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Data from recent wars indicate that a wounded Marine had a 20% lower risk of dying than an Army soldier. Possible reasons for this difference are (1) Navy care is superior, (2) soldiers sustained more severe wounds, and (3) the services count casualties differently. Injury severity was measured in random samples of Marines and soldiers that were selected from the Wound Data and Munitions Effectiveness Team database. There was no difference in the lethality of injury and the prevalence of lifesaving first aid. Wounded Marines were more likely to wear protective vests, and this decreased Marine mortality in Vietnam. Hospitalized Marines had lower Injury Severity Scores and were less likely to be returned to duty without first being admitted to a medical treatment facility. Lower Marine combat mortality is primarily the result of the fact that a Marine with a minor soft tissue wound was more likely to be hospitalized than was a soldier with a similar injury.

Suspended animation is defined as the therapeutic induction of a state of tolerance to temporary complete systemic ischemia, i.w., protection-preservation of the whole organism during prolonged circulatory arrest ( > or = 1 hr), followed by resuscitation to survival without brain damage. The objectives of suspended animation include: a) helping to save victims of temporarily uncontrollable (internal) traumatic (e.g., combat casualties) or nontraumatic (e.g., ruptured aortic aneurysm) exsanguination, without severe brain trauma, by enabling evacuation and resuscitative surgery during circulatory arrest, followed by delayed resuscitation; b) helping to save some nontraumatic cases of sudden death, seemingly unresuscitable before definite repair; and c) enabling selected (elective) surgical procedures to be performed which are only feasible during a state of no blood flow. In the discussion session, investigators with suspended animation-relevant research interests brainstorm on present knowledge, future research potentials, and the advisability of a major research effort concerning this subject. The following topics are addressed: the epidemiologic facts of sudden death in combat casualties, which require a totally new resuscitative approach; the limits and potentials of reanimation research; complete reversibility of circulatory arrest of 1 hr in dogs under profound hypothermia ( < 10 degrees C), induced and reversed by portable cardiopulmonary bypass; the need for a still elusive pharmacologic or chemical induction of suspended animation in the field; asanguinous profound hypothermic low-flow with cardiopulmonary bypass; electric anesthesia; opiate therapy; lessons learned by hypoxia tolerant vertebrate animals, hibernators, and freeze-tolerant animals (cryobiology); myocardial preservation during open-heart surgery; organ preservation for transplantation; and reperfusion-reoxygenation injury in vital organs, including the roles of nitric oxide and free radicals; and how cells (particularly cerebral neurons) die after transient prolonged ischemia and reperfusion. The majority of authors believe that seeking a breakthrough in suspended animation is not utopian, that ongoing communication between relevant research groups is indicated, and that a coordinated multicenter research effort, basic and applied, on suspended animation is justified.

The medical effects of weapons used in modern conventional warfare are, overwhelmingly, penetrating. Fragments from explosive munitions such as shells, rockets, and grenades are the predominate source of missiles, especially in high-intensity war. Bullets from assault rifles and machine guns cause fewer casualties, except in counterinsurgency operations. The threat from penetrating missiles depends upon the part of the body that is struck and, to a lesser extent, upon the physical characteristics of the missile. The missile's mass and velocity determine its potential to do physical damage, but the extent to which this potential is realized depends upon diverse factors such as shape, construction, and stability. The American experience in the wars of this century indicate that approximately 20%-25% of all casualties died on the battlefield and are therefore classified as killed in action. Approximately 3%-5% die while receiving care, and thus are classified as died of wounds. Wounds of the brain or heart and great vessels are the most common causes of death. Prevention of sepsis in soft-tissue and orthopedic wounds is the major medical treatment problem in survivors. Since it determines the quality and quantity of combat casualty care, the single most important factor determining mortality or morbidity for combat casualties is the tactical situation.

Events such as the Falklands War and naval actions in the Persian Gulf have emphasized the unique nature of battle casualty care on warships. The purpose of this paper is to describe two actions which illustrate the problems that a medical officer may confront when a warship sustains battle damage: that of the USS Franklin in March 1945 and that of the USS Stark in May 1987. Although neither ship was sunk, damage was severe and about one-quarter of each ship's crew became casualties. More than three-quarters of the casualties were killed, death being due to blast, fire and smoke inhalation.

Battle injuries sustained in conventional warfare are more likely to be lethal than are injuries sustained by civilians. Depending on the tactical situation, mortality may range from 20% to more than 80% of all casualties. The American experience indicates that about 90% of the total mortality occurs on the battlefield. Such casualties, those classified as killed in action, die before reaching medical care. More than 90% of all battle injuries (morbidity) are caused by penetrating missiles. Exsanguination from wounds of the heart/great vessels and penetrating/perforating wounds of the skull cause the majority of battlefield deaths. The frequency distribution of injury severity appears to be bimodal. A large peak occurs at low injury severity and indicates a population of casualties with relatively benign soft tissue wounds. A smaller peak at high injury severity represents those killed in action.