Causes of Death in U.S. Special Operations Forces in the Global War on Terrorism: 2001-2004

John B. Holcomb, MD; Neil R. McMullin, MD; Lisa Pearse, MD; Jim Caruso, MD; Charles E. Wade, PhD; Lynne Oetjen-Gerdes, MA; Howard R. Champion, FRCS; Mimi Lawnick, RN; Warner Farr, MD; Sam Rodriguez, BS; Frank K. Butler, MD


Annals of Surgery. 2007;245(6):986-991. 

In This Article

Abstract and Introduction

Background: Effective combat trauma management strategies depend upon an understanding of the epidemiology of death on the battlefield.
Methods: A panel of military medical experts reviewed photographs and autopsy and treatment records for all Special Operations Forces (SOF) who died between October 2001 and November 2004 (n = 82). Fatal wounds were classified as nonsurvivable or potentially survivable. Training and equipment available at the time of injury were taken into consideration. A structured analysis was conducted to identify equipment, training, or research requirements for improved future outcomes.
Results: Five (6%) of 82 casualties had died in an aircraft crash, and their bodies were lost at sea; autopsies had been performed on all other 77 soldiers. Nineteen deaths, including the deaths at sea were noncombat; all others were combat related. Deaths were caused by explosions (43%), gunshot wounds (28%), aircraft accidents (23%), and blunt trauma (6%). Seventy of 82 deaths (85%) were classified as nonsurvivable; 12 deaths (15%) were classified as potentially survivable. Of those with potentially survivable injuries, 16 causes of death were identified: 8 (50%) truncal hemorrhage, 3 (19%) compressible hemorrhage, 2 (13%) hemorrhage amenable to tourniquet, and 1 (6%) each from tension pneumothorax, airway obstruction, and sepsis. The population with nonsurvivable injuries was more severely injured than the population with potentially survivable injuries. Structured analysis identified improved methods of truncal hemorrhage control as a principal research requirement.
Conclusions: The majority of deaths on the modern battlefield are nonsurvivable. Improved methods of intravenous or intracavitary, noncompressible hemostasis combined with rapid evacuation to surgery may increase survival.

Analyzing combat mortality data determines new strategies for treatment, equipment, and training and focuses research agendas to meet contemporary goals and needs. In civilian systems of trauma care, analysis of deaths from injury has long been a cornerstone of trauma system development and is essential to ongoing evaluation.[1,2] Equivalent studies have been conducted on several military data sets,[3,4,5] most recently from Vietnam casualties described by the Wound Data and Munitions Effectiveness Team (WEDMET) database. WEDMET has directed military medical research, logistics, and medical tactics since that time, but it is now 40 years old. Changes in body armor, improved medical care, equipment, and training since Vietnam raise the question of the applicability of the WEDMET data in the current experience. Additionally, and perhaps more importantly, 30 years of experience in maturing trauma systems research have transformed methods of death analysis.[6] The reliability of this study type has been analyzed in the past.[7] In 1992, the Preventable Death Study Group determined that a multidisciplinary group, using a panel consensus rule, with autopsy reports, adequate medical records, and a standardized approach, can approximate the upper bound for potentially preventable deaths.

Tactical Combat Casualty Care (TCCC) is designed to provide all Special Operations Forces (SOF) operators (medical and nonmedical) in deploying units with sufficient medical skills to sustain casualties until evacuation and if necessary, while under fire.[8,9]

TCCC training emphasizes:

  • Tourniquets for extremity wounds with life-threatening bleeding to gain initial control of hemorrhage.

  • Sustained direct pressure for severe external bleeding in an anatomic location where a tourniquet cannot be applied.

  • Proper casualty positioning and cricothyroidotomy instead of intubation for maxillofacial trauma associated with airway trauma.

  • Needle decompression of tension pneumothorax.

The goal of this review was to identify which fatal injuries in the SOF between 2001 and 2004 were potentially survivable and would have been amenable to TCCC prevention and treatment modalities. The resulting data was compared with previously published data from civilian and military trauma autopsy studies. The second focus of this study was to use these findings to identify potential areas of improvement for future treatment, training, or equipment and to direct future research initiatives.


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