Combat Fatalities Research Articles

Development and Evaluation of the Advanced Joint Airway Management System for Educational Utility in Endotracheal Intubation, as Assessed by Expert Paramedic Instructors.

Between 2011 and 2014, The Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among U.S. combat fatalities. This study identified a major training gap in critical airway management. To address this gap, the Advanced Joint Airway Management System (AJAMS) was designed and assessed for physical fidelity and educational utility in a population of paramedic instructors. Paramedic instructors served as participants in this prospective observational pilot study (n = 12). Participants interacted with three airway management trainers: The AJAMS trainer, the Laerdal Airway Management Trainer, and the TruCorp AirSim Advance Bronchi X Trainer. Participants then completed an evaluation of the trainer using a purpose-built data collection instrument that queried the trainer's realism and educational utility. Within-group differences were analyzed via a 1-way repeated measures ANOVA, with a Bonferroni post hoc analysis. Rank data were analyzed via non-parametric Freidman's test, and Wilcoxon signed-rank test post hoc analysis, corrected using the Bonferroni correction. The AJAMS trainer conveys significantly more physical fidelity (visual: P < .001, ηp2 = 0.977; tactile: P < .001, ηp2 = 0.983; and behavioral: P = .001, ηp2 = 0.971) and overall educational utility (χ2(2) = 15.273, P < .001) than the two commercially available skill trainers. These data suggest that physical fidelity is an important attribute in the design of simulators for health care, as perceived by expert instructors. These data illustrate that the AJAMS-integrated simulator demonstrates unparalleled physical fidelity, relative to commercially available airway management skill trainers.

Endotracheal Intubation Performance in Novices: Comparing the Training Effect Resulting From Two Airway Management Training Simulators.

Between 2011 and 2014, the Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among American combat fatalities. This study identified a major training gap in critical airway management. Because of the high rate of morbidity and mortality associated with poor or incorrect airway management, an effort to address this training gap was necessary. This experiment compared the training using the Advanced Joint Airway Management System, a novel high-fidelity airway simulator, relative to one of the most utilized simulators for endotracheal intubation (ETI) via a parallel group randomized control trial design. Before training, participants (n = 19) attempted an ETI on a cadaver using direct laryngoscopy. Performance during the attempt was recorded and scored by trained blinded raters. Participants were then randomly allocated to either novel or conventional training. Post-training, participants completed a second ETI under the same parameters. Analysis was completed via 2 × 2 mixed analysis of variance for (1) ETI Score, (2) Errors, (3) Critical Failures, and (4) Duration, across both the pre- and post-training tests and between the two groups. A priori power analysis required a total sample size of 84 participants in this experimental design. Consequently, this study is under-powered to reach statistical significance. Scores for all trainees did improve with training, yet analyses did not reveal a difference in overall ETI score between the novel and conventional training group, at baseline or at the post-training test (P = .249). The Advanced Joint Airway Management System simulator presents a training effect that is comparable to the conventional training model. However, given this study's small sample size, these results must be considered preliminary and further research is merited to draw firm conclusions about its impact on trainee performance. Future studies engaging larger cohorts of trainees and exploring the other capabilities of the Advanced Joint Airway Management System (cricothyroidotomy, needle chess decompression) are needed to further examine the educational potential of this novel airway management training system.

Danish military fatalities in international operations 2002–2018

IntroductionThis study describes deaths among Danish soldiers in international operations 2002–2018. Having been part of UN and later NATO forces in ex-Yugoslavia, in 2002 the first Danish contingent took part...

Development of a Simulation Surgical Cricothyroidotomy Curriculum for Novice Providers: A Learning Curve Study.

