Training for Combat Casualty Care In Armor Units

, and Captain Ralph Briggs What sort of casualties can a commander expect over a 24-hour period in a future conflict of high intensity, such as the October 1973 Arab-Israeli War? What skills do soldiers need to treat the wounded, and what is the best way to train for combat casualty care? This article will give a better understanding of the number and types of battle injuries that a combined arms battalion may sustain, the skills essential for their management, and how best to train for combat casualty care at the unit level. The Wounded Soldier We have used Danon's analysis of 1,499 Israeli battle casualties from the October 1973 war to get an approximate distribution of the casualty load that a combined arms unit may expect in a high-intensity conventional war. Additionally, we have used a British study of 333 tank and 769 crew injuries from WWII, and two smaller studies for Korea (57 tanks and 181 casualties). and Vietnam (40 tanks and 57 casual tie^).^-^* lo Let us assume the casualties are from a. I-series TOSrE combined arms battalion. A commander could expect over 24 hours to have approximately 80 battle casualties of the following relative distribution: 20 KIA (25 percent mortality) 10 Head/Face/Neck 30 Extremities (arms and legs) 7 Trunk (chest and abdomen) 5 Multiple (some combination S Burns of the above) In addition to those who are wounded in action, one could expect about 15-20 soldiers who would fall into the category of psychiatric or combat stress reaction. Some authors would put this figure higher. Fcw of these soldiers will have true psychiatric disorders, such as schizophrenia? Soldiers who have been wounded in combined arms units have two basic types of injuries: thermal and ballistic. Unlike non-mechanized infantry war wounds, there are a larger number of bums. About 10- 12 percent of wounded soldiers with combined arms units have bums as opposed to one to nine percent for the foot soldier.'" Toxic fumes, blast overpressure, and blunt trauma are relatively infrequent, and are usually associated with other injuries. Injuries of those in and around tanks are also different. About 25 percent of tank crew casualties sustain burns. These are mostly flash-type burns of the face, neck, hands, and forearms. This distribution does ar to have changed since

WWII.

