Wartime Casualties Research Articles

Forging alliances: examining civil-military partnerships and their impact on war-time casualty care in Sri Lanka

Over the course of the 26-year civil war in Sri Lanka between the Liberation Tigers of Tamil Eelam (LTTE) and the government forces, LTTE’s ‘military’ capacity and strategy evolved from guerrilla-type ambushes using landmines to semi-conventional warfare with light arms and eventually to heavy artillery and improvised explosive devices. This evolution required both military and civil surgeons to enhance their knowledge and skills in managing high-energy war wounds to handle the large number of casualties admitted to health institutions. The Sri Lanka Medical Corps (SLMC) had been meticulously organized into echelons of care with graded capacity and capability to medivac battle injured personnel from point of injury to definitive care facilities. All injured personnel eventually found their way to Colombo Army Hospital and Ragama Rehabilitation Hospital for comprehensive rehabilitation. The civil war in Sri Lanka presented a significant influx of war-related injuries, demanding the creation of a comprehensive system seamlessly integrating both military and civilian elements. With a decade of peace, accompanied by shifts in injury epidemiology, the evolving landscape has mandated the exploration of innovative strategies to sustain and enhance the surgical skill-base for both military and civilian casualty care.

Antibiotic Usage in the Management of Wartime Casualties.

Antibiotic Usage in the Management of Wartime Casualties.

The Putin Predicament: Problems of Legitimacy and Succession in Russia by Bo Petersson (review)

Reviewed by: The Putin Predicament: Problems of Legitimacy and Succession in Russia by Bo Petersson Darrell Slider Petersson, Bo. The Putin Predicament: Problems of Legitimacy and Succession in Russia. Soviet and Post-Soviet Politics and Society, 237 ibidem, Stuttgart, 2021. 219 pp. Notes. References. €34.90 (paperback); €22.99 (e-book). The 'predicament' in this informative study by Bo Petersson is that Putin's regime is based primarily on personal charisma. Charismatic legitimacy can disappear quickly and is difficult to transfer to a successor. The author argues that this makes the regime vulnerable and portends future instability. In part, the system is vulnerable by design: institutions that could provide for succession have been systematically dismantled or undermined. For example, there is no genuine ruling party that could put forward a successor; the nominal ruling party, United Russia, is a creature of Putin's Presidential Administration. After an overview of scholarship on leadership, charisma and succession, Petersson proceeds to analyse how major issues that have confronted the [End Page 191] Kremlin in recent years have impacted political stability and Putin's legitimacy. The author restricts his analysis largely to Putin's numerous speeches, interviews and press conferences; he also focuses primarily on the period from 2011 to 2021, arguing that the political system changed dramatically with Putin's return for his third and fourth terms. Protests against Putin and election fraud in late 2011–12 and the rise of a rival, Alexei Navalny, created a new set of potential threats to the regime that underscored the political dilemma. Though the book was completed a year before Putin's 2022 invasion of Ukraine, the framework presented here supports the argument that fears of declining legitimacy may have been a key motive. The 2014 annexation of Crimea and Russia's fostering of separatism in Ukraine's eastern provinces provided a major legitimacy boost at a critical time of declining trust in the president. It also provided a useful target for media attacks, post-Maidan Ukraine, along with the United States in the role of 'puppet master.' In one chapter, Petersson demonstrates how 'othering' has produced a changing cast of enemies who both threaten Russia's existence and promote values (in short, 'Gayropa') that repel most of its citizens. Constitutional changes pushed through in 2020 figure prominently in the book, and Putin used the plebiscite to postpone the problem of term limits for himself that otherwise could have caused problems in 2024 when his second term (and fourth overall) came to an end. The new provisions allow Putin to continue to serve, if reelected, until 2036; thus, '[t]he answer to who was to succeed Putin was — Putin' (p. 181). Petersson contends that by early 2021, though, the 'Crimean consensus' had weakened, and the Kremlin was on the defensive. Fears of a resurgent opposition were heightened by the exposure of the FSB plot to kill Navalny, his widely seen documentary on the gaudy palace under construction on the Black Sea coast, and large protests following Navalny's imprisonment on returning to Russia. One problem that is not addressed sufficiently in this study is how the Russian public would recognize Putin's missteps and policy failures as they happen. Petersson argues that a key component of Putin's charisma derives from his reputation as a leader 'who can and will deliver the goods' (p. 62). Yet that perception can easily be the result of manipulation. Policy outcomes that outsiders objectively understood as failures, including several discussed in this study, were not perceived as such by Putin's core supporters. Russia's response to the Covid-19 pandemic, for example, was an abject failure; excess deaths in Russia as a percentage of the population were higher than for any other major country. Russians, though, were repeatedly told by Putin and his media that he handled the crisis more effectively than other world leaders. More recently, the 2022 attack on Ukraine failed to provide an anticipated quick victory and led to a level of wartime casualties not seen since World War Two. State media [End Page 192] covered up these failings, and the Russian public rallied around a wartime leader seeking to preserve the homeland against...

