery does 

not connote haste. Careful attention to a full examination; frequent checks of the 

patient’s evolving physical and mental status; and constant scrutiny for missed 

sources of bleeding, infection, and compartment syndrome require time and 

tedium. But explicit in battlefield care is the requirement for resuscitation to be 

undertaken in the context of timely evacuation to higher echelons of capability. 

These then are some of the recurring themes in this book:

•	 Frequent reference to EWS.

•	 Setting priorities; emphasis on early consideration of damage control resuscitation.

•	 Appropriate incorporation of damage control principlesinto a moving scheme

of aeromedical evacuation.

•	 Defining state-of-the-art combat trauma surgery as practiced in the conflictsin

Iraq and Afghanistan.

Another recurring theme is evident in these cases. Battlefield casualties immediately 

include noncombatant civilians, including women and children, along with host 

national allies and enemy combatants. All of these individuals are entitled to 

medical and surgical care. Although all combat casualties are initially resuscitated 

and stabilized in the immediately available deployed medical facilities, if further 

definitive care is necessary, US military casualties are evacuated out of theater 

and rapidly moved along a chain of ever-escalating levels of medical capability. 

In contrast, host nationals and enemy combatants remain in the combat theater 

for all of their care, eventually returning to the host country’s indigenous medical 

system (except for enemy combatants who remain in designated US military 

medical facilities). Since CSHs are designed to provide resuscitation, stabilization, 

and rapid evacuation for injuries requiring more definitive care, the initially 

deployed CSHs were neither equipped nor staffed to provide the protracted, 

resource intensive care necessary for long-term definitive care or rehabilitation. Ad 

hoc accommodations had to be made for complex orthopaedic, oral-maxillofacial, 

neurosurgical, and burn care, among many other difficult-to-manage combat 

wounds. US military physicians would often embark on heroic salvage efforts for 

severely injured extremities. They understood that in the depleted, underresourced, 

and overstretched host nation hospitals, amputation of the involved limb was, by 

far, the most likely outcome. Military general surgeons, in particular, have had to 

broaden their expertise in order to attend patients whose injuries in a stateside 

setting would often place them under the care of subspecialty trained colleagues. 

These shortcomings of deployed military medical facilities were especially poignant 

for pediatric casualties. Both experience and equipment were wanting in the care of 

these injured children. As deployed medical assets have matured in theater, many 

shortfalls have been corrected. Nonetheless, the dichotomy of different pathways 

of care for American versus host nation casualties remains an ongoing challenge.

“Battlefield 

casualties 

immediately 

include 

noncombatant 

civilians, 

including 

women and 

children, along 

with host 

national allies 

and enemy 

combatants.” 
xxii | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

. . . to care for him who shall have borne the battle, 

and for his widow, and his orphan, . . . .

 —Abraham Lincoln

Second Inaugural Address, 1864 

 

This textbook is not intended to represent an historical account of the US Army 

Medical Department in the ongoing conflicts in Afghanistan and Iraq. That history 

waits to be written by others. Nonetheless, we recognize that what is presented here 

as a clinical-technical work of applied medicine, with time, necessarily becomes an 

historical reflection of the state-of-the-art and capability of military medicine at the 

opening of the 21st century.

The editors profoundly share the hope, expressed herein by Mr. Woodruff, that 

“attention to the wounded remains as focused in the long journey to heal as it is in 

those white-hot moments . . . when nothing is spared to save a life.”

The focus of this book is immediate trauma care. But the wounds attended, as 

well as the experiences that accompany them, are too often lifelong. Recovery 

is incomplete. Management becomes rehabilitation. Life is interrupted—forever 

demarcated in terms of “before” and “after” a split second in war.

