Understanding weapons effects: A fundamental precept in the professional preparation of military physicians1

In   Issue .

AM smith, RF Bellamr

Short of participation  in medical support of actual combat, there is no optimal educational  medium  to facilitate competence in the precepts of wartime casualty care. Consequently, there have been periodic calls for “military specific curricula” to help orient medical officers to the differences between the unique science of military medicine, and the practice of medicine in a peacetime military. Ultimately, any such military specific course of study  should facilitate its students’ understanding of the medical impact of weapons systems. The insights  gained will foster a greater understanding of the entire spectrum of casualty care systems in war.

Whereas the profession of combat arms has traditionally focused its attention upon  the relationship between weapons, ammunition, and their targeting, a concurrent  appreciation for the impact of munitions upon  human targets, and the wounding process, would benefit military physicians.Empowered with a better understanding of the physical impact of specific weapons,  physicians can better comprehend  the rationale  for their tactical utilisation. Further endowed with a knowledge of the special requirements for management of resulting combat injuries, medical officers may logically develop a greater appreciation for medical logistics needs as well. This level of professional insight will permit them to competently assess the intrinsic assets and liabilities of the casualty treatment continuum supporting operational plans, and thereby assist combat commanders in becoming better informed “consumers” of medical care services.

WEAPONS  EFFECTS

The military value of contemporary armaments is primarily adjudged by their effectiveness in producing physical trauma. Through the combined destructive forces of projectiles, blasts and incendiary agents, the judicious employment of today’s combat weapons may create a diverse and widely distributed spectrum of personnel damage. Rationally, however, the goal of modem warfare is not necessarily to annihilate an adversary, but more directly to reduce an enemy’s capability for further resistance. Whether through intimidation  or physical damage, the military usefulness of weapons must ultimately be judged in terms of their contribution  to this objective. Indeed, the proportion of non-lethal injury may have an even greater impact on operational success than the absolute number of deaths among an opponent’s force’ Observations on the fear that men develop relative to specific weapons are unfortunately quite limited. While the extent to which military effectiveness correlates with the potential for generating fear is a concept not well understood, history suggests that its role can occasionally be pivotal. For example, whistles were added to some aerial bombs during World War II specifically for psychologic effect. Perhaps the best example of a weapon system designed for the purpose of intimidation  was the German “Stuka” dive bomber of World War II. When diving on its target, a wind driven siren attached to its wing was activated. Known as the ”Jericho Siren”, an ear-piercing shriek was produced which was loudest just before the bomb exploded. Likewise, some of the appeal of chemical weapons lies in their presumed psychologic effects as well. Except for chemical agents, however, the design of pre-nuclear weapons was not significantly influenced by psychologic considerations. The character of modem weapons is ever changing, however, and considerable advances have been made in broadening and increasing their effectiveness. Furthermore, the principles of their use have been expanded. Given the often unique constitution of each tactical situation, these improvements, together, may provide  an increasingly greater variety of options  for operational commanders. Regardless of the methods employed, the time honoured axiom remains valid: increasing the proportion of wounded among adversary forces is a very effective “force reducer”.

Effective antipersonnel weapons cause  not only multiple  casualties in a population of troops, but may also inflict multiple wounds in each of their affected targets. In evaluating the potential effectiveness of a new exploding missile,  the principal question to be asked is: “How far does it go in expanding the fragmentation envelope?” Rephrased in the context of intensity of injury: “How can more  hits  be produced without reducing the summation of damage  – by creating too many minor  hits and  too few major  hits?”

From the perspective of weapons designers, exploding missiles carry a far greater  probability of hits than solid  projectiles  of the same size. From a medical standpoint, a weapon producing multiple random wounds is more likely  to injure a critical organ than  a single injury  caused by an aimed missile such as a rifle bullet. Furthermore, by creating  greater numbers of casualties among  opposing forces,  many with multiple  wounds, the enemy force will not  only be weakened, but the logistic needs  of their medical services will be increased. This may often evolve at the expense  of the combat  arms,  since more enemy logistical resources and personnel will need  to be withdrawn from offensive operations to care for the injured  and facilitate their  evacuation.

