Tactical Management of Urban Warfare Casualties in
Special Operations
25
October 1999
Editors
Frank K. Butler, Jr
CAPT MC
USN
Director
of Biomedical Research, Naval Special Warfare Command
John H. Hagmann
LTC MC
USA
Medical
Director, Casualty Care Research Center, Uniformed
Services University of the Health Sciences
Transcription Editor
David
T. Richards Ph.D.
Casualty
Care Research Center, Uniformed Services University
of the Health Sciences
Conducted at the 1998 Meeting of the
Special Operations Medical
Association
Tampa, Florida
7 December 1998
Acknowledgement
Special thanks to Mark Bowden, author of Black
Hawk Down. To present an accurate and balanced
account of events that occur in combat is an exceedingly
difficult task, but Mr. Bowden's reporting of the
casualties in this battle was indispensable to the
conduct of this workshop. If we are successful in
our efforts to use the results of this workshop to
improve the care provided to US forces in future conflicts,
part of the credit must go to him.
The opinions and assertions of both the participants
in this workshop and the editors of the workshop proceedings
are theirs alone and do not necessarily reflect the
views of their respective services or the Department
of Defense.
This
workshop was supported by a grant from the U.S. Special
operations Command Medical Technology Development
program (Biomedical R+D Task 11-97.)
Panelists
Lt Col Rob Allen
Lt
Col Allen is an emergency physician currently serving
as the Senior Medical Officer for the 24th Special
Tactics Squadron at the Air Force Special Operations
Command. He is a Flight Surgeon and one of only two
Diving Medical Officers in the Air Force. He is the
head medical officer for Special Operations Pararescue
and has extensive field experience in this area.
CAPT
Frank Butler
CAPT Butler is a Navy
ophthalmologist and diving medical officer. For the
past 10 years, he has been the Director of Biomedical
Research for the Naval Special Warfare Command. CAPT
Butler has served previously as a platoon commander
in the Navy Underwater Demolition and
SEAL (Sea/Air/Land commando) teams. He also
spent 5 years as a Diving Medical Research officer
at the Navy Experimental Diving Unit. CAPT Butler
was the Chief of Ophthalmology at the Naval Hospital
Pensacola before assuming his current duties at the
Naval Special Warfare Command. He also serves as an
ophthalmic consultant to the Divers Alert Network.
Dr. Howard R. Champion
Dr.
Howard Champion is the Director of the Research Program
in Trauma at the University of Maryland in Baltimore.
He is also Professor of Surgery, Senior Advisor in
Trauma, and Professor of Military and Emergency Medicine
at the Uniformed Services University of the Health
Sciences in Bethesda, Maryland. Dr. Champion is an
internationally recognized trauma surgeon, critical
care specialist, educator, and author. Dr. Champion
has written over 200 reviewed articles and book chapters
and serves on the editorial board and as a consultant
reviewer for numerous medical publications. Dr. Champion
was one of the first Trauma Fellows at the Maryland
Institute for Emergency Medical Services Systems (MIEMSS)
in 1972 and subsequently became the Assistant Clinical
Director of MIEMSS. He directed and developed the
Surgical Critical Care and Trauma Services at the
Washington Hospital Center, the MEDSTAR Trauma Unit,
and the MEDSTAR Helicopter Program, as well as the
Trauma Surgical Training Program for military residents
and fellows. Dr. Champion is a Fellow of the Royal
College of Surgeons of Edinburgh, the American College
of Surgeons, and the American Association for the
Surgery of Trauma. He has served on the Board of Managers
of the American Association for Surgery and the Executive
Committee of the American College of Surgeons Committee
on Trauma.
LTC Cliff Cloonan
Dr.
Cloonan is a former Special Forces 18 Delta medic.
He is also a registered nurse and an emergency medicine
physician. LTC Cloonan is currently the Dean of the
Joint Special Operations Medical Training Center
LTC John Hagmann
Lt Col
Hagmann is an emergency physician who is currently
the Medical Director of the Casualty Care Research
Center at the Uniformed Services University of the
Health Sciences in Bethesda, Maryland. He has extensive
experience in providing medical support and training
to various Special Operations and federal law enforcement
organizations.