Approximate dynamic programming for the aeromedical evacuation dispatching problem: Value function approximation utilizing multiple level aggregation

Sequential resource allocation decision-making for the military medical evacuation of wartime casualties consists of identifying which available aeromedical evacuation (MEDEVAC) assets to dispatch in response to each casualty event. These sequential decisions are complicated due to uncertainty in casualty demand (i.e., severity, number, and location) and service times. In this research, we present a Markov decision process model solved using a hierarchical aggregation value function approximation scheme within an approximate policy iteration algorithmic framework. The model seeks to optimize this sequential resource allocation decision under uncertainty of how to best dispatch MEDEVAC assets to calls for service. The policies determined via our approximate dynamic programming (ADP) approach are compared to optimal military MEDEVAC dispatching policies for two small-scale problem instances and are compared to a closest-available MEDEVAC dispatching policy that is typically implemented in practice for a large-scale problem instance. Results indicate that our proposed approximation scheme provides high-quality, scalable dispatching policies that are more easily employed by military medical planners in the field. The identified ADP policies attain 99.8% and 99.5% optimal for the 6- and 12-zone problem instances investigated, as well as 9.6%, 9.2%, and 12.4% improvement over the closest-MEDEVAC policy for the 6-, 12-, and 34-zone problem instances investigated.

Iraqi women die too: Exploring Iraq’s invisible female casualties

Abstract In questioning the lack of gender-specific casualty data, this analysis helps to reveal the reasons responsible for the invisibility of Iraq’s female dead. Iraqi women, gleaning from existing casualty counts, are noticeably neglected, dwarfed by other female heroines: the foreign service woman, the suicide bomber and – not least – men in combat boots. The hierarchy that places occupying forces at a higher rank than occupied populations has long rendered Iraqi life inconsequential, or the death of its people ‘inevitable’, and therefore, ungrievable. However, this alone does not account for the absence of Iraq’s female dead. More fundamentally, what purpose does their exclusion from death counts serve, and when and why are female wartime casualties logged?