Airway obstruction is the third most common cause of preventable death on the battlefield, accounting for 1%-2% of total combat fatalities. No previous surgical cricothyroidotomy (SC) studies have analyzed the learning curve required to obtain proficiency despite being studied in numerous other surgical technique training experiments. The aims of this study were to establish expert SC performance criteria, develop a novel standardized SC curriculum, and determine the necessary number of practice iterations required by a novice to reach this pre-determined performance goal. A standardized checklist and SC performance standards were established based on the performance of 12 board certified Military Health System surgeons with prior experience on performing a SC using a simulated trauma mannequin. Expert-level criteria were defined as a SC time to completion of 40 s or less and checklist score of at least 9/10, including all critical steps. Study subjects included 89 novice providers (54 active-duty first- and second-year medical students and 35 Navy corpsmen). Subjects received instruction on performing a SC using the principles of mastery learning and performed a final test of SC proficiency on a trauma mannequin within a realistic simulated MEDEVAC helicopter. The total number of subject practice attempts, checklist scores, and time to completion were measured and/or blindly scored. Learning curve and exponential plateau equations were used to characterize their improvement in mean time to SC completion and checklist scores. Mean pre-test knowledge scores for the entire group were 11.8 ± 3.1 out of 24 points. Total mean practice learning plateaued at checklist scores of 9.9/10 after 7 iterations and at a mean completion time of 30.4 s after 10 iterations. During the final test performance in the helicopter, 67.4% of subjects achieved expert-level performance on the first attempt. All subjects achieved expert-level performance by the end of two additional attempts. While a significantly larger proportion of medical students (79.9%) successfully completed the helicopter test on the first attempt compared to corpsmen (54.3%), there were no statistically significant differences in mean SC completion times and checklist scores between both groups (P > 0.05). Medical students performed a SC only 1.3 s faster and scored only 0.16 points higher than corpsmen. The effect size for differences were small to negligible (Cohen's d range 0.18-0.33 for SC completion time; Cohen's d range 0.45-0.46 for checklist scores). This study successfully defined SC checklist scores and completion times based on the performance of experienced surgeons on a simulator. Using these criteria and the principles of mastery learning, novices with little knowledge and experience in SC were successfully trained to the level of experienced providers. All subjects met performance targets after training and overall performance plateaued after approximately seven iterations. Over two-thirds of subjects achieved the performance target on the first testing attempt in a simulated helicopter environment. Performance was comparable between medical student and corpsmen subgroups. Further research will assess the durability of maintaining SC skills and the timing for introducing refresher courses after initial skill acquisition.

Segregation, Integration, and Death: Evidence from the Korean War

AbstractHow does the design of military institutions affect who bears the costs of war? We answer this question by studying the transformative shift from segregated to integrated US military units during the Korean War. Combining new micro-level data on combat fatalities with archival data on the deployment and racial composition of military battalions, we show that Black and white soldiers died at similar rates under segregation. Qualitative and quantitative evidence provides one potential explanation for this counterintuitive null finding: acute battlefield concerns necessitated deploying military units wherever soldiers were needed, regardless of their race. We next argue that the mid-war racial integration of units, which tied the fates of soldiers more closely together, should not alter the relative fatality rates. The evidence is consistent with this expectation. Finally, while aggregate fatality rates were equal across races, segregation enabled short-term casualty discrepancies. Under segregation there were high casualty periods for white units followed by high casualty periods for Black units. Integration eliminated this variability. This research note highlights how enshrining segregationist policies within militaries creates permissive conditions for either commanders' choices, or the dictates and variability of conflict, to shape who bears war's costs.