LTC John Holcomb
LTC
John Holcomb is an Army general surgeon with a special
interest in trauma. He has deployed numerous times
with Special Operations forces as a trauma surgeon.
He was formerly the Chief of Military Trauma Research
at the Army Institute for Surgical Research in San
Antonio and is now the Military Director of the Tri-Service
Trauma Training Program at Ben Taub in Houston. LTC
Holcomb was one of two trauma surgeons in Mogadishu
during the time of the Battle of the Black Sea and
performed life-saving surgical procedures for 36 consecutive
hours after the engagement.
Dr. Craig H. Llewellyn
Dr.
Llewellyn is a preventive medicine specialist with
vast experience in Special Operations medicine. He
is the immediate Past President of the Special Operations
Medical Association. During his 24 years of active
duty in the Army he served as the Group Surgeon with
the 5th Special Forces Group in Vietnam. COL Llewellyn
was also the Manager of the Combat Casualty Care Research
Program for the Army Surgeon General, the Commander
of the U.S. Army Biomedical Laboratory at the Aberdeen
Proving Ground, and the Commandant of Students at
the Uniformed Services University of the Health Sciences.
He is currently Professor and Chairman of the Department
of Military and Emergency Medicine at the Uniformed
Services University of the Health Sciences.
CPT Robert Mabry
CPT Bob Mabry enlisted in the United States
Army after graduating from high school in 1984. His
first three years of service were spent as a machine
gunner and infantry team leader in the 3rd Ranger
Battalion. In 1987, he attended the Special Forces
Qualification Course and spent the next 8 years at
Fort Bragg, North Carolina as a Special Forces medic.
In 1995, he completed his medical school pre-requisites
and was accepted into the Uniformed Services University
of the Health Sciences School of Medicine in Bethesda,
Maryland. CPT Mabry graduated from medical school
in May of 1999 and is currently an intern at Brooke
Army Medical Center in San Antonio, Texas. Cpt Mabry
was a participant in the Battle of Mogadishu.
Dr. Norman McSwain
Dr.
Norman McSwain is a Professor of Surgery at Tulane
University and a retired U.S. Navy Captain. He served
for 2 years in Vietnam with the U.S. Air Force and
deployed on the hospital ship Comfort during Operation
Desert Storm. Dr. McSwain was the first Chairman of
the Advanced Trauma Life Support subcommittee of the
American College of Surgeons Committee on Trauma.
He was the founding physician of the Prehospital Trauma
Life Support (PHTLS) Committee and still serves as
the Editor of the PHTLS Manual. Dr. McSwain is internationally
known for his expertise and research accomplishments
in the field of trauma management and is the author
of 20 books, over 300 peer-reviewed articles and 90
book chapters in that field.
RADM (sel) Eric Olson
RADM
(sel) Eric Olson graduated from the U.S. Naval Academy
in 1973. He graduated from Basic Underwater Demolition/SEAL
Training as the Honor Man in Class 76 and has been
a qualified SEAL operator since 1974. He has served
as both the Executive Officer and the Commanding Officer
of SEAL Delivery Team One. He has also commanded Special
Boat Squadron Two and the Naval Special Warfare Development
Group. RADM (sel) Olson saw combat action in Desert
Storm and was decorated by the President for his action
as a participant in the Battle of Mogadishu. He was
the Chief of Staff of the Joint Special Operations
Command at the time of the workshop, but has since
been selected for promotion to Rear Admiral and to
serve as the Commander of the Naval Special Warfare
Command.
Dr. Edward Otten:
Dr. Otten is a Professor of Emergency Medicine
and Pediatrics at the University of Cincinnati College
of Medicine and Director of the Division of Toxicology.
He is the current President of the Wilderness Medical
Society. Dr. Otten served as a medic with the US Army
in Vietnam and is now a Captain in the Naval Reserve.
He has extensive experience serving with Marine Corps
and Special Operations units, including: Naval Special
Warfare Group Two in Little Creek, Virginia; the second
Special Operations Training Group in Okinawa, Japan;
the 10th Special Forces Group in Fort Devens, Massachusetts;
and the Second Force Recon in Camp Lejeune, California.
LCDR Jeff Timby
Dr.