A Pediatric Opportunity in Adolescents to Prevent Adult Heart Attacks

Importance: Cardiovascular disease is the number one cause of death in the adult population, greater than all cancers combined. When a heart attack or stroke occurs, many individuals have no advance warning, thus making prevention difficult. Cardiovascular disease begins early, i.e., in the developing fetus, and progresses throughout childhood and adolescence, such that it is identifiable both radiographically and ultrasonographically in the adolescent. Observations: There are multiple lines of evidence that atherosclerosis is present in the pediatric population. This evidence is based on autopsy studies in accident victims, coronary artery calcium scoring and carotid intermedia thickness measurements, intravascular ultrasound studies of hearts transplanted from teenage accident victims, and wartime casualties in young males. Multiple studies of cardiovascular risk factors (e.g., hypertension, obesity, insulin resistance, glucose intolerance and hyperlipidemia) have emphasized their importance in contributing to the pathogenesis of atherosclerosis. With the recent increase of obesity in the pediatric population, these risk factors will assume increasing importance in the development of clinical cardiovascular disease in the adult population. Prevention of atherosclerosis will require measuring a lipid profile in adolescents and initiating intervention to reduce the triglyceride and LDLc concentration. Education of both the adolescent at risk and his/her family will be necessary. Lifestyle changes are paramount. Hyperlipidemic medication should be reserved for individuals with severe lipid abnormalities. Conclusion and Relevance:Atherosclerotic changes of arteries begin during gestation and progress throughout the pediatric years into adulthood. Pediatricians’ contribution to reducing the progression of atherosclerosis in their patients can have major effects in controlling this epidemic in adults. Education of adolescents and their parents concerning a healthy lifestyle is paramount to a successful cardiovascular disease prevention program.

How Exposure to Violence Affects Ethnic Voting

How does wartime exposure to ethnic violence affect the political preferences of ordinary citizens? Are high-violence communities more or less likely to reject the politicization of ethnicity post-war? We argue that community-level experience with wartime violence solidifies ethnic identities, fosters intra-ethnic cohesion and increases distrust toward non-co-ethnics, thereby making ethnic parties the most attractive channels of representation and contributing to the politicization of ethnicity. Employing data on wartime casualties at the community level and pre- as well as post-war election results in Bosnia, we find strong support for this argument. The findings hold across a number of robustness checks. Using post-war survey data, we also provide evidence that offers suggestive support for the proposed causal mechanism.

Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan

IntroductionTraumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. Materials and methodsA descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. ResultsOn 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). ConclusionThe results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.

Steven Casey. When Soldiers Fall: How Americans Have Confronted Combat Losses from World War I to Afghanistan.

Evoking military theorist Carl von Clausewitz's famous dictum on war and politics, When Soldiers Fall: How Americans Have Confronted Combat Losses from World War I to Afghanistan proposes that wartime casualties, like war itself, have often served as a continuation of political intercourse in twentieth-century conflicts. In fact, Steven Casey proposes we should consider casualties suffered during modern American wars as narratives both constructed and managed for political purposes. Such an argument is as sobering as it is persuasive. Casey builds his structural framework around three broad themes. First, he stresses how American presidents have treaded carefully in persuading the nation to fight. Casey, the author of an earlier work on public opinion in World War II, notes that during the early years of the war Franklin D. Roosevelt “often fretted that the public remained casualty sensitive” (p. 51). Lyndon Johnson similarly approached Vietnam hoping to avoid a debate over prospective American losses in Southeast Asia. Casey reinforces this argument by highlighting Richard Nixon's “‘pointed reference’ to how much lower casualties were compared to Johnson's last year in office” (p. 183). Likewise, George W. Bush is presented as a commander-in-chief reluctant to discuss casualty issues during the Iraq war. Casey suggests that since World War I American presidents have been less concerned about the human tragedy of U.S. losses abroad than the political ramifications of those losses. Casualties enthuse far less personal sympathy than electoral anxiety.