Shawn Christian Nessen, DO, FACS, LTC, MC, US Army

Dave Edmond Lounsbury, MD, FACP, COL, MC, US Army (Retired) 

Stephen P. Hetz, MD, FACS, COL, MC, US Army (Retired)

 

 Washington, DC

 October 2007

“. . . attention 

to the wounded 

remains as 

focused in the 

long journey to 

heal as it is in 

those white-hot 

moments . . . 

when nothing 

is spared to 

save a life.”
prologue | 1

prologue

Trauma System Development and

Medical Evacuation in the Combat Theater

Introduction

Throughout history, care of the wounded soldier has been the essence of military 

medicine. The first trauma centers were, by their very nature, military facilities. 

Many medical advancements have been made during warfare—from the use of 

a makeshift “ambulance” by Baron Dominique Jean Larré to move casualties 

off Napoleon’s battlefields quickly and back to surgical units in the rear to the 

advent of blood transfusions during World War I. Lessons learned by military 

physicians during times of conflict eventually made their way into peacetime 

practice. In Korea and Vietnam, Mobile Army Surgical Hospitals (MASHs) 

were deployed to decrease the transit time from the site of injury to definitive 

surgical treatment. One of the great advances that made the transition from the 

Vietnam battlefield to the present urban landscape has been the development of 

similar urban trauma centers and systems. 

The helicopter, the advanced training of field medics, and the concentration of 

surgical resources in a single center all expedited the development of centers for 

trauma care. The late 1960s to the late 1970s saw the evolution of our modern 

civilian emergency medical system (EMS) and trauma center capabilities. Few 
2 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

young people learning to be paramedics today could imagine a time when the 

local undertaker’s hearse also doubled as the community ambulance. Over the 

past few decades, the American College of Surgeons/Committee on Trauma 

(ACS/COT) has established guidelines to facilitate the development of civilian 

trauma centers and systems. The US military deployed its medical assets in Iraq 

and Afghanistan to support its troop dispositions. With these assets in place, the 

US Army Medical Department then spearheaded joint efforts to connect and 

operate these separate facilities as much as possible in accord with ACS/COT 

standards. This latter effort included establishing subspecialty care centers (eg, 

neurosurgery), on-site wounding and outcomes data collection, and theaterwide 

Clinical Practice Guidelines (CPGs). The result has been the development and 

deployment of the world’s largest and most complex trauma system.

Trauma System

ACS/COT emphasizes “optimal care given available resources.” This reflects 

the important and abiding principle that the needs of all injured patients are 

addressed in as timely a fashion as possible and at the highest standard of care 

reasonably available. A trauma system is an arrangement of available resources 

coordinated for the effective delivery of emergency healthcare services in a 

geographical region. The goal is to “Get the Right Patient to the Right Hospital 

in the Right Amount of Time”—the motto of the US Central Command Joint 

Theater Trauma System (JTTS) team.

“A trauma 

system is an 

arrangement 

of available 

resources 

coordinated 

for the effective 

delivery of 

emergency 

healthcare 

services in a 

geographical 

region.”
prologue | 3

Military Health System Echelons of Care 

Current routes of patient evacuation, from site of injury to definitive care, include 

four echelons of care for US forces (Fig. 1): 

1. Level I Echelon of Care—This unit level, the Battalion Aid Station/Combat 

Medic, is initiated at the Self-Aid/Buddy Care level, and consists of 

immediate first aid and transport. It includes care by combat lifesavers, 

nonmedical soldiers who receive additional training in wound care. Both 

the medic and the casualty patient may still be under fire, and there is limited 

medical equipment available. The combat medic has increasingly assumed 

the responsibility—and capability—of recognizing and treating potentially 

preventable causes of death: exsanguinating hemorrhage (early tourniquet 

application topical hemostatics), pneumothorax (needle angiocatheter), 

and airway control (oral intubation, cricothyroidotomy). Triage outcome 

at level I is either return to duty with minimal treatment or evacuate from 

the battle zone. Casualty evacuation is ideally less than 1 hour to the level 

II echelon of care. 

2. Level II Echelon of Care—This level often includes a Forward Surgical Team 

(FST). Each service provides this level, staffed with from 5 to 20 personnel. 