Timby is triple-boarded in Internal Medicine, Pulmonary
Medicine and Critical Care Medicine. He is currently
Chief of the Department of Internal Medicine and Director
of the Intensive Care Unit at the Naval Hospital,
Pensacola. Dr. Timby spent 4 years as a Critical Care
Consultant at the Intensive Care Unit at Memorial
Medical Center, a Level One Trauma Center in Savannah,
Georgia.
Dr. Ken Zafren
Dr.
Zafren is an emergency medicine physician in Anchorage,
Alaska. He was the Co-Chairman of the Tactical Management
of Wilderness Casualties in Special Operations Workshop
conducted in 1997 by the Wilderness Medical Society.
He is a past member of the Wilderness Medical Society
Board of Directors.
He is the Medical Director for the Denali National
Park Mountaineering Rangers and is the Associate Medical
Director (North America) for the Himalayan Rescue
Association. Dr. Zafren is also the U.S. representative
on the International Commission for Alpine Emergency
Medicine.
Table Of Contents
Panelists...............
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Table
Of Contents...............
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Editor’s
Summary of Key Points and Research Issues.
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Introduction.....
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Overview
OF THE BATTLE OF MOGADISHU
19
Scenario
1 - Fast Rope Casualty during Assault.....
25
MANAGEMENT
PLAN....................
27
DISCUSSION..............
29
Scenario
2 – First Helicopter Crash.........
33
MANAGEMENT
PLAN....................
34
DISCUSSION..............
38
Scenario
3 – Second Helicopter Crash.........
39
MANAGEMENT
PLAN....................
41
DISCUSSION..............
46
Scenario
4 – RPG Explosion in Vehicle......
48
MANAGEMENT
PLAN....................
49
DISCUSSION..............
54
Scenario
5 – First Assault Team Rescue Element Casualties
58
MANAGEMENT
PLAN....................
59
DISCUSSION..............
62
Scenario
6 – Second Assault Team Rescue Element Casualties
66
MANAGEMENT
PLAN....................
66
DISCUSSION..............
71
Scenario
7 – Helicopter Hit by RPG Round.........
76
MANAGEMENT
PLAN....................
76
DISCUSSION..............
80
Scenario
8 – QRF Casualty in an Exposed Location..
82
DISCUSSION..............
89
Scenario
9 – Chest Wound in the Rescue Convoy......
93
MANAGEMENT
PLAN....................
93
DISCUSSION..............
97
Concluding
Remarks......................
103
Editor’s Summary of Key Points
and Research Issues
1.
An operation that is planned and initiated as humanitarian/civic
mission may rapidly evolve into a combat action.
2.
Many of the decisions regarding the management
of casualties in Mogadishu had important tactical
implications. Instruction in tactical medicine should
be added to training courses for small-unit mission
commanders and their senior enlisted leadership.
3.
Helicopter evacuation of casualties in Mogadishu
was not feasible because of the threat of RPG fire
and a lack of adequate landing zones due to the narrow
streets. Vehicle evacuation was difficult because
of roadblocks, ambushes, and RPG fire. A specialized
vehicle is needed to evacuate casualties from urban
environments. This vehicle must:
a. Offer reliable protection from small-arms
fire.
b. Be hardened as feasible against RPG fire.
c. Be able to negotiate roadblocks
d. Be able to provide fire support for the
casualties and rescuers.
The
Israeli Merkava vehicle was suggested as being possibly
suitable for this task, but other armored vehicles
might suffice as well.
4.
The number of hostile combatants can increase
very quickly in the urban environment as a result
of recruitment from the urban population. In addition,
fire and maneuver is difficult for ground forces with
casualties. These two factors may result in overrun
situations for friendly units sustaining casualties,
with the entire unit being killed or captured as a
result. Fixed-wing air gunfire support is essential
if successful evacuation of casualties is to be reliably
accomplished in the urban environment.
5.
There was a prolonged (15 hour) delay to evacuation
for most of the casualties injured in Mogadishu. Plans
for managing combat trauma on the battlefield should
take the probability of such delays into account.
6.
