Tactical management of urban warfare casualties in special operations

Military Medicine, Apr 2000 by Butler, Frank K Jr

Editor's Summary of Key Points and Research Issues

1. An operation that is planned and initiated as a humanitarian/civic action 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: (1) offer reliable protection from small-arms fire; (2) be hardened as feasible against RPG fire; (3) be able to negotiate roadblocks; and (4) 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 found 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 pre-hospital fluid resuscitation of hemorrhagic shock resulting from penetrating trauma to the chest or abdomen produced a greater mortality than KVO (keep vein open) 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 fluid resuscitated. Alternatives proposed were either an empiric fluid load of 1000 cc of Hespan or providing sufficient fluid to resuscitate the casualty 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.