What the Constitution Means to Me by Heidi Schreck

Reviewed by: What the Constitution Means to Me by Heidi Schreck Natka Bianchini WHAT THE CONSTITUTION MEANS TO ME. By Heidi Schreck. Directed by Marielle Heller. Amazon Prime Video, October 16, 2020. What the Constitution Means to Me, Heidi Schreck’s mostly solo show about her experience as a teenager giving speeches on the US Constitution for prize money at American Legion Halls across the country, has had amazingly prescient timing. While Schreck developed and workshopped the piece for about a decade, its official theatrical premiere, at New York Theatre Workshop (NYTW) in fall 2018, coincided with the confirmation hearings of Supreme Court Justice Brett Kavanaugh. Two years later, the film version of the show premiered on Amazon’s Prime Video just days before Justice Amy Coney Barrett was confirmed in October 2020. The themes of Schreck’s show—how the Constitution has failed to protect women from domestic violence over centuries of inherited trauma on both the personal and national levels—were heightened against the political backdrop of these confirmations: two staunchly conservative justices poised to further imperil the same rights and protections that Schreck exposes as threadbare and insufficient. Prior to its streaming release, Schreck’s show was an established success. After extending the initial run at NYTW, the production (directed for the stage by Oliver Butler) was remounted at the Hayes Theater on Broadway, where it ran from March to August 2019. Schreck was nominated for two Tony Awards, and the production subsequently enjoyed a national tour. In its final weeks on Broadway, film director Marielle Heller recorded several performances at the Hayes to create the version available on Amazon. Like the stage show, the film runs 100 intermission-less minutes, attempting to replicate onscreen the embodied experience of witnessing the performance live. Schreck begins by reenacting the competition speech she gave on the Constitution as a 15-year-old high school student. Rachel Hauck’s brilliantly claustrophobic set recreates in vivid detail the American Legion Hall in Wenatchee, Washington. The set is a masterpiece of period details: wood paneling, maroon carpet, and a blond-wood, tabletop podium flanked by flags. But the most salient feature of the design is the suffocating rows of framed portraits: men in uniform, stacked four rows high and surrounding Schreck on three sides of a doorless room, more than 150 in all. As Schreck reveals that the twentieth century saw more American women killed by male partners than the total US combat fatalities for all wars combined, including 9/11, concluding that “rampant violence against women’s bodies is there underneath everything, all the time, humming,” the unspoken yet menacing threat of these silent portraits is inescapable. Click for larger view View full resolution Heidi Schreck in What the Constitution Means to Me. (Photo: Joan Marcus.) [End Page 251] Because so much of the show is a solo performance and because it lacks any whizz-bang moments of technical wizardry, What the Constitution Means to Me is ideally suited for this transfer to the small screen. Yet one element of the film I found striking was Heller’s decision to include many audience-reaction shots, reminding the viewer frequently that this was a live performance. During the theatrical run (which I also had the privilege of seeing), Schreck was lit onstage and the audience was, save for a few key moments, in darkness. Heller brought in extra lighting instruments to illuminate the audience during filming. This allowed her to capture dozens of audience-reaction shots and edit them into the film. The editing highlights the success of the show as a dialogue between performer and audience, and underscores the audience’s role as active participant—a vocal counterpart to the wordless stares of those framed male portraits on-stage. Schreck herself is white and careful both to note her family’s white privilege and to lift up the stories of women of color who are even more vulnerable under the US legal system. The audience, at least as showcased through Heller’s editing choices, is surprisingly diverse in race, age, and gender (a rarity for Broadway), and so Heller is able to punctuate Schreck’s words by whose faces she shows...

Comprehensive analysis of combat casualty outcomes in US service members from the beginning of World War II to the end of Operation Enduring Freedom.

Advances in combat casualty care have improved combat survivability over the past two decades. However, these outcomes remain incompletely framed in the broader context of combat casualty outcomes over the past eighty years. We hypothesized that starting with World War II, combat survival worsened at the beginning of each new conflict but then improved over time. To evaluate long-term trends in combat casualty outcomes, monthly combat injuries and deaths during World War II, the Korean conflict, the Vietnam conflict, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) were collated. From these numbers, we calculated the monthly case fatality rate (CFR), the killed in action rate (%KIA), and the died of wounds rate (%DOW). We analyzed these metrics for significant trends during and between each conflict using linear and Loess regression. We then simulated alternate outcome scenarios by eliminating outcome variability. In this comprehensive analysis, CFR decreased over the study period in parallel with a decrease in %KIA. When examining individual conflicts, however, several unfavorable trends emerged including a spike in all fatality measures at the end of Vietnam and a rise in %DOW over the course of Korea and OIF. In comparing CFR at the beginning of each conflict to the best CFR from the prior conflict, high mortality outliers occurred in every conflict after a period of relative peace, and a clear peacetime effect occurred in both World War II and Vietnam. Eliminating these negative trends and the attendant preventable deaths would have reduced combat fatalities over the course of eighty years by 107,256 (39.7%). In summary, although combat mortality rates have generally improved since World War II, closer examination indicates several unfavorable trends both during and between conflicts. Identifying factors behind these trends will reveal further opportunities to improve combat casualty outcomes in the future. LEVEL OF EVIDENCE: III, Epidemiological.

Fusing attack detection and severity probabilities: a method for computing minimum-risk war decisions

State actors can minimize the risk of combat deaths by making decisions consistent with a likelihood ratio test that fuses attack detection data with prior war probabilities. The power-law, which has for decades been used to model the distribution of combat fatalities, is invalid as a probability because the mean is divergent. An investigation of Correlates of War data reveal that combat fatalities follow a log-gamma or log-normal probability distribution depending if a state’s strategy is offensive or defensive. This finding is linked to a state actor model where combat deaths have logarithmic utility and defensive strategies appear lower risk than offensive strategies. Results suggests that minimum-risk decision thresholds be derived from defensive statistics. The method of computing the thresholds is illustrated using war statistics from NATO countries.