The Ben Taub study found that aggressive prehospital
fluid resuscitation of hemorrhagic shock resulting
from penetrating trauma to the chest or abdomen produced
a greater mortality than KVO fluids only. There was,
however, a clear consensus in the panel that should
a casualty with uncontrolled hemorrhage have mental
status changes or become unconscious (blood pressure
of 50 systolic or less), he should be given enough
fluid to resuscitate him to the point where his mentation
improves (systolic blood pressure of 70 or above.)
Additional animal research is needed to optimize fluid
resuscitation strategy in this circumstance. Panel
members stressed the importance of not trying to aggressively
administer IV fluids with the goal of achieving "normal"
blood pressure in casualties with penetrating truncal
injuries.
7.
Optimum care of casualties may be in direct
conflict with maximum prosecution of the mission in
the urban warfare environment. The impact of delays
to evacuation on the expected outcome of specific
injuries is a critical element of information for
small-unit commanders responsible for making tactical
decisions after casualties have been sustained by
his unit. This should be addressed as a high-priority
research effort.
8.
Several casualties died as a result of hemorrhage
from superficial but
non-extremity bleeding sites where tourniquets
could not be used. Attempts to maintain direct pressure
on a hemorrhage site may be complicated by multiple
bleeding sites and/or the need to return fire. A hemostatic
dressing such as that now being developed by the Army
Medical Research and Materiel Command would be an
invaluable asset in such cases and is the best chance
that such casualties have for survival. This project
should be a top priority for research and procurement
funding.
9.
The prolonged (15 hour) delay to evacuation
for most of the casualties in Mogadishu serves to
emphasize that the results of civilian prehospital
fluid resuscitation studies (in which the delay to
arrival at the hospital is usually 15 minutes or less)
may not be applicable to the combat environment.
10.
Treatment of casualties on SOF missions involves
a combination of good medicine and good tactics. Controlled,
prospective human studies that address the entire
spectrum of issues peculiar to battlefield trauma
care are not likely to ever be accomplished. Optimum
guidance for combat medical personnel on these issues
will require a combination of combat-appropriate animal
studies and consensus opinion from focused expert
consideration of these issues. In general, interventions
of questionable value should not be undertaken when
they entail significant additional risk to mission
personnel or the mission itself.
11.
The femoral artery bleeding described in Scenario
7 was stopped with an improvised tourniquet. Many
SOF operators are unhappy with the U.S. military standard
issue tourniquets and stressed the need for improvements
which can be put on one-handed and which can reliably
stop arterial bleeding. This should be a top priority
for research funding.
12.
Hespan has the potential advantage of being
retained in the intravascular space longer than Lactated
Ringer's. A majority of the panel felt that Hespan
is a better choice than Lactated Ringers for the treatment
of hypovolemic shock resulting from controlled hemorrhage
in combat casualties who may experience delays to
surgery beyond those seen in civilian trauma studies.
13.
The participants in the Mogadishu action were
in the field for up to 15 hours in almost 100 degree
heat with only two canteens (2 quarts) of water, adding
dehydration as a significant stressor in this operation.
The impact of this level of dehydration on the management
of hypovolemic shock has not been not well studied.
Additional research is needed in this area.
14.
Although Hespan has the potential advantage
of being better retained in the intravascular space,
Lactated Ringer's wider distribution might make it
a better choice than or a necessary addition to Hespan
in patients who are both dehydrated and suffering
from hemorrhagic shock. Additional animal research
is needed in this area.
15.
The best bet for improvement in prehospital
fluid alternatives for combat casualties was felt
to be a hypertonic saline/colloid combination. Continued
efforts to obtain FDA approval for this type of fluid
should be undertaken. Additional animal research is
needed to evaluate the efficacy of these solutions
as compared to Lactated Ringers, normal saline, hypertonic
saline and Hespan. These studies should address the
delayed surgery and dehydration that will often be
present in combat and should use both controlled and
uncontrolled hemorrhage models.
16.
Casualties who are unconscious from falls may
have both a closed-head injury and bleeding from intrathoracic
or intra-abdominal injuries. The optimum fluid resuscitation
strategy for these patients has not been determined.
Hespan offers a theoretical advantage in these patients
in that it is retained in the intravascular space
and may contribute less to cerebral edema than crystalloids.