World War I and the humanitarian impulse

World War I and the humanitarian impulse William I. Hitchcock (bio) The Great War is quite rightly associated with the tragedies of the battlefield, with combat deaths of nearly ten million soldiers, with the construction of the vast network of cemeteries all across northern Europe that Kipling called “cities of the dead,” and with the emotional and psychic scarring of a generation of European peoples. Knowing the political and military history of post-1918 Europe, we think of the Great War as but the first act in a century of horrors. Yet when we consider the legacies of the Great War, it is worth recalling that one less melancholy outcome was the creation of a new conception of humanitarian action on behalf of wounded soldiers and distressed civilians. The humanitarian impulse that surged in 1914 has, no less than the ideologies of genocide and barbarism, been one of the hallmarks of the past century, though it has been far less scrutinized by scholars. Lately, historians and social scientists who are interested in the rise of civil society and the place of non-state actors in international relations have turned to the early twentieth century to chart the emergence of the humanitarian idea. This essay reviews some of that scholarship and tries to assess its enduring meaning for our times. I The First World War did not invent humanitarianism. The impulse to respond to the suffering of others had mobilized [End Page 145] communities of people into action since the Enlightenment. Such networks responded to a variety of stimuli. Slavery; war and its associated human tragedies; ethnic and religious conflict and atrocities; famine and natural disasters; health emergencies and epidemics—all these calamities triggered humane responses in North America and Europe in the eighteenth and nineteenth centuries.1 In some cases humanitarianism could be politically radical: the abolitionist movement of the nineteenth century was animated by more than a desire to offer succor. Its aim was nothing less than the destruction of the practice of slavery, with all the dramatic political implications such an agenda contained. Humanitarianism was also stimulated by the growth and formal expansion of the British Empire in the nineteenth century, during which time the concept of improving newly conquered peoples, and developing them into an “imperial race,” served to legitimate the practice of conquest.2 Missionary groups too often used the premise of an imperial mandate to call for the cleaning up of abusive labor practices in the colonized world.3 And humanitarianism was spurred when religious and liberal political agendas overlapped in certain nineteenth-century social improvement campaigns.4 Yet the rise of the modern humanitarian community is really the product of war. The mid-nineteenth century nationalist conflicts in Europe coincided with a growing sentimental view that civilized societies ought to respond to suffering with care and human kindness rather than indifference.5 This moral imperative met the nationalist fury on the battlefields of Europe, and it was the suffering of wounded soldiers during one such conflict (the Franco-Austrian tangle triggered by the Italian wars of independence) that prompted Henri Dunant, a Swiss evangelical Christian and businessman, to take action. In June 1859, Dunant came across the blood-soaked battleground of Solférino, where thousands of French, Italian and Austrian soldiers lay dying. Shocked by the absence of medical care, Dunant mobilized local civilians to provide ambulances and medical aid for the men. Upon his return to Geneva, he wrote a best-selling exposé, and then convened a group of like-minded citizens to form an international relief society to treat war victims. Dunant’s appeal to his friends came at a time when Europeans had been sensitized to the issue of wartime casualties through the work of Florence Nightingale during the Crimean War (1853-56), when she had campaigned for [End Page 146] military health reforms. Dunant’s efforts struck a chord and his group formed an organization in 1864 that would soon call itself the International Committee of the Red Cross. The humanitarian impulse now had an institutional home.6 The founding document of the humanitarian movement was the Geneva Convention of August 22, 1864, whose brief articles laid out simple rules...

Frequency and relevance of acute peritraumatic pulmonary thrombus diagnosed by computed tomographic imaging in combat casualties