WEAPONS EFFECTIVENESS: THE TACTICAL IMPACT

As a tactical situation changes, differing  degrees of injury intensity may vary in their military impact. In one situation, where enemy capabilities for replacement are not great, as in the  attack  on an isolated strong point, weapons capable  of only transient impairment of efficiency, although affecting a substantial part of the enemy force, may be of greater tactical value than weapons causing more permanent wounds to a much smaller number.  Altematively, in another situation, a premium may be placed  on lethal or permanently disabling effects. Stated otherwise, are 10 casualties, losing 10 days each, equivalent to 100 losing one day each? The dilemma may be re-defined as weighing immediate tactical advantage against a long term effect upon  manpower.

The expenditure of ammunition by various military forces has been reasonably well recorded. It has thus far proven impractical, however, to relate a given expenditure of munitions to a given number of enemy casualties, much less relate them to a particular type of weapon. Nevertheless, penetrating wounds  of the body surface have historically caused 90% of combat trauma injuries  in land warfare (in the civilian sector, where  blunt injuries  predominate, penetrating wounds comprise only 25 to 50 per cent of trauma cases). Blast, bums, and blunt  trauma account  for the other  10% of injuries experienced  in land combat.  [In naval warfare,  the predominant form of injury is thermal.  During  the Falklands war, for example, 34% of British  naval casualties at sea were bums.]

In most  conventional land wars, wounds  caused by fragment  penetrations have historically outnumbered bullet wounds. Wounds from explosive fragmentary munitions have accounted for between 44 and 92 percent  of all surgical cases. Under  circumstances where fragments predominate, and weapons cannot be aimed at particular body regions, missiles  tend to be randomly distributed in space, and hits are a function of the frequency and extent to which  the various regions of the body are exposed.

Today, even terrorists may utilise  explosive fragmentation devices that are as sophisticated as those  used in modem warfare.

Under certain warfare conditions the ratio of fragment to bullet injuries may reverse. During combat at close quarters, where  ambush and sniping are frequent, directed fire may increase, and hits upon vital areas  may be more frequent. These include: military  operations in urban environments; light infantry actions – such as Vietnam where 50% of the casualties had  bullet wounds; low intensity warfare; counter-insurgency actions;  and jungle warfare.

These differences in bullet versus  fragment distributions are important to recognise, since bullets are more likely  to kill their victims  than fragments from explosive munitions such  as artillery shells or grenades (33 versus 10 to 20 per cent).

As a result of the ongoing perfection  of a class of anti-personnel munitions known as fuel-air explosives (FAE), future wars will probably  have even higher proportions of casualties with primary  blast injury as

well. In addition, if larger numbers of troops serve in armoured fighting vehicles, the proportion  of bums in land warfare will also increase. Due to e::o.:posure of crew members to batde damage fires, burns have constituted an important component  of wounds seen in the protracted armour  operations of the past (20 to 40 per cent). Armour casualties may experience more than bum  injuries, however. They are also prone to the combined impact of blast injury, toxic gas inhalation, and tissue wounds from both the penetrators of anti-armour munitions and the shrapnel fragments emanating from the defeated armour.

The nature of war wounds is always prone to continuing change with  the development and use of new weapons systems. Innovations such as futuristic laser-charged particle beams and high powered microwaves, for example, are now just beginning to demonstrate their impact as well.

EXPLOSIVE FRAGMENTATION MUNITIONS: WHAT ARE  THEY?