The Army FST is typically composed of a 20-person team, with 1 orthopaedic 

surgeon, 3 general surgeons, 2 nurse anesthetists, 1 critical care nurse, and 

technicians. The team is able to perform lifesaving resuscitative surgery. 

This team, when used in its doctrinal configuration, is capable of at least 10 

operating room (OR) cases per day and a total of 30 operations within 72 

hours. In present operations in Iraq and Afghanistan, it is not uncommon 

for an FST to be split into two geographically separate facilities. When split, 

however, its capabilities are degraded. Evacuation to level III care typically 

occurs as soon as possible after treatment.

“The combat 

medic has 

increasingly 

assumed the 

responsibility . . . 

of recognizing 

and treating 

potentially 

preventable 

causes of 

death. . . .” 
4 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

3. Level III Echelon of Care—Army combat support hospitals (CSHs), but also 

Navy ships and Air Force theater hospitals, are all capable of further definitive 

care, and are often located within the combat zone. Level III provides triage, 

resuscitation, transfusion, initial surgery, definitive and reconstructive surgery, 

postoperative care, intensive care, and patient holding capacity. Patients are 

either returned to duty in theater or stabilized for further evacuation. Such 

facilities are modular and allow for a 44-bed to a full 248-bed configuration 

as required. In full complement (248 beds), the CSH has six OR tables, 

allowing 96 operating hours per day. Professional capability routinely includes 

general, orthopaedic, thoracic, and oral and maxillofacial surgeons; anesthesia 

providers (as anesthesiologists and certified registered nurse anesthetists 

[CRNAs]); and internists, emergency medicine physicians, a radiologist, and 

a psychiatrist. Within 48 to 72 hours, a strategic evacuation can be underway 

to the next level of care and (in Operation Iraqi Freedom/Operation Enduring 

Freedom [OIF/OEF]) out of the combat theater. In the shortest timeframes 

today in Iraq, this can begin less than 12 hours from the time of wounding. 

Patients who are host nationals, however, are not evacuated out of area and 

may require definitive surgeries and prolonged hospitalization at a sustained 

level of care not originally envisioned for the CSH (see Introduction). 

Figure 1. Military system echelons of care.

Battalion Aid Station

LEVEL I

Forward Surgical Teams

LEVEL II

Combat Support Hospital

LEVEL III

Definitive Care

LEVEL IV

t

t

t

Casualty evacuation

1 hour

Tactical evacuation

24 hours

Strategic evacuation

48–72 hours

Current Route from Injury to definitive care

surgical capability
prologue | 5

Table 1. Echelons of Military Medical Care

Military Designation Description of US Civilian Counterpart US Civilian Designation

I. Battalion Aid Station EMS/corpsman/medic ambulance team __

IIA. Area medical Outpatient clinic __

support facility

IIB. FSTs Community hospital with limited IV

emergency surgery capability 

III. Theater hospital in Regional trauma center, III

Iraq—eg, Army CSH and limited capability, 

(formerly) MASHs 30-day ICU holding capability 

IV. LRMC Major trauma center II

V. For example, WRAMC, Major trauma center with teaching

BAMC, NNMC, WHMC and research I

BAMC: Brooke Army Medical Center (Fort Sam Houston, Texas); CSHs: Combat Support Hospitals; EMS: emergency medical system; 

FSTs: Forward Surgical Teams; ICU: intensive care unit; LRMC: Landstuhl Regional Medical Center (Landstuhl, Germany); MASHs: 

Mobile Army Surgical Hospitals; NNMC: National Naval Medical Center (Bethesda, Maryland); WHMC: Wilford Hall Medical Center 

(Lackland Air Force Base, Texas); WRAMC: Walter Reed Army Medical Center (Washington, DC).