Posttraumatic pulmonary embolism is historically diagnosed after clinical deterioration within the first week after injury. An increasing prevalence of immediate and asymptomatic pulmonary embolism have been reported in civilian and military trauma, termed hereafter as acute peritraumatic pulmonary thrombus (APPT). The objective of this study was to define the frequency of APPT diagnosed by computed tomographic (CT) imaging in wartime casualties. An additional objective was to identify factors, which may be associated with this radiographic finding A 1-year retrospective cohort analysis conducted using the US and UK Joint Theater Trauma Registries performed to determine the prevalence of and risk factors for the diagnosis of APPT in casualties admitted to Bastion Hospital, Afghanistan. APPT imaging characteristics were collected, and demographics, injury severity and mechanism, and risk factors were included in the analysis. Logistic regression was used to identify factors independently associated with APPT. APPT was found in 66 (9.3%) of 708 consecutive trauma admissions, which received a CT chest with intravenous contrast as part of their initial evaluation. Diagnosis of APPT at the time of injury was made in 23 patients (3.2%), while thrombus was detected in 43 additional patients (6.1%) at the time of reexamination of CT images. Of the APPTs, 47% (n = 31) were central, 38% (n = 25) were segmental, and 15% (n = 10) were subsegmental. Forty-seven percent (n = 31) had bilateral APPT. Logistic regression found presence of deep venous thrombosis on admission (odds ratio, 5.75; 95% confidence interval, 2.44-13.58; p < 0.0001) and traumatic amputation (odds ratio, 2.53; 95% confidence interval, 1.10-5.85; p = 0.030) to be independently associated with APPT. All APPTs were felt to be incidental and likely would not have required interventions such as anticoagulation or vena caval interruption. This report is the first to characterize acute, peritraumatic pulmonary thrombus in combat injured. Nearly 1 in 10 patients with severe wartime injury has findings of pulmonary thrombus on CT imaging, although many instances require repeat examination of initial images to identify the clot. APPT is a phenomenon of severe injury and associated with deep venous thrombosis and lower-extremity traumatic amputation. Additional study is needed to characterize the natural history of peritraumatic pulmonary thrombus and the indications for anticoagulation or vena cava filter devices.

Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation

The effectiveness of damage-control resuscitation (DCR) has been demonstrated in recent US conflicts. Wartime casualties treated for hemorrhagic shock from vascular wounds were studied to report the 24-hour transfusion requirements, graft patency, and amputation-free survival for major vascular injuries. Joint Theater Trauma Registry data from August 2006 to April 2011 (56 months) were retrospectively reviewed. Included were casualties with a vascular injury who presented to US combat support hospitals in Iraq or Afghanistan. Amputation-free survival and graft patency were determined from record and imaging review. The study group consisted of 497 severely wounded local national and military casualties (mean [SD] Injury Severity Score [ISS], 17 [8.5]) presenting with acidosis (pH 7.29 [0.15]), tachycardia (heart rate, 110 [29.31]), and coagulopathy (international normalized ratio, 1.6 [2.33]). Given DCR and early management of vascular injury, blood pressure, heart rate, temperature, hemoglobin, and base deficit improved promptly (p < 0.05) by intensive care unit admission. Transfusion requirements included packed red blood cells (15 [13] U; range, 1-70 U), fresh frozen plasma (14 [13] U; range, 1-72 U), cryoprecipitate (13 [15] U; range, 1-49 U), and platelets (8 [6] U; range, 1-36 U). Mean operative time was 232 minutes (range, 16-763 minutes). US casualties (n = 111) had limb salvage attempted for 113 extremity vascular injuries (3 [2%] iliac, 33 [30%] femoral, 23 [20%] popliteal, 13 [12%] tibial, 33 [30%] brachial, 4 [3%] ulnar, and 4 [(3%] radial). In this subgroup, 28 (25%) were revascularized by a primary repair or end anastomosis, 80 (71%) were revascularized by saphenovenous grafts, and 15 (3%) [corrected] were revascularized by prosthetic grafts. The follow-up ranged from 29 days to 1,079 days, (mean, 347 days), during which 96 grafts (84.9%) remained patent, 16 casualties (14.2%) required a delayed amputation, and 110 (99.1%) survived. Popliteal injuries had the highest amputation rate (7 of 23, 30.4%). The amputation-free survival was 84%. In severely wounded casualties, wartime surgical strategies to save both life and limb evidently permit definitive procedures at initial surgery with excellent limb salvage results. This outcome analysis in a large cohort can help to refine surgical judgment and support contemporary DCR practices for major vascular injury. Epidemiologic study, level III; therapeutic study, level V.