Ballistic injury is responsible for the majority of the rest of the injuries seen with tank crewman. Those are characterized by multiple small-fragment injuries, often of soft tissues (skin, subcutaneous fat, and skeletal muscle) only. During WWII, wounds to British crewman inside of tanks were from multiple small fragments, which weighed less than about 4 grains in 80 percent of the sampling. This is less than 1/15 of thc weight of the M-16A2 rifle bullet, the M-855. HeadFaceINeck- Living wounded soldiers generally have soft tissue injuries only. The incidence of eye injuries is about five to seven percent of the hospitalized soldiers in the October 1973 war, and for British tank crewman in WWII, which is higher than the one to two percent seen in non-mechanized infantry casualties. Airway compromise is very infrequent, from 0.3 to 0.8 percent. Tmnk (chest and abdomen) - The collapsed lung is the most life-threatening of injuries to this area, involving about three to four percent of all casualties. Injuries to the abdomen need prompt surgical care over the next several hours to prevent overwhelming infection. In- - 76 ARMOR - November-December 7989 juries to both the chest and the abdomen may cause a patient to go into shock, which requires urgent treatment. Extremities (arms and legs) - These compose the single largest category of wounds. About one half of the hospitalized patients will have fractures or traumatic amputations. Triage What system do we have to evaluate casualties? Triage is a means of providing care first to those who need it most, based on the predicted outcome of certain groups of patients. It is accomplished, initially, by the corpsman at the company level who sets priority for his treatment and evacuation plan. Casualties can be divided into roughly three types at this level: Urgentllmmediate: Those who have life-threatening problems that need timely care. A traumatic amputation or a collapsed lung are two examples. By analysis of Vietnam data, about 14 percent of casualties required treatment of the "ABCs" - airway, breathing, and circulation - 10 percent in shock, two to three percent respiratory compromise, and 0.8 percent airway compromise." One survey of battle casualties, taken in Italy during WWII, found that about nine percent of the casualties were non-transportable and needed urgent surgery. 14 Minimal/Delayed This is a patient whose clinical course will not be altered by a delay of several hours. Most soft tissue wounds fall into this category, as well as the majority of the extremities wounds. This category of battle casualties is the most frequent. Expectant: This patient's course cannot be altered to any great degree. Very few individuals fall into this category. A person with a ARMOR - November-December 7989 77 penetrating head wound, with fuced, dilated pupils, who is not breathing on his own, is an example. Evacuation of a wounded crewmember is a hazardous task that may, ironically, cause further casualties. The chain of evacuation in a combined arms unit starts from the individual vehicle to the medical M- 113 at the company level. The majority of casualties will be able to do so by themselves, or with the help of one another. When to remove a crewman is dependent on the tactical situation. Only patients in the urgenthm-mediate category need to be evaluated at the BAS as soon as possible. Lightly wounded crewman should seek treatment during a lull in the fighting. Ideally. a wounded crewman should leave the vehicle when it is in a hide position. safe from small arms and artillery fire. If the vehicle is immobilized. this may not be possible. Medical M-113 drivers should emphasize tactical driving to avoid losing medical assets when extracting combat casualties under fire. Because the large majority of soft tissue wounds, fractures, and burns can be managed at the company level for several hours, vehicle runs are feasible by the medical M-113 to the patient collection point or battalion aid station. Medical M- 113s are usually set up for two litter and five ambulatory paticnts. When there are a large number of casualties, alternative vehicles may be used. Treatment What treatment is required at the company level for our group of casualties? (See chart, upper right.) Those who have psychiatric or combat stress reaction will receive evaluation initially at the company level. Light cases of combat stress reaction may return to duty. More severe cases may need further care at the battalion aid station, or with the combat stress control dctachment attached to the medical company of the forward support battalion. The majority of soldiers with combat stress reac-Company-Level Treatment and Supplies for Typical Casualties Bums HeadlFacelNeck Extremities (6 traumatic amputations) Trunk Multiple Antibiotic cream Bandages Analgesia, if needed Bandages Analgesia, if needed 6 Tourniquets 24 splints (or more, some may be multiple) 6 IVs Bandages Analgesia, if needed 4 Occlusive Dressings 7 Intravenous fluids Bandages Analgesia, if needed. Combination of above. tion can return to duty before 72 hours, and can perform on a par with their peers. Treatment for combat stress reaction is as far forward as possible, and consists of the "four Rs" - rest, refreshment, reassurance. and return to duty (within 72 hours). Prevention "Stout armor" is the best protection from injury to armored vehicle crews. Unfortunately, at some point, any vehicle's armored envelope can be overmatched by antiarmor weapons. When designing an armored vehicle, there is always a trade-off between protection, mobility, and firepower. Crew survivability was the top priority for the design of the Abrams M1 tank. "Live-fire testing" has been carried out on the Abrams with actual Threat weapons. Results show the majority of injuries expected would be ballistic, and that the Abrams design reduced burns. As mentioned above, there is about a five-to-seven percent incidence of eye injuries with combined arms or armor units. No eye injuries occurred with Israeli crewmen in Lebanon in 1982, when they wore go_ggles with 2 mm polycarbonate lenses. No casualty data are available for tank crewman with and without body armor. In a Korean War study, the protective vests stopped about 75 percent of small fragments, and reduced the percentages of KIAs (killed in action) from chest wounds from 26.7 percent to 16.9 percent. Protective armor appears to save lives. Israeli use of Nomex suits (Nomex is a proprietary flameproof fabric. - Ed.) does not appear to have altered the distribution of burn injuries when compared to British WWII tank crewman, though Israeli data shows a reduction in burn severity from 1973 to 1982.l.' In the 1982 Lebanon War, Israeli use of Nomex gloves reduced the percentage of hand burns from 75 percent to nine percent: Because about 75 percent of burned crewman have facial bums, a usable face mask for 78 ARMOR - November-December 7989 burn protection is being developed, and needs to be fielded. Training skills for the treatment of combat casualties need to be reinforced on a regular basis beyond basic training. Not all first aid common tasks apply to combo[ casualties. For example. casualties do not die of heart attacks; therefore, cardiopulmonary resuscitation (CPR) is of limited usefulness on the battlefield. The first aid common tasks that are most useful for combat casualty are"^.'^ are application of tourniquets and pressure dressings, splinting, and bandaging. Current annual testing of these skills is inadequate to maintain a high level of proliciency; therefore, we recommend soldiers be tested on a quarterly basis to ensure those skills are second nature. This can free the medics to perform triage, start IVs, give pain medication, as well as adjust splints and bandages. How should the medics train? From analysis of combat casualties, the skills most needed will be: 0 Triage (patient evaluation). Splinting (a variety of splints with various materials. as shown in First Aid for Soldiers. FM 21-11) 0 Hare Traction Splints e Intravenous (IV) fluids 0 Intramuscular (IM) injections Starting IVs is a skill that needs to be practiced on actual patients. Temporary duty in a hospital to practice starting IVs and giving intramuscular (IM) injections will ensure the medics' proficiency in wartime. (Civilian Quality Assurance standards may not allow this practice in Army hospitals.) It is necessary that the medic practice triage with a realistic number of patients, so that all of the important wartime skills can be maintained. It is imperative for the commander to be the driving force behind maintaining proficiency for skills necessary for the treatment of combat casualties. The quality and specific programs for training are the responsibility of the battalion surgeon, or the brigade surgeon if one does not exist at battalion. Failure to do so may result in a needless loss of life in a future conflict. Notes ' Wright, H. B.; Harkness, R. D. A Survey of Casualties Amonast Armored Units in NW Europe, Jan 1946. Medical Research Council Team, 21st Army Group. McRae. V.; Coox, A. D., Tank vs Tank Combat in Korea, Operations Research Group, Tech Memoranda, ORO-T-278. 8 Sep 1954. Daily, J., Some Observations of RPG ImDacts on the M48. M551. and M113 in South Vietnam, Mar 1977, USAMSAA, Aberdeen, MD. Bellamy, R. F., "The Causes of Death in Conventional Warfare: Implication for Combat Casualty Care Research," Medicine 149, pp.55-62, Feb. 1984. Bellamy, R. F., "How Shall We Train for Combat Casualty Care?," Military Medicine 152, 12:617-621, 1987. Bellamy, R. F., "Death on the Battlefield and the Role of First Aid," Military Medicine 152, 323634635. 1987. Shafir. R.; Nili, E.; Kedem, R., "Burn Injury and Prevention During the Lebanon War. 1982." Israeli Journal of Medical Science 20:311-313. 1984. G i n, M. E.; Treister, G.; Shlomo, D., "Eye Injuries and Ocular Protection During the Lebanon War, 1982." lsraeli Journal of Medical Science, 20:333-338, 1984. Belenky, G. L.; Tyner, C. F.; Sodetz, 9 S. J., Israeli Battle Shock Casualties 1973 and 1982, Walter Reed Army Institute of Research Report NP-83-4,