4. Level IV Echelon of Care—This definitive care stop is the general hospital that 

is en route back to the continental United States (CONUS). During the current 

conflicts in Southwest Asia, this is Landstuhl Regional Medical Center (LRMC) 

in Germany. (Some would describe LRMC as a level V facility given its location 

outside of the theater of war. By this criterion, level IV is a definitive surgical 

capability within the actual theater of war, but outside of the combat zone.) This 

level IV echelon of care reevaluates and treats all en route patients. The LRMC 

is staffed and equipped for general and specialized medical and surgical care. 

Patients not expected to return to duty are stabilized and evacuated to CONUS. 

Reconditioning and rehabilitating services are provided for those patients 

who will be returned to duty within theater. LRMC finds itself in a unique 

position because it is the common pathway node between theater operations 

in Southwest Asia (OIF/OEF) and CONUS medical facilities. Virtually 100% 

of US troops evacuated from those two theaters of operations pass through 

LRMC for additional care. LRMC provides multidisciplinary trauma surgical 

management to those who have sustained catastrophic injury and is where 

the first step in the process of rehabilitating the wounded begins. The average 

length of stay is less than 4 days. Then, the patient is transferred to the Level 

V Echelon of Care in CONUS military medical centers. These levels of care 

should not be confused with the civilian ACS/COT levels of trauma center 

designation, which uses these ordinals in reverse order (Table 1).
6 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Aeromedical Evacuation 

The aeromedical evacuation system is capable of moving more than 1,000 

casualties per month from theater operations in Southwest Asia. Critical Care 

Air Transport Teams (CCATTs) are flying intensive care units with a staff of 

three (typically, a physician trained in critical care, a critical care nurse, and a 

respiratory therapist) capable of not only transporting a ventilated critically 

ill casualty, but also able to continue resuscitation and advance the care of the 

casualty patient en route to the next echelon of care. From September 2001 

through September 2007, there have been more than 44,000 air evacuation/

CCATT patients transported by the US Air Force aeromedical evacuation 

system from OIF/OEF. This capability, which did not exist more than 10 years 

ago, undergoes continual scrutiny and refinement. 

Movement of severely injured patients is always a critical event that requires 

appropriate timing and careful attention to minute details. Determining the 

optimal time of transfer in the continuum of military medical care requires 

balancing the benefit of resources available at the next echelon against the 

risks inherent in moving a critical patient with all the necessary tubes, lines, 

monitors, and equipment in a ground and/or air ambulance. Many patients 

are initially too unstable to be placed in a system in which the present air 

evacuation component (from Southwest Asia) often exceeds 10 hours of flight 

time. The system, however, is evolving. Traditional air evacuation moved stable

patients who required little intervention outside preflight orders. CCATT 

enables the safe transport of stabilized patients—stability that depends on 

ongoing intervention, such as ventilator management, sedation, pressors, etc. 

Ideally, each of these parameters should be met prior to transfer of any 

patient:

•	 Heart rate < 120.

•	 Systolic blood pressure > 90.

“Critical Care Air 

Transport Teams 

. . . are flying 

intensive care units 

with a staff of three 

. . . capable of not 

only transporting a 

ventilated critically 

ill casualty, but also 

able to continue 

resuscitation and 

advance the care of 

the casualty patient 

en route to the next 

echelon of care.”
prologue | 7

•	 Hematocrit > 27%.

•	 Platelet count > 50,000.

•	 INR < 2.0.

•	 pH > 7.30.

•	 Base deficit < 5.

•	 Temperature > 35°C.

When any one or more of these criteria is not met, the responsible physician 

should hold the patient and continue treatment or document the limitations at 

the current facility that compel urgent, high-risk transfer.

Combat Trauma System Implementation

Organizing and appointing working groups to implement an ACS/COT-like trauma 

system within the US Army Medical Department doctrine were pivotal to the 

successful development and implementation of a modern combat trauma system. 

In addition to providing a rapidly deployable, mobile, modular, and sustainable 

infrastructure, such a system would need to constantly improve coordination of 

care, provide data to address and answer operational questions, predict manpower 

needs, and provide medical situational awareness (ie, injury patterns and evaluate 

protection/prevention maneuvers). Such data could be collected to evaluate 

outcomes, assess training, improve continuity of care, and facilitate system-wide, 

data-driven, and real-time improvements. 