The prototype of the exploding munition  is the shell. Originally composed of a hollow metal casing, explosive powder was packed within, along with a fuse for ignition. Depending upon the shell design, various kinds of fragments, projectiles, chemicals, or other agents were dispersed upon explosion. In older designs, fragments of the shell casing created most of the damage. Subsequendy, artillery forces incorporated shrapnel  to increase the antipersonnel effectiveness of explosive munitions. A shrapnel ball contained explosive as well as many small lead spheres (the shrapnel)  packed in resin. Blasted out of the shell at detonation, the lead spheres gready increased the number  of projectiles from the explosive munition. Subsequendy, more specialised modem  exploding munitions evolved, such as hand grenades, rockets, bombs and mines.

Depending upon the size and design of the explosive  munition, several thousand metal fragments may be produced upon detonation.  Fragments radiating from the detonation site may retain their wounding potential for up to several hundred  metres. Such munitions can also injure through  blast and burning effects. A casualty close to the point of detonation of an explosive weapon, although extensively injured by the mutilating effects of a high concentration of fragments, may also sustain blast and bum injuries. Most of these casualties die immediately from multiple high energy transfer wounds,  while some die from traumatic amputations caused by the dynamic blast over-pressure. The majority of the surviving wounded, however, these generally located distant from the explosion site, will have multiple, relatively low energy-transfer wounds caused by fragments of variable size with low impact velocities. At one British Army Hospital during  the 1991 Gulf War, 81% of the casualties suffered from fragment wounds. An average of nine low energy transfer wounds were inflicted per patient!

Two antipersonnel fragment families exist; one older and “random”, and the other modem and “improved”.

OLDER “RANDOM” FRAGMENTATION MUNITIONS

The older fragment family is the product of detonation of artillery shells and large caliber mortar bombs. Natural fragmentation of the projectile casing results in fragments varying in size from dust particles to metal pieces weighing more than 1 000 grams. Initial fragment velocities may be very high (as much as 1 500 to 1 800 metres per second), but decline rapidly because of the poor aerodynamic characteristics  of their irregular shape.  Some fragments have a Limited effective range and poor tissue penetrating  power. Others, as a consequence of heavy mass and high kinetic energy, may penetrate deeply and cause massive damage. Because of their irregular shape and ragged edges, fragments produced by random fragmentation munitions often cause wounds with Jagged shape due to the drag of the projectiles within soft tissues.

IMPROVED FRAGMENTATION MUNITIONS

On future conventional batdefi.elds, the majority of wounds will likely result from “improved” military fragmentation munitions  (IFMs). The development  of these newer improved munitions required a design in which the “shell” broke up into fragments smaller than those associated with random fragmentation munitions. In reality, the size of a fragment that will cause a casualty is surprisingly small – several hundred milligrams only. One of the earliest examples of the implementation of the IFM concept was the “pineapple” hand grenade of World War I (although some believed that this design characteristic resulted primarily from a desire to give the soldier  a rough surface  to grip).

IFMs designed  post World War II usually incorporate etched  fragmentation plates or notched wire fragmentation coils. Some IFMs are filled with preformed rods – hardened  steel bits packed  inside  the munition, which  are expelled  when it explodes  (a “canister shot”, for example, is a shotgun-like container that can hold thousands of pre-formed  rods or slugs).

Modem (improved) fragmentation munitions, such as contemporary hand grenades  small mortars  and antipersonnel mines, contain  either  multiple uniformly constructed metallic spheres, or aerodynamically fashioned  dart-like arrow  shaped projectiles (flechettes), all of which  have been designed for great penetration. Detonation of these munitions disperses a large number of such small pre­ formed fragments.  Weapons designers have expended considerable effort in producing a consistent fragment size, which  offers an optimum compromise between range,  velocity, probability  of hit, and target wounding effectiveness. Their aim is to incapacitate by inflicting multiple low energy “transfer” wounds to areas not protected by modem helmets  and body armour. Although the mechanical  injury  may be quite modest among surviving casualties who reach surgical facilities, many will have multiple wounds, often heavily contaminated with  clothing, soil and skin.