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Introduction: US Air Force Critical Care Air Transport Teams (CCATTs) are a unique component of the military medical evacuation system. An understanding of the epidemiology of contemporary warfare is essential for pre-deployment training and optimal outcomes for critically injured warriors. We performed an epidemiological analysis of military patients transported by CCATTs during a discrete period of time. Hypothesis: The epidemiology of contemporary wartime casualties requiring critical care air transport contrasts with the characteristcs of patients seen in previous conventional conflicts. Methods: The primary source of data was the US Transportation Command (TRANSCOM) Regulating and Command and Control (C2) Evacuation System (TRAC2ES). Secondary sources were reviewed and abstracted to compare injury patterns. Descriptive statistics were used to describe the cohort. Results: Final analysis of 2011 TRAC2ES data included 396 CCATT patient transports, representing 290 patients after duplicate transports were removed. The median age was 25 years (IQR, 22 to 33). The majority of transports were male (97.6 %). The most common ICD-9-CM diagnosis was bilateral lower extremity amputation (40%). Nineteen cases of acute coronary syndromes were reported (6.6%). Nine patients with stroke were transported (3.1%). Forty-six cases of traumatic brain injury were reported (15.9%), although reporting for this injury was inconsistent. Only two patients (0.7%) had a primary diagnosis of burns. 125 subjects were injured as the result of an improvised explosive device (IED) explosion (43%), of which 87 (66%) occurred while patients were dismounted from vehicles. In 2011, more non-battle related injuries and illnesses were reported, as compared to historic data from 2001-06. Conclusions: The epidemiology of patients transported by CCATT has changed with contemporary warfare. Amputations and IED injuries were more prevalent in 2011. A higher prevalence of non-battle related injuries and explosion-related injuries may be expected in similar future conflicts. Studies of CCATT epidemiology will help focus training programs and direct evidence-based practices aimed at improving both survival and morbidity for the most severely injured casualties.

Challenges in International Medicine: Ethical Dilemmas, Unanticipated Consequences, and Accepting Limitations

While personal and organizational challenges occur in every area of health care, practitioners of international medicine face unique problems and dilemmas that are rarely discussed in training programs. Health professions schools, residency and fellowship programs, nongovernmental organizations (NGOs), and government programs have a responsibility to make those new to international medicine aware of the special circumstances that they may face and to provide methods for understanding and dealing with these circumstances. Standard "domestic" approaches to such challenges may not work in international medicine, even though these challenges may appear to be similar to those faced in other clinical settings. How should organizations ensure that well-meaning health intervention efforts do not cause adverse unintended sequelae? How should an individual balance respect for cultural uniqueness and local mores that may profoundly differ from his or her own beliefs, with the need to remain a moral agent true to one's self? When is acceptance the appropriate response to situations in which limitations of resources seem to preclude any good solution? Using a case-based approach, the authors discuss issues related to the four major international medicine domains: clinical practice (postdisaster response, resource limitations, standards of care), medical systems and systems development (prehospital care, wartime casualties, sustainable change, cultural awareness), teaching (instruction and local resources, professional preparation), and research (questionable funded studies, clinical trials, observational studies). It is hoped that this overview may help prepare those involved with international medicine for the challenges and dilemmas they may face and help frame their responses to these situations.

Reframing the Casualties Hypothesis: (Mis)Perceptions of Troop Loss and Public Opinion about War