WEIGHING THE MILITARY OPTION: THE EFFECTS OF WARTIME CONDITIONS ON INVESTMENTS IN HUMAN CAPITAL

Serving in the military is an important vehicle through which young Americans invest in their human capital. As such, changes in the desirability of military service may affect the attainment of enlistment requirements, such as a high school degree or equivalent. Using American Community Survey data, we find that exposure to home‐state combat fatalities during the Iraq and Afghanistan Wars decreased the probability of high school completion, and increased the probability of general equivalency diploma completion. Using military data, we confirm that exposure to home‐state fatalities selectively deterred some individuals from enlisting. The results suggest military service and educational investments are complements. (JEL I20, I26, J24)

British Parliamentary By‐Elections during the First World War, 1914–18

AbstractDuring the First World War, British by‐elections were more frequent than in either the pre‐ or post‐war period due to the length of the parliament, the stress of the war, and combat fatalities. Due to an agreement among the chief whips of the principal British parties, these by‐elections were infrequently contested. This party truce meant that in most by‐elections only a single official candidate from the incumbent party stood. However, an independent candidate (or in four instances, two independent candidates) did challenge the official candidate in 29 of the 118 by‐elections (or 24.6% of the time). The challengers were more than three times likely to support the war than call for peace by negotiation. In only seven by‐elections (or 5.9%), peace by negotiation candidates stood, and they polled much more poorly on average than the candidates who supported the war. Only three independent candidates defeated the official candidate, and all were strongly supportive of the war effort. Several independent candidates stood espousing a narrow issue, such as wartime liquor controls, veterans’ rights, conscription of married men, co‐operative taxes, or agricultural concerns. Further, the by‐election results foreshadowed the post‐war replacement of the collapsing Liberal Party by Labour as the principal rival of the Conservatives.

Impact of prehospital airway management on combat mortality

IntroductionAnalysis of modern military conflicts suggests that airway compromise remains the second leading cause of preventable death of combat fatalities. This study compares outcomes of combat casualties that received prehospital airway interventions, specifically bag valve mask (BVM) ventilation, cricothyrotomy, and supraglottic airway (SGA) placement. The goal is to compare the effectiveness of airway management strategies used in the military pre-hospital setting. MethodsThis retrospective chart review of 1267 US Army medical evacuation patient care records, compared outcomes of casualties that received prehospital advanced airway interventions. The patients consisted of US military injured in Operation Enduring Freedom January 2011–March 2014. Compared outcomes consisted of vent-, ICU-, and hospital-free days. ResultsThose with SGA placement experienced fewer vent-free days, ICU-free days, and hospital-free days compared to BVM and cricothyrotomy patients. The groups did not significantly differ in rates of 30-day survival. The odds for survival were not significantly higher for BVM versus SGA patients (OR 1.5, 95% CI 0.2–9.8), cricothyrotomy versus SGA patients (OR 3.9, 95% CI 0.6–24.9), or cricothyrotomy versus BVM patients (OR 2.7, 95% CI 0.5–13.8) in a logistic regression model adjusting for GCS. ConclusionThis study supports prehospital BVM ventilation as a possible alternative to cricothyrotomy as there was no difference in measured outcomes between the groups. It further cautions against SGA use in the prehospital combat setting due to higher morbidity demonstrated by fewer ventilator, hospital, and ICU free days than those receiving cricothyrotomy or BVM ventilation. There was no difference in 30-day survival between the groups.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Introduction.

As we transition from a high-volume combat casualty flow era to a low-volume era, we must not forget the lessons learned during the wars in Iraq and Afghanistan. Furthermore, as the world around us seems to be erupting in an unpredictable state of chaos with both intentional violence and natural disasters, we must ensure that these advances in combat extremity trauma care are translated into the civilian medical community so that all may benefit. Over the previous 15 years, we have seen incredible progress, accentuated by the highest US military casualty survival rate ever seen. This was due to improvements in the care of combat-injured service members made at every step along the medical evacuation chain, from prehospital care to the creation of a robust and rapid medical evacuation system. But it took some time to get there. In fact, some data suggest that our success was the result of the growing amount of clinical experience we, as military medical providers, gained treating combat injured patients.1 Put more bluntly, we got better over time as we treated more patients. After all, we were managing a spectrum of injuries that most have never seen before, and we were seeing them at an extremely high volume. The type and constellation of wounds seen earlier in the conflicts were starkly different than those seen in the latter portions of the conflict. In addition, the injury patterns evolved with changes in tactical operations, particularly as troops transitioned from mounted to dismounted maneuvers. Many of the more recent injury patterns were characterized by multiple extremity injuries and amputations usually secondary to improvised explosive devices. What is important to recognize is that as the injury patterns and severity evolved, so too did our management of them. One of the great advances made was the implementation of the battlefield tourniquet. During the early years of the conflicts, there were reports suggesting that up to one-third of combat fatalities were the result of compressible extremity hemorrhage.2,3 This problem was identified, the solution created, and policy changed to make the battlefield tourniquet a standard issue. It not only has resulted in saving limbs but also has saved lives.4 More importantly, its success in the prehospital treatment of extremity hemorrhage has led to rapid implementation into the civilian emergency medical system. Although we are all thankful to have entered a low-volume combat casualty flow state, we do not want this progress to be lost. In fact, we want it to be shared so that all may benefit.