An example of an improved conventional munition of the Vietnam  era was the “beehive  round”, a 105 mm antipersonnel round filled with 8 800 flechettes. The flechettes  were released from the shell  at a time determined by the fuse setting, and their aerodynamic properties allowed them  to pass through helmets and armoured vests more easily than irregular  fragments.

Another improved  conventional munition, the cluster  bomb,  acts as a cargo carrying  munition. It contains many small sub-munitions that in tum  are filled with numerous small preformed  fragments  – the size and shape of which have been designed  to cause a large number of casualties.  Even more recent  updates to this class of munitions are the US Army’s Multiple Launch  Rocket System  (MLRS) munition containing 644 M77 submunitions, and the 155 mm Howitzer artillery  projectile containing 64 M42 and 24 M46 submunitions. When  a cluster  munition is detonated, (either before or upon the carrier’s impact), its submunitions or bomblets  are disseminated over the surrounding terrain. When  they explode, the fragments are dispersed  over a much wider area than would  have been affected if the same mass of potential fragments  had been derived  from a single  thick walled shell casing. The fragments of such  weapons  tend  to be small and numerous, with the expressed purpose of achieving  not only the high probability of a wound, but multiple wounds to each casualty. They are also fairly regular  in shape, ensuring adequate range and consistent performance.

The most modem improved conventional munitions have combined antipersonnel with anti­ materiel  potential. The latter characteristic is obtained by incorporating a shaped charged  warhead into  each of the individual submunitions. When  the munition detonates, fragments  from the side walls are disseminated in a radial direction around the armour piercing jet produced by the shaped charge warhead. Such cluster  munitions, incorporating dual purpose sub-munitions, were used with great effectiveness in the Persian Gulf War.

OTHER FRAGMENTATION  THREATS
Following  the surface  or subsurface detonation of an explosive munition, secondary missiles are also produced from objects within  the environment, such as dirt, rocks, trees, or debris  from buildings. The nature  of the secondary fragments  is generally unpredictable. They tend  to be irregularly shaped, with a wide range of masses and impact  velocities, and may have considerable potential to cause injuries.  In the aerial bombing  of cities,  for example, secondary missiles  often cause the greatest  volume of casualties. The wounds created  by secondary missiles, however, may become  badly contaminated. A landrnine, for example, creates high velocity secondary missiles  from the ground in which it is buried.  It is therefore likely that any severe wounds created will also be filled with dirt, pebbles and even chunks of plants.

THE  WOUNDS  CREATED BY FRAGMENTATION MUNITIONS
Penetrating missiles may cut, crush  and  lacerate tissues direcdy in the missile’s path.  When  penetrating the skin, an antipersonnel fragment  of low mass and low velocity  causes an injury confined principally to the immediate track of the missile through the soft tissue. The visible passage  created  in the tissue includes the wound of entrance, and if it completely passes through the tissue, the wound  of exit as well. These low energy transfer wounds arise simply from the cutting and crushing action of the projectile as it penetrates the tissues. Faster moving heavy missiles have more energy to transfer, and have the potential to cause more tissue damage. This damage is caused not only by direct contact between the missile and the tissue, but by tissue being violendy thrown away from the missile’s path through it. The radial stretching and tearing of tissue around  the missile’s track is known as “cavitation”.

The impact velocity of a projectile can occasionally be a misleading indicator  of its potential for injury. All projectiles cut, crush, bruise and displace tissues. Some projectiles, by virtue not only of speed but also their shape, may undergo a tumbling motion within the tissues. This induces further indirect injury to tissues not direcdy in their path. The radial or peripheral stretching and tearing induced by such projectiles, or “temporary  cavitation”, is variable, and is a consequence of increasing levels of transferred energy. The excess energy or fragment motion may induce merely a bruise around the missile path, or alternatively, a grossly explosive effect such as a shattering of the heart or skull radial to the missile path. Even if cavitation is not immediately lethal, its contribution  to the occurrence of war wound infection is widely overlooked.