The goal was to develop and implement a trauma system modeled after recent 

successes of stateside civilian systems (which, in turn, were modeled on experiences 

from the Vietnam War), but leavened by the realities of combat. A trauma system 

director and a team of trauma nurse coordinators have been utilized for just this 

purpose. One tenet used to guide trauma care algorithms and the location and 

“A modern 

combat trauma 

system provides a 

rapidly deployable, 

mobile, modular, 

and sustainable 

infrastructure that 

coordinates care, 

provides data to 

address and answer 

operational questions, 

predicts manpower 

needs, and provides 

medical situational 

awareness.”
8 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

capability of resources equates to the following: elapsed time from injury to lifesaving 

surgery is to be as short as possible; but, in every case, less than 2 hours (ie, “deliver 

the right casualty to the right care at the right place and in the right time”).

Care for injured soldiers in current theater operations has been the focus of the JTTS. 

Additionally, the JTTS continues to work on performance improvement issues. 

Some of the responsibilities of the trauma system director include the following: 

•	 Recommending optimal placement of surgical assets within theater.

•	 Developing triage criteria for casualty evacuation to the appropriate level

of care.

•	 Ensuring adequate communication at/between military treatment facilities at

every level of care.

•	 Standardizing approaches to common battle injury patterns across theater.

JTTS also has the responsibility to review and maintain a Joint Theater Trauma 

Registry (Fig. 2), conduct and collate morbidity and mortality reporting and operative 

case reporting, and develop a Performance Improvement Program and initiatives 

for the entire trauma system. This includes evaluating the Casualty Evacuation/Air 

Evacuation System (evacuation times and casualty outcomes) and assisting with 

development of the clinical information management scheme for theater. 

Figure 2. 

(Front) Theater 

trauma registry.
prologue | 9

Areas for system improvement have been identified in the need for smoother 

transmission of healthcare information along the multiple and physically distant 

echelons of care and a smoother transition between healthcare teams when 

units rotate into and out of theater (ie, retention of operational memory). The 

requirement is to educate all healthcare providers in the importance of information 

flow, standardize documentation of health forms, and have a central electronic 

patient data repository. This patient data repository is intended to have all available 

medical records scanned at the level III echelon of care and then placed on a secure 

Web site, thus giving providers access to critical healthcare information at all 

echelons of care. 

Stateside, where civilian casualties typically present one at a time, we are challenged 

with documenting patient encounters adequately. It is difficult to imagine how 

daunting a task it is for a field medic—under fire, with multiple injured comrades, 

as well as numerous enemy casualties—to document even the simplest of clinical 

findings or events on the battlefield. Recordkeeping is much more difficult at aid 

stations or FST locations, where military healthcare is conducted under the most 

austere conditions. Documentation there is often, necessarily, an afterthought. 

“Areas for system 

improvement have 

been identified in the 

need for smoother 

transmission 

of healthcare 

information along 

the multiple and 

physically distant 

echelons of care and 

a smoother transition 

between healthcare 

teams when units 

rotate into and out of 

theater. . . .”

Figure 2. 

(Back) Theater 

trauma registry.
10 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Trauma Registry

To optimally capture documentation and evaluate injury patterns, as well as the 

care provided, the US Army Institute of Surgical Research has developed the 

Joint Theater Trauma Registry. This repository is collected on forms developed 

exclusively for use by the deployed military while, at the same time, designed to 

facilitate completion of nurse and physician examinations and treatment records. 

(See Fig. 2 for an early version of this form.)

This field clinical information—collated, tabulated, dissected, analyzed, and 

thoughtfully reviewed—will become the database of battlefield casualty 

management in Iraq and Afghanistan. 