The profile of wounding in civilian public mass shooting fatalities.

The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy. A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity. The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries. Prognostic/epidemiologic study, level IV; therapeutic/care management study, level V.

Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03

Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

Partisan Discourse, Polarization, and the Politics of Military Fatalities in Iraq

Public deliberation on the costs of war is important to democratic decision-making. This article explores congressional rhetoric about military fatalities within the U.S. House of Representatives and in television news media interviews from 2004 to 2006. In the House, the results are consistent with the “ideological opportunism” model of congressional rhetoric, which suggests that politicians–particularly the president’s partisan opponents–will be highly communicative about combat deaths in an effort to express ideological perspectives on war and criticize opponents’ positions. The results also show that as local combat fatalities accumulate, the president’s partisan opponents tend to become increasingly vocal about these deaths. The results do not support the “newsworthiness” model of congressional rhetoric in TV media interviews, which expects opposition party support and presidential party criticism of the president. Politicians on the far ends of the ideological spectrum dominate discussions about the loss of troops in the House, and politicians in both the House and TV news interviews advance largely unwavering partisan positions on the conduct of war. The findings suggest members of Congress reinforce political polarization in debates over the use of force.

Weather, terrain and warfare: Coalition fatalities in Afghanistan

The study of conflict increasingly focuses on events and relationships within wars. Among these is the relationship between physical geography and violence. Careful examinations of the relationship between physical geography, especially weather, and events within wars are, however, still few. With increasingly available data on the violence within wars and the physical geography within states, the opportunities for such quantitative analysis have grown. In particular, the ongoing war in Afghanistan provides a useful opportunity to examine this relationship. Using this conflict, we test an argument about how the constraints and opportunities provided by physical geography, in particular daily and seasonal measures of weather, explain combat fatalities. We evaluate our argument with a series of event count models and find consistently significant evidence connecting warm temperatures, decreased visibility and windy conditions to coalition combat fatalities. Alternatively, we find mixed support that the more commonly studied elements of physical geography, distance and rough terrain are connected to these fatalities.

A Study on the Establishing Process and the Meaning of Management System for UNMCK(United Nations Memorial Cemetery in Korea)

This article is a study on UNMCK(United Nations Memorial Cemetery in Korea) in Busan. I investigate the UN troops’ participation in the Korean War and the meaning of it, in the background of establishment of UNMCK. And I research the formation of the cemetery and the interment state of the fallen soldier, furthermore study the legal meaning of the establishment of UNMCK and the management of it. The result is followings : Firstly, United Nations Commander is not different GHQ/FECOM(General Headquarters Far East Commander) essentially. Although 90% of UN troops is U. S. Army, and also 90% of the combat fatalities is U. S. Army, merely 2,300 persons which interred at UNMCK are only a little more than 5% of the fallen soldiers, because of the all fallen U.S. forces repatriated to their homeland. Secondly, UNMCK had been the official equipment which is based on a legal foundation in 1959 after nine years from the formation of it. At this time, the legal right was ‘be inviolable’ and ‘complete title’, had a èxtraㆍterritórial meaning. Thirdly, after 1973 which UNCURK(United Nations Commission for the Unification and Rehabilitation of Korea) was dissolved, UNMCK had been unrelated with UN. Finally, UNMCK is faced with new present, in the condition that the Korea Government contribution out of management costs is increased revolutionary and the needs in regard of development of the local community is increased gradually.

Death on the battlefield (2001–2011)

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. 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. 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. 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.

An Analysis of Battlefield Cricothyrotomy in Iraq and Afghanistan

Historical review of modern military conflicts suggests that airway compromise accounts for 1?2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined ?successful? if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patients? record were also noted in the review.Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PC?s failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PC?s (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.