All war wounds are contaminated  from the outset by soil, clothing, and skin. Fragments and any other projectiles with sharp irregular surfaces have been shown to cut clothing materials and skin efficiendy, and also transfer notable quantities of these contaminants into wounds. Low velocity projectiles regularly transfer such ragged pieces of clothing and skin contaminants into wounds. When  the fragment velocity is raised and a temporary cavity is formed by the projectile, the nature of clothing contamination is further altered, fibres and large pieces of material may be finely shredded and rapidly dispersed due to the formation of the temporary cavity, resulting in contamination of tissues far distant from the permanent wound track. If the temporary cavity involves the exit wound, substantial quantities of material may also be sucked into the wound from the exit hole, creating even greater widespread contamination, and the potential for infection at multiple sites.

Describing conditions in the Korean War, one historian  noted:

“Even UN soldiers arrived in hospitals with most wounds . . . grossly contaminated with field dirt, leaves of rice plants, and crumbs of human excrement plainly visible in some of them. Wounded North Korean prisoners of war showed the same problem in exaggerated form, their injuries frequendy infested with hordes of maggots.”1

BULLETS AND THEIR WOUNDS

Both the design and construction  of a bullet determine the kind of wound  created. The wounding effects of deforming hollow point and soft-nose hunting ammunition, for example,  which change shape after penetrating tissue, are noticeably different and potentially  more devastating than those of non­ deforming bullets. Most bullets are long and thin, and are spun  along their long axis to provide stability, and accuracy. After entering soft tissue, however, spin stabilisation is overcome and bullets become unstable. They may tumble and tum  through 180 degrees, thus increasing  the surface area of tissue presenting to the forward moving missile. This results in significandy greater tissue damage. If the wound track through tissue is long enough,  all bullets will tumble. As a bullet tumbles, it may become deformed or break up – especially if it contacts  hard, high density bone.

Bullet wounds in the batdefield are generally caused by fully jacketed military ammunition as defined by the Hague Declaration of 1899. The latter prohibited  the use of any “bullet which expands or flattens easily in the human body”. To meet this requirement, bullets  designed for military use are comprised  of lead and steel components clad within a metal jacket. As a result, it has been suggested that designers  of military small arms, ostensibly formulating bullets to prevent flattening deformity of the missile, use alternatives such as bullets which readily fragment in order to cause equivalent tissue effects.

Even if not designed as such, many bullets may nevertheless fragment at close range if they strike bone. The tendency to break-up is governed by the construction of the bullet, principally the thickness of the Jacket and the efficiency of the base in preventing extrusion. The disruption of the bullet into small pieces produces irregular fragments, each with large potential for energy transfer. A temporary cavity around the fragmenting bullet will be associated with multiple diverging  wound tracks. Multiple  lacerations of the tissues surrounding the original wound track are the result. If the victim’s skeleton is damaged  by a missile as well,  the fragmented bone may provide an even larger number of secondary fragments. When scattering bone fragments are combined with  bullet fragmentation, widespread disruption of soft tissues is produced within the vicinity  of the bone – including any adjacent blood vessels, nerves and other soft tissues.

 

BLAST INJURIES  FROM   FUEL-AIR EXPLOSIVES

An explosive  munition, on detonation, produces a transient pressure  that can propagate through the air at an initial  velocity exceeding the speed  of sound It may rupture eardrums and severely bruise  and rupture both the lungs and  other gas tilled organs  (such  as the intestines), leaving no tell-tale external marks  on the victim. Very high  overpressure can also cause  air to be pumped into a victim’s circulation, causing dangerous and often fatal air embolism of the heart  and  cerebral blood vessels. It can also liberate  fragments of debris from the environment that may act as penetrating missiles. Furthermore, the mass of moving  blast wind may forcibly blow the casualty against solid  objects  in the area, thereby  inducing blunt  injury  as well.