Washington. D. C. 20307. 3 4 1 7 ARMOR - November-December 7989 lo Danon, Y. L; Nili. E.; Dolev, E., "Primary Treatment of Baffle Casualties in the Lebanon War, 1.982," Israeli Journal of Medical Science. 20:300-302, 1984. Herget, C. M.; Coe, J. B.; Beyer, J. C., Chapter XII, "Wound Ballistics and Body Armor in Korea." In Wound Ballistics (edited by J. C. Beyer) Government Print-in Office, Washington, D. C., 1962. 92 Bellamy, R. F., Personal to the author, Feb 20, 1989. l3 STP 21-1-SMCT, Soldiers Manual of Common Tasks, Skill Level 1, pp.455512. Government Printing Office, 1987. l4 Snyder, H. E., Chapter XVI, Fifth U. S. Army. In Activities of the Suraical Consultants, Volume 1, p403. Government Printing Office, Washington, D. C., 1962. Captain Paul J. Dougherty serves on the orthopedic surgery service at Letterman Army Medical Center, San Francisco. He earned his medical degree at the Uniformed Services University of the Health Sciences, Bethesda, Md., after undergraduate and graduate studies in anthropology at San Francisco State University, where he was also a lab instructor in anatomy. His professional interests include trauma surgery and gunshot wound ballistics. Captain Ralph Briggs is a 1979 graduate of Virginia Military Institute. He attended the Armor Officer Basic and Advanced Courses and was troop commander of 4-4 Cav, 3d Infantry Division. He is currently an instructor at the Armor School Leadership Branch, Command and Staff Department, Fort Knox, Ky. 19

ARMOR - November-December 7989