The casualties hypothesis predicts that as the casualties suffered by a nation mount during a military intervention, public opinion will turn against the intervention and its people will demand troop withdrawal. We use the U.S. war in Iraq as a context for testing the perceived casualties hypothesis, which predicts that public beliefs about the actual number of casualties account for public opinion about a military intervention independent of the number of casualties actually suffered. Using data from several thousand respondents to telephone surveys conducted by the Pew Research Center for the People and the Press in 2005 and 2006 as well as data on the number of U.S. casualties suffered as of the interview date, we find that relative to correct estimators and underestimators, respondents who believed the U.S. had suffered more casualties than had really occurred were most supportive of withdrawing troops from the conflict. Attention to the news predicted accuracy in one’s beliefs about the number of casualties, but not opinion about the intervention (when accounting for perceptions of the number of casualties suffered), suggesting that accuracy of one’s knowledge mediates the effect of attention to the news on public opinion. Ancillary analyses answer the question as to who is paying attention to the news about the war and who is more likely to have accurate knowledge of casualties. This article was first submitted to IJPOR January 8, 2009. The final version was received September 9, 2009. Corresponding author: Teresa A. Meyers; e-mail: myers.867@buckleyemail.osu.edu In 1922, Walter Lippmann proposed the following hypothetical in his book, Public Opinion: There is an island in the ocean where in 1914 a few Englishmen, Frenchmen, and Germans lived. No cable reaches that island, and the British mail steamer comes but once in sixty days . . . It was, therefore, with more than usual eagerness that the whole colony assembled at the quay on a day in mid-September . . .They learned that for over six weeks now those of them who were English and those of them who were French had been fighting in behalf of the sanctity of treaties against those of them who were Germans. For six strange weeks they had acted as if they were friends, when in fact they were enemies. (p. 1). In this foundational work on public opinion, Lippmann articulates the idea that people’s opinions and actions are driven by their understanding of what is happening, not by the actuality of events. As he states, ‘‘we can best understand the furies of war and politics by remembering that almost the whole of each party believes absolutely in its picture of the opposition, that it takes as fact, not what is, but what it supposes to be the fact’’ (p. 4, emphasis added). In other words, our attitudes and behavior are influenced as much, more so, or perhaps even exclusively by what we believe to be so rather than what is actually so. In this study, we apply Lippmann’s important insight to testing the casualties hypothesis—that the public’s willingness to remain engaged in a military intervention declines as casualties mount—but we do so focusing not on objective counts of casualties accrued, as have others before us, but instead on the public’s beliefs, right or wrong, about how many casualties have occurred at a given point in time (by ‘‘casualties’’, we mean deaths to soldiers engaged in the military intervention). In the context of the U.S. war in Iraq, we show that there is important individual-level variance in peoples’ beliefs about how many casualties the U.S. has suffered. Additionally, these beliefs about how many casualties have occurred are related to a person’s willingness to remain engaged in the conflict even after accounting for how many casualties have actually occurred. These findings provide further support to claims (at least in the U.S.) that the public is casualties averse, while at the same emphasizing that what people believe about reality plays a role in shaping public opinion independent of the objective reality. EXISTING RESEARCH TESTING THE CASUALTIES HYPOTHESIS Troop fatalities have been shown to be related to a variety of outcomes. Wartime casualties reduce the legitimacy and political capital of state leaders across the world (Stam, 1966; Jackman, 1993; Eichenberg, Stoll, & Lebo, 2006). This lack of legitimacy can then lead to an inability for those leaders ( M I S ) P E R C E P T I O N S , C A S U A L T I E S , A N D O P I N I O N 257

The Changing Face of Wartime Casualty Management: A 20th and 21st Century Historical Perspective

The Changing Face of Wartime Casualty Management: A 20th and 21st Century Historical Perspective

Renal replacement therapy in support of combat operations

Renal replacement therapy has been used by the U.S. Army at the combat support hospital echelon of care since the Korean conflict. Although there has been a general decline in the incidence of wartime acute kidney injury, the mortality associated with acute kidney injury and the use of renal replacement therapy remain unchanged, in the range of 60% to 80%. The U.S. Army official doctrine is that field dialysis is provided through a specialized Hospital Augmentation Team; however, this team has not been deployed to either Iraq or Afghanistan as a result of the ability to rapidly evacuate most cases requiring renal replacement therapy. The history of wartime renal replacement therapy is reviewed along with the general epidemiology of battlefield acute kidney injury and renal replacement therapy. Recent literature documents cases of renal replacement therapy performed in and out of theater in support of the current operations. In-theater renal replacement therapy has been provided through a variety of modalities, including conventional hemodialysis, peritoneal dialysis, and both continuous venovenous and continuous arteriovenous hemodialysis. Out of theater, casualties have received both intermittent and continuous hemodialysis at Landstuhl Regional Medical Center and Walter Reed Army Medical Center, whereas patients sustaining burns have undergone aggressive continuous venovenous hemofiltration or hemodiafiltration at Brooke Army Medical Center. Acute kidney injury requiring renal replacement therapy in wartime casualties is an uncommon occurrence but one with extremely high mortality. Future doctrine should be prepared for contingencies in which the incidence may be increased as a result of mass crush injury casualties or prolonged evacuation times.