A typical Fuel-Air Explosive (FAE) consists of a cylindrical container of a liquid fuel, such  as ethylene oxide or propylene oxide, the walls of which  are scored so that  the container can break apart  in a controlled manner. It also contains a burster charge located at the center,  which extends along  the long axis of the container. When  the burster charge detonates, the contents of the fuel container will be dispersed as a mist-like disk shaped fuel-air  cloud over the ground. It flows around objects such as trees and rocks, and  into structures or field fortification ventilation systems. Next, a small secondary charge ignites the fuel-air  mixture. The vast dimensions of the FAE cloud  ensure  that  the blast effects will occur over a much  wider area than  that affected by any conventional explosive munitions. The FAE blast wave can go around comers, penetrating the apertures in bunkers, the open hatches in armoured fighting vehicles, and  the hollows  of trenches and foxholes. In Afghanistan, such  FAE munitions, labelled vacuum bombs, comprised a significant proportion of the munitions dropped by Soviet aircraft. Since the Vietnam  War, FAE weapons have been improved so that  their blast effects now rival that of a small tactical nuclear  warhead.

OTHER MILITARY SPECIFIC INJURIES

There are other mechanisms of injury  predominandy confined  to the military spectrum. These include bums from napalm, incendiaries, flame munitions, and white phosphorus. Crush injuries  also occur in greater abundance in the military setting. The implications of crush  injury extend  to needed repair of skin, bone, muscle, blood vessels, and nerves, as well as the possibility  of treatment for kidney failure, a common result of this form of trauma. In addition, military inhalation injuries may result. These occur from breathing the byproducts of ammunition and plastics combustion, and inhalation  of particulate metallic aerosols  (such  as “chaff” which may be released to cloud electromagnetic transmissions of attacking  missiles). Other inhalation  injuries  result from the breathing of rocket fuel combustion fumes, and environmental obscurant  agents such as picric acid and anthracene- all common  to the modem batdefield,  with few equivalents in peacetime.

IMPLICATIONS FOR  DELIVERY OF MEDICAL SERVICES

Most peacetime  models and experiences are of limited value when  preparing medical officers for service in the combat setting. Many of the enormous peacetime technical advances in modem  surgery – those which have  transformed  the oudook  for patients born with congenital  abnormalities, or those suffering from such degenerative conditions as arthritis, heart  disease, and cancer – do not have immediate application on the batdefield! The wartime phenomena of large numbers of casualties which  are generated simultaneously, many bearing multiple  wounds and concurrent injuries from the entire spectrum  of militarily unique weapons,  are not ordinarily seen in peacetime medical practice. They differentiate and complicate  casualty management in the military medical field system. As a noted  authority in combat  medical care once noted: “The  practice  of medicine and surgery in peacetime prepares physicians for war as well as police department duty would prepare infantry for combat, or as well as commercial  aviation experience  prepares pilots for close air support in wartime”.2 There are undeniably fundamental differences, oftentimes forgotten, between medical treatment practices in peacetime and  those employed  in war. Indeed,  the very nature of warfare precludes a neat transformation in place from such  successful peacetime models  of healthcare. These are best exemplified  by two contrasting hypothetical examples:

  • In the peacetime setting, a victim of urban violence who sustains a perforating soft tissue wound of the thigh by a 9 mm pistol bullet, is often  rapidly  transferred by emergency  medical services, within minutes, to a civilian  trauma hospital designed  to provide a full spectrum of needed care. Within these centres, in response to multiple demands of such  nature, effective treatment methods have evolved. These efforts are commonly supported by the general availability of teams of multi-disciplinary consulting specialists, buttressed by sophisticated medical imaging  techniques such as CT scanning and  NMR (nuclear magnetic resonance) scans. The most modem broad spectrum antibiotics are often administered within minutes of wounding. Finally, there is access to well staffed intensive care units, where  changes in patients’ conditions can be intensively followed  for days and weeks, often without time limits.
  • A military rifleman, recently  sustaining a similarly located  thigh wound following the nearby explosion of a rocket  propelled  grenade, perhaps complicated by blast injury to his lungs and white phosphorus bums of his torso, lies in a muddy field heavily contaminated with human and animal  wastes elsewhere across the globe.  Because of tactical and logistical limitations, the soldier may have remained  in that muddy field for many  hours before being retrieved, causing his general  condition to worsen, and bacteria  in his wounds to multiply. He may  then be deposited, with a group of other  bleeding  wounded, at a military evacuation hospital which  is so busy that only 5 minutes can be allotted to the immediate care of each  casualty. Subsequently, he may be entered into a protracted evacuation chain entailing temporising increments of treatment. This process may involve multiple transfers and the passage of a significant  amount of time until arrival at a definitive  care facility.