The importance of maintaining cerebral perfusion pressure
(avoiding hypotension) in casualties with closed-head
injuries was emphasized.
17.
Not all individuals injured in combat need
IV fluid resuscitation. Combat medical personnel should
not generally initiate fluid resuscitation in individuals
who are not in shock in order to: (1) minimize interference
with combatants who can continue to participate in
the engagement; (2) conserve limited IV fluid supplies;
and (3) attend to casualties with more severe wounds.
All significantly injured patients should, however,
have a saline lock started when tactically feasible
in anticipation of the possible need for subsequent
IV fluids, analgesia, or antibiotics.
18.
Even with optimal care in civilian trauma centers,
trauma patients who present with systolic blood pressures
below 90 mmHg as a result of trauma have a survival
rate of only approximately 50%. The presence of hemorrhagic
shock on the battlefield is a grave prognostic sign.
19.
The prolonged delay to surgery in Mogadishu
and the reported high incidence of subsequent infectious
complications emphasizes the need for antibiotics
to be administered to casualties as soon as possible.
Cefoxitin was felt to be a good choice by the panel,
although ceftriaxone was suggested as an alternative.
Ceftriaxone was noted to be more expensive and to
have a narrower range of antibiotic coverage than
cefoxitin, but it does offer the advantage of once-a-day
dosing in prolonged
evacuation situations.
20.
The antibiotic coverage and absorption after
oral dosing of the fluoroquinolones is excellent.
Use of a fluoroquinolone taken by mouth with a small
amount of water in a combat setting may be helpful
in reducing combat medical equipment weight and treatment
complexity. Animal research is needed in this area.
21.
Preliminary research data in a pig model from
the U.S. Army Institute of Surgical Research has shown
that needle thoracostomy with a 14-gauge needle is
as successful as a chest tube in relieving a tension
pneumothorax and that the therapeutic benefit persists
for at least four hours.
22.
If a casualty has a chest wound, but is having
no severe or increasing difficulty with his breathing,
there is no need to do either a needle thoracostomy
or to insert a chest tube emergently. The theoretical
advantage of expediting hemostasis in lung parenchymal
wounds will not be realized unless suction is applied
to the chest tube. This type of suction is not available
on the battlefield. Use of a chest tube without suction
has been shown in animal studies at the Army Institute
of Surgical Research to be unsuccessful in re-expanding
lungs with a pneumothorax following penetrating chest
trauma.
23.
If a casualty has a chest wound, and develops
increasingly severe respiratory difficulty, needle
thoracostomy should be performed. If this is not successful
in relieving the respiratory distress, there are additional
measures that may be considered: (1) inserting a second
needle at the 5th intercostal space at the anterior
axillary line on the wounded side of the chest; (2)
inserting a chest tube in the injured side of the
chest; (3) simply making a chest-tube sized hole in
the chest if the corpsman, PJ, or medic is not carrying
a chest tube; or (4) inserting a needle on the other
side of the chest if the clinical findings suggest
a contralateral tension pneumothorax.
24.
The patency of a needle or catheter inserted
to relieve a tension pneumothorax can be checked by
observing the attached Heimlich valve for the passage
of air. If air is seen to be moving through the valve,
then it may be assumed to be functioning.
25.
Multiple panel members noted that they routinely
give up to 20 mg of morphine IV to myocardial infarction
patients in the Emergency Department without producing
respiratory depression or marked mental status changes.
26.
The fire provided by casualties whose wounds
are relatively minor may be very important in maintaining
fire superiority, but there are a number of reasons
that combat casualties might have an altered mental
status. Among these are stress or panic reactions
to the wound, a head injury, hemorrhagic shock, and
analgesic medications. Casualties who have an altered
state of consciousness from any cause should be disarmed
immediately. The decision regarding disarming casualties
must be individualized for each casualty and situation.
Training in this aspect of tactical decision making
should be added to combat medical training programs
for both combat medical personnel and small-unit leaders.
27.
SOF combat medical personnel who carry morphine
should also carry naloxone and be trained in its use.
28.
The armored floor mats from the helicopter
at the first crash site were removed from the aircraft
and used to provide cover for the crew and the CSAR
team. This is an excellent innovation and should be
incorporated into training for all individuals who
might be rendering assistance at helicopter crash
sites in a combat environment in the future.