SUGGESTED READING

Appendix 3: Theater Joint Trauma Record. In: Emergency War Surgery, Third 

United States Revision. Washington, DC: Department of the Army, Office of The 

Surgeon General, Borden Institute; 2004.

Chapter 2: Levels of medical care. In: Emergency War Surgery, Third United 

States Revision. Washington, DC: Department of the Army, Office of The Surgeon 

General, Borden Institute; 2004.

Chapter 4: Aeromedical evacuation. In: Emergency War Surgery, Third United 

States Revision. Washington, DC: Department of the Army, Office of The Surgeon 

General, Borden Institute; 2004.

Hetz SH. Introduction to military medicine: a brief overview. Surg Clin North Am. 

2006;86:675–688.

“To . . . capture 

documentation 

and evaluate injury 

patterns, as well as 

the care provided, 

the US Army 

Institute of Surgical 

Research has 

developed the Joint 

Theater Trauma 

Registry.”
prologue | 11

Are We Doing Better?

Assessing Combat Casualty Data

Combat casualty data are readily available during the present war in Afghanistan and 

Iraq, with some newspapers even publishing summaries of the numbers of Americans 

killed and wounded on a daily basis. It is common to read analyses of these data in 

which they are interpreted to show remarkable improvement in the outcome of the 

management of combat injury compared with historical norms. However, caution is 

needed when coming to such a conclusion because deaths in combat are determined by 

a multitude of factors, of which the effectiveness of the deployed medical system is only 

one. Certainly, the total number of combat casualties has little to do with medical care, 

but has everything to do with the number of warriors at risk and the casualty-generating potential of the battlefield (ie, the weapons used and the war-fighting tactics). One 

might think that the ratio of the killed in action (KIA) to wounded is closer to telling 

us the effect of medical care, but this proportional mortality more likely reflects the 

lethality of the weapons. The unprecedented use and effectiveness of today’s protective equipment (all other factors being equal) should make for a less lethal battlefield 

because armor decreases the lethality of weapons. When a blunt index of injury severity is used (the number of wounded divided into those who returned to duty quickly 

and those who did not), we are closer to assessing the effect of medical care. Because 

combat casualty care is unlikely to affect casualties with only minor injuries, the ratio 

of KIA to those surviving with wounds of severity preventing rapid return to duty is 

likely to be more affected by the excellence of combat casualty care. 

Combat casualty care can and does prevent deaths. However, the lethality of the 

weapon and the anatomical location of wounds remain dominant. Most of those 

who are killed in combat die quickly and before lifesaving surgery is possible. Perhaps the index most sensitive to the quality of combat casualty care is the fraction 

of those with potentially fatal wounds who are evacuated from the battlefield alive, 

but who then die in the hospital (ie, died of wounds [DOW]). But even this measure 

will be affected by the lethality of weapons and the speed of the evacuation from 

the battlefield. Indeed, fast evacuation of the very severely injured—those likely to 

die despite aggressive care—may even increase the number of casualties who are 

ultimately categorized as DOW.

With these factors in mind, it is interesting to calculate some indicators of mortality 

outcome in the present conflict in Iraq. Data on DOW in Iraq (US Army and Marines) 

from March 2003 through the end of June 2007 are as follows: 

• 	 total DOW for all services—663; and

• 	 total wounded not returned to duty within 3 days—11,831.1,2

The unprecedented use and effectiveness of 

today’s protective equipment (all other factors being equal) 

should make for a less lethal battlefield because 

armor decreases the lethality of weapons.
12 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

DOW mortality is calculated to be 5.3%. Data for the conflict in Vietnam are as 

follows:

• 	 total DOW for all services—5,289; and

• 	 total wounded not returned to duty within 1 day—153,303.3

DOW mortality is calculated to be 3.3%. It appears that medical treatment facility mortality outcome was better in the Vietnam War; however, this conclusion 

seems implausible. It may be that, in the present war, better treatment of the gravely 

wounded is vitiated by more lethal injuries and more rapid evacuation of the mortally wounded. Or, it may be that the difference is a statistical artifact because the 

same time periods are not used for data collection (ie, return to duty in 1 day for 

Vietnam, 3 days for the present war). 