The contrast between the two hypothetical examples is self evident, yet directly relevant  to the unique characteristics of the professional practice  of military  medicine in the operational setting. Indeed, the historical record  readily confirms  that military physicians must  periodically provide their  treatments in such  a setting of physical and logistic austerity as denoted in the second example, and  further carry them out in the incremental or echeloned fashion typical of military  field medical systems. These require medical judgements far removed  from those utilised in peacetime! Unfortunately, military surgeons have traditionally received  their indoctrination to wartime surgery  by “on-the-job training” within the combat zone. In contrast to clinical practices  during peacetime, surgeons have had  to become reoriented to various historically validated special  techniques for rendering rapid but  often only “adequate” care to victims of massive military  wounds and  massive trauma.  US Army surgeon Captain  Richard Hornberger of the 8055th Mobile Army Surgical Hospital  (MASH) in Korea, speaking as Richard Hooker, pseudonymous author of M*A*S*H, provided meaningful perspective on this one phase of reality during the early surgical  reception of combat casualties:

“Meatball surgery is a specialty itself. We are not concerned with  the ultimate reconstruction of the patient.  We are concerned only with  getting  the kid out of here alive enough for someone else to reconstruct him. Up to a point we are concerned with fingers, hands,  arms and legs, but sometimes we deliberately  sacrifice a leg in order  to save a life, if the other  wounds are more important. In fact, now and then we may lose a leg because if we spent  an extra hour  trying to save it, another guy in the preop ward would  die from being  operated on  too late… Our general attitude around here is that we want to play par surgery  on this course. Par is a live patient”3

SUMMARY

Sustainability during combat  operations is a paramount concern of every operational commander. His judgements will often determine whether his war­ fighting concepts and  plans are supportable. Since health  maintenance and casualty management programs are crucial  underpinnings of any operational plan,  the structure and  operation of combat  medical services must  be thoroughly integrated with tactical operations. Therefore, the decision  for a specific form

of supporting activity in any given  manoeuvre, such as medical support, is ultimately the commander’s responsibility!

As a commander weighs the various benefits and tradeoff’s associated  with a combat  casualty support program,  he must  also assess the cost of such support in terms of the competing demands of an essentially logistical function for portions of his offensive assets, as well as their impact upon his tactical mobility. For these decisions, the operational commander is beholden to his medical staff for informed advice. The inherent differences between  wounding agents,  as well as the unique  logistical requirements for management of combat-unique casualties,  within  a setting of austerity and restricted support, must  therefore  be clearly recognised – not only by professional medical authorities, but by the line commanders who depend upon  their counsel and support.
The ground rules for practicing the precepts of combat  medical support differ from those utilised in peacetime military  medical  practices.  It is therefore incumbent upon  medical officers to become well informed resources for their operational counterparts. An understanding of weapons effects is an important facet of that required knowledge base, in order  to facilitate  a functional transition from the procedures and expectations of peacetime  medical practice  to the realities  of combat.

 

Acknowledgements

References

L   Cowdrey AE. The Medics War. The US Anny in the Korean War Series. Vol4. Center of Military History, US Anny; 1987: p87  
  1. Llewellyn CH. Education and training for war surgery: Mil Med 1990; 155:192.
 
  1. Hooker R. "M*A*S*H". New York: Wm. Morrow &: Co; 1968: pl88.