Physical Medicine and Rehabilitation in the Military: Operation Iraqi Freedom

This article describes the role of a physical medicine and rehabilitation (physiatry) physician (physiatrist) as a general medical officer within a forward support battalion during the invasion and nation-building phases of Operation Iraqi Freedom. Between March 10 and May 3, 2003 (invasion phase), 364 patients were evaluated. Thirty-two percent had musculoskeletal noncombat injuries, 9% had combat-related traumatic injuries, and the remaining 59% had nontrauma/nonmusculoskeletal conditions. Between May 4 and July 25, 2003 (nation-building phase), 1,387 patients were evaluated. Of these, 19% had musculoskeletal injuries, 1% had combat-related traumatic injuries, and the remaining 80% had nontrauma/nonmusculoskeletal conditions. During this nation-building phase, the musculoskeletal workload seen at the division-level combat support hospital was 4 times the workload seen in the forward support battalion. This experience underscores the role of physiatry in wartime casualty management and profiles the combat support hospital as the most suitable place for the physiatrist during wartime. Interventions focused on acute management and rehabilitation counseling for all musculoskeletal injuries, as well as consultation services to the combat support hospital and local civilian hospitals for the evaluation of complex neuromusculoskeletal trauma cases.

War Casualties, Policy Positions, and the Fate of Legislators

Politicians appear to anticipate that the public will hold them accountable for war deaths. Yet, little is known about why some politicians openly oppose costly conflicts while others do not and the difference this makes to their electoral fortunes. Examining U.S. Senate elections from 1966-1972, we find that state-level casualties, military experience, and a variety of other factors affect candidate positions on the Vietnam War. Challenger and incumbent positions are negatively related, suggesting that strategic considerations play a role in wartime policy formation. We also find that war plays a role in elections. Incumbents from states that experience higher casualties receive a smaller percentage of the vote, an effect ameliorated when the incumbent opposes the war and his or her opponent does not. Wartime casualties, we conclude, influence both the perceived cost of the war and its salience, affecting both candidate positions and elections, suggesting that selectorate/electorate-type arguments about war and domestic politics can apply to the US system.

Damage control laparotomy in the Australian military.

Damage control laparotomy (DCL) is a physiological approach to the management of selected critically injured patients where the surgical technique is directed at minimising the metabolic insult, rather than restoring anatomic integrity. DCL consists of an abbreviated initial laparotomy that is limited to control of haemorrhage and contamination, intra-abdominal packing, and temporary closure. Secondary resuscitation continues in the intensive care unit for 24-48 h until normal physiology has been restored. The subsequent reoperation involves removal of the packing with definitive repair and closure. Using this approach 50% of civilian patients who would previously have died undergoing a definitive trauma laparotomy will survive. Doctrinal change in Australia has yet to enshrine a strong focus on restoration of key physiological variables as a major objective in treatment of all wartime casualties. Yet the philosophy of damage control is uniquely suited to the Australian military environment. However, transition of DCL to the military setting has to take account of operational constraints. The most important unresolved issue is how to provide adequate postoperative intensive care. An evacuation capability incorporating critical care transport teams needs to be present, as the patient must reach definitive care within 48 h.