The second index mentioned previously (ratio of KIA to casualties with wounds of 

such severity that rapid return to duty is prohibited) also needs to be considered, 

even though it is less likely to reflect the influence of medical treatment. Data of 

American KIA as of June 2007 are as follows: 

•	 total KIA for all services—2,265; and

•	 total wounded not returned to duty within 3 days—11,831.1,2 

KIA mortality is calculated to be 16.1%. Data for the conflict in Vietnam are as follows: 

•	 total KIA for all services—40,934; and

•	 total wounded not returned to duty within 1 day—153,303.3

KIA mortality is calculated to be 21.1%. Clearly, casualties in the present war are 

less likely to die before reaching a medical treatment facility than in the Vietnam 

War. Why? It cannot be due to better medical care in a medical treatment facility, 

but it could and probably is at least partially due to better battlefield first aid at the 

site of wounding. The military has made enormous efforts to improve battlefield 

first-aid training and equipment. It is likely that at least some of the decrease in the 

number of KIA reflects this effort. A second explanation involves battlefield lethality. The explosive devices used by terrorists have a fearsome reputation, and therein 

lays a paradox. If the weapons are more lethal, the proportion of those injured who 

are KIA should increase. The fact that the proportion is actually less clearly points 

to the excellent protection afforded by the military’s wide use of individual body 

armor. Historical data indicate that penetrating missile wounds of the trunk were 

responsible for about one third of combat deaths.4 Defeating even one half of such 

threats might well be expected to decrease mortality and therefore accord with the 

observed percent KIA. 

The military has made enormous efforts to improve 

battlefield first-aid training and equipment. 

It is likely that at least some of the decrease in the 

number of KIA reflects this effort. 
prologue | 13

The widespread belief that mortality has been reduced in the present war—compared 

with historical norms—appears, then, to be well founded. However, until more data 

are made available, it will remain difficult to separate conclusively the effect of medical care on mortality from battlefield factors, such as weapons lethality. It is certainly 

possible that evacuation in the present war is so fast that many more casualties with 

potentially fatal wounds reach hospital-level care and are saved by modern surgery 

than in past wars. But only data on evacuation time and, ideally, quantitative injury 

severity assessment will allow this question to be addressed. 

 

—Ronald F. Bellamy, MD, FACS, COL, MC, US Army (Ret.)

REFERENCES

1. Global War on Terrorism—Operation Iraqi Freedom: By Casualty Category Within Service, March 19, 2003 Through June 30 2007. Available at: http://siadapp.dmdc.osd.mil/

personnel/CASUALTY/OIF-Total.pdf. Accessed December 2007.

2. Operation Iraqi Freedom (OIF) U.S. Casualty Status—Fatalities as of: June 29, 2007, 10 

a.m. EST.* Available at: http://www.defenselink.mil/news/casualty.pdf. Accessed December 2007. [*The KIA category given by the DefenseLink Web site appears to include DOW, 

as well as KIA.]

3. Military Casualty Information. U.S. Military Casualties in Southeast Asia—Vietnam 

Conflict. Vietnam Conflict—Casualty Summary, as of June 15, 2004. Available at: http://

siadapp.dmdc.osd.mil/personnel/CASUALTY/OIF-Total.pdf. Accessed December 2007.

4. Bellamy RF. Combat trauma overview. In: Zaitchuk R, Grande CM, eds. Anesthesia and 

Perioperative Care of the Combat Casualty. Textbook of Military Medicine. Washington, 

DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995: 

1–42. 

However, until more data are made available, 

it will remain difficult to separate conclusively the effect of 

medical care on mortality from battlefield factors, 

such as weapons lethality.


This four-litter ambulance was struck by an RPG en route 

to the 28th CSH in Iraq. The medic on board placed himself 

across his casualty and was killed in the attack.