Died of wounds on the battlefield: causation and implications for improving combat casualty care.

BACKGROUND: Understanding the epidemiology of death after battlefield injury is vital to combat casualty care performance improvement. The current analysis was undertaken to develop a comprehensive perspective of deaths that occurred after casualties reached a medical treatment facility. METHODS: Battle injury died of wounds (DOW) deaths that occurred after casualties reached a medical treatment facility from October 2001 to June 2009 were evaluated by reviewing autopsy and other postmortem records at the Office of the Armed Forces Medical Examiners (OAFME). A panel of military trauma experts classified the injuries as nonsurvivable (NS) or potentially survivable (PS), in consultation with an OAFME forensic pathologist. Data including demographics, mechanism of injury, physiologic and laboratory variables, and cause of death were obtained from the Joint Theater Trauma Registry and the OAFME Mortality Trauma Registry. RESULTS: DOW casualties (n = 558) accounted for 4.56% of the nonreturn to duty battle injuries over the study period. DOW casualties were classified as NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. Traumatic brain injury was the predominant injury leading to death in 225 of 271 (83%) NS cases, whereas hemorrhage from major trauma was the predominant mechanism of death in 230 of 287 (80%) PS cases. In the hemorrhage mechanism PS cases, the major body region bleeding focus accounting for mortality were torso (48%), extremity (31%), and junctional (neck, axilla, and groin) (21%). Fifty-one percent of DOW casualties presented in extremis with cardiopulmonary resuscitation upon presentation. CONCLUSIONS: Hemorrhage is a major mechanism of death in PS combat injuries, underscoring the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.

Nurses' role in the Joint Theater Trauma System.

Nurses' role within the Joint Theater Trauma System's trauma performance improvement program spans the entire trauma continuum. Nurses serve as trauma nurse coordinators at combat zone medical treatment facilities, flight nurses within the US Air Force Aeromedical Evacuation system, multidisciplinary trauma teams at overseas and stateside military and Veterans Affairs healthcare organizations, and members on trauma video teleconferences. Many of the trauma performance improvement initiatives that have occurred since the Joint Theater Trauma System inception have been led by nurses serving within the trauma continuum and resulted in successful outcomes for patients with polytrauma.

Performance improvement on the battlefield.

The Joint Theater Trauma System (JTTS) is a formal system of trauma care designed to improve the medical care and outcomes for combat casualties of Operation Iraqi Freedom and Operation Enduring Freedom. This article describes the JTTS Trauma Performance Improvement Plan and how JTTS personnel use it to facilitate performance improvement across the entire continuum of combat casualty care.