29.
Where transportation for evacuation or maneuvering
is not readily available, the urban environment may
provide many vehicles of opportunity that can be commandeered.
Training and appropriate technology to take advantage
of these opportunities should be provided.
30.
At the two helicopter crash sites, there were
large numbers of hostiles who converged on the crash
sites, knowing that the crew was injured and vulnerable.
Improved area denial techniques need to be identified
or developed for this type of situation in the future.
These area denial techniques must be designed to keep
hostile forces out but allow access to friendly rescuing
forces.
31.
Non-lethal technologies designed to incapacitate
an enemy but not result in fatalities are often suggested
as being useful in urban warfare environments. Given
the cost and the complexity of employing such weapons
rapidly when needed in urban warfare, forces may be
better served by increased carriage and application
of conventional ordnance.
32.
Currently only Combat Search and Rescue Teams
carry equipment designed to free casualties trapped
in airframes after crashes. This equipment may need
to be used by other groups in the absence of the CSAR
team. Positioning this equipment in aircraft or vehicles
or making it available through other means is necessary
if future casualty scenarios that entail trapped crash
or wreck victims are to be managed effectively.
33.
When a rescuer is approaching a helicopter
crash site, he should take the following steps: (1)
immediately assess for the possibility of fire or
explosion; (2) be aware of the possibility of ambush
or booby traps if the crash site may have been under
hostile control; (3) attempt to establish verbal communications
with survivors before approaching the crash so that
they will not mistake rescuers for hostile forces;
and (4) establish crash site security before beginning
rescue attempts.
34.
There were two dead pilots trapped inside the
first helicopter crash. It was extremely difficult
to remove them from the wreckage, causing a delay
in tactical maneuvering. Current Special Operations
doctrine dictates that neither the wounded nor the
dead are to be left behind. How do we deal with the
next fatalities trapped in a crashed helicopter? If
immediate evacuation had been available, should everyone
have been evacuated, everyone have stayed, or something
in between?
35.
Providing adequate gunfire support in Mogadishu
was problematic because of the presence of buildings
that provided cover adequate to protect hostile forces
from 7.62 caliber fire. Future urban warfare gunfire
support plans should incorporate provision for weapons
capable of building penetration.
36. Traditional
triage considerations may need to be rethought for
in-flight aircraft casualty scenarios. Scenario 7
contained an aircraft with two severely injured individuals,
a runaway minigun, and a dazed pilot. The panel member
discussing this scenario pointed out that the primary
consideration in managing in-flight aviation casualties
should be to ensure that the aircraft remains in the
air, even though this might entail treating even relatively
lesser injuries in the pilot before attending to other
crew or passenger injuries.
37.
Tactical medicine should be taught to all pilots
and aircrew members so that they can deal most effectively
with injuries sustained while in flight.
38.
If an aircraft is disabled, has casualties
aboard, and must make an emergency landing, the immediate
action should be to arrange for the CSAR aircraft
or any other aircraft that might be available to land
in a nearby location. After an emergent transfer of
personnel, the second helicopter should destroy the
disabled aircraft, if possible, before departing.
39.
If an aircraft is disabled, has casualties
aboard, and is about to make an emergency landing,
it is generally more important to ensure that all
personnel, including the casualties, are prepared
for a crash landing than to render medical care.
40.
If a pilot is injured and in significant pain,
the potential detrimental effects of narcotic analgesic
medications must be weighed against those resulting
from the pain. Intravenous or intramuscular ketorolac
might be a good alternative in this scenario despite
its potential adverse affects on platelet function.
Another possibility is simply to withhold analgesic
medications until after the aircraft has landed.
41.
Urban warfare casualties should generally be
moved to the best tactical location as quickly as
possible before treatment for their injuries is undertaken.
42.
Urban warfare may result in blunt trauma casualties
from fast-rope injuries, falls, and motor vehicle
accidents. Casualties with possible spinal cord injuries
from these mechanisms may need to be moved to cover
before long spine boards and C-collars are available.
Improvised spine boards may be fashioned from doors
or other available materials. If these subs
