Minimising Losses and Casualties

Modern First Aid Harp Kit

In the light of the available data and the studies carried out by scientists, ballistic helmets and vests protecting the head and chest areas where there are more injuries have started to be used in the armed forces. However, it is necessary to stop the bleeding of the wounded as soon as possible after the basic first aid procedures necessary to reduce the loss rate in injuries where existing protective mechanisms are ineffective. For this reason, some of the recognised products available worldwide are listed in the table below.

(Bkz: CELOX)

In order to adapt to changing combat environments, there has been a great increase in biomedical research to develop better haemostatic plugs (bleeding stoppers). An ideal haemostat: It should be effective, easy to use, reliable, anti-bacterial, anti-microbial, anti-fungal, have the highest logistic capability, be durable, have labels that can be read by night vision systems in special operations, do not create heat when used, do not allow re-bleeding and do not cause pain to the wounded. The use of effective haemostatic plugs is of great benefit in many combat wounds (whether life-threatening or not) because more effective control of bleeding is the first step in saving lives, and an appropriate haemostatic plug should be able to combat infection of the wound site.

The raw material of such new biotechnological haemostatic plugs is chitosan obtained from chitin. Chitin is the most abundant natural polymer in the world after cellulose and is found in the shells of arthropods such as crabs, shrimps, lobsters and in the cell walls of some bacteria and fungi. The haemostatic properties of chitosan, which is obtained by deacetylation of the biopolymer chitin poly-N-acetyl-D-glucosamine, are completely independent of the body coagulation mechanism, biologically accepted by the body, antibacterial, antifungal, antimicrobial, polyelectrolytic structure and controlled release of drugs into the body. At the same time, chitosan is a biopolymer that helps healing in terms of wound care. In current scientific research, it has formed a clot that does not re-bleed for at least 2 hours in 4.4 mm aortic bleeding models.

1. Depending on the manufacturing technique used for the product’s mechanisms, such as nano-technology production:
2. Osmotic flow filtration,
3. Cationic binding capability, meaning its positively charged molecular structure attaches to negatively charged electric fields of filtered red blood cells like a magnetic catalyst,
4. Activating platelets and forming fibrin clots (beta chitosan) rapidly,
5. Aiding in the rapid cessation of bleeding in arteries, arterioles, capillaries, venules, and veins,
6. Effective clotting in the absence of clotting factors,
7. Assisting in rapid clot formation in patients using blood thinners.

Areas of Use:

• In all kinds of GNH (Close Quarter Battle) operations conducted in urban and rural areas,
• In all types of armed deep operations carried out by Special Forces units (especially due to ease of use and lack of pain during application, which is important for operational secrecy),
• In combat, mine and explosive ordnance disposal teams in conflict areas,
• For explosive ordnance disposal teams assigned to firing ranges,
• In border outposts where emergency response capabilities are limited, in remote J. outposts, and in independently operating units,
• At all checkpoints,
• In the first aid kits of all vehicles on duty,
• In medical units,
• In personnel of the Kıt’a unit responsible for providing initial aid,
• In infirmaries on sea voyages,
• In patrol and control vehicles of all types,
• For personnel performing technical duties on all types of aircraft,
• In search and rescue operations,
• In all search and rescue teams.
• In natural disaster relief missions,
• In intelligence teams.

Level to be used:

• Single Private; can be carried in War Packs, pockets, backpacks. (Can be added to Single Private equipment.)
• As many packs per Manga/Time/Item –
• In healthcare units, especially in First Aid Units and emergency services,
• No additional measures or special storage are required for packages.
• No special or additional training is required for use. (It is a product that can be used by any personnel without the need for medical knowledge.)
• The product can be used in all types of weather/atmospheric conditions, including moist and wet environments.
• It should have a minimum shelf life of 3 years and should be storable in specified quantities as a Combat Load, with its original packaging.
• It should not be affected by harsh storage conditions and should be storable in hot, cold, and humid environments.
• Packages should have readable labels for night vision equipment.
• Packages should not tear with shock, cutting tools, or blunt impacts.

Characteristics of the Hemostatic Plug:

• Should not produce heat
• Should provide definite results in patients using blood thinners
• Should provide results in hypothermic patients
• Should not have placement issues
• Should rapidly clot in arterial and venous main vessels (arterial/venous) and should not allow re-bleeding
• Should not cause pain during use
• Should not create additional irritation or damage to the wound site
• Should not require additional measures during use
• Should be easy to clean after use on the trauma site
• Should have packaging that is easy to open
• Should be easily applicable by one person to others and themselves
• Should be easily cleanable from wounds
• Should have no side effects, be biocompatible, and not cause allergic reactions
• Should create an antimicrobial, antibacterial, and antifungal environment in the trauma area to minimize infection

Result:

A significant number of casualties on the battlefield occur before medical intervention. First Aid in case of injuries is firstly the responsibility of the Soldier himself, and then the duty and humanitarian responsibility of the Tk./Bl. K., that is to say, the duty and humanitarian responsibility of the people in the battle/conflict field itself. In the group of casualties in combat, there may be internal bleeding (chest, abdominal cavity) or in the extremities (suitable for the use of haemostats and/or tourniquets). Theoretically, extremities can be controlled by compression, but the reality is somewhat different. When trauma occurs in an artery/vein, the bleeding is so rapid and intense that the casualty often dies before help can arrive due to the trauma death cycle of hypovolemia, hypothermia and metabolic acidosis.

For this reason, in the current asymmetric combat conditions, the scientific conclusion reached with the use of haemostatic plugs and their use, which is an indispensable element of the modern first aid warfare kit, is: ‘Stopping bleeding in small and medium-sized arteries and veins in injury areas where tourniquet use is not possible, especially in the groin, back, hip and armpit areas, and reducing bleeding in large-sized (groin) arteries and veins22 provides life-saving. The inclusion of new biotechnology products such as haemostatic plugs in the war bag will bring material and moral success to our country in the current environment. Due to the fact that all casualties are caused by haemorrhage, indispensable materials in the War Packs:

1. Haemostatic Plug – THE FASTEST STOPPER
2. Modern combat tourniquet that can be applied with one hand in 10 seconds, for example: NSN 6515015217976
3. For example, 200% elastic emergency trauma bandage for head, limb, abdomen, chest and back injuries with special compress pads for explosive and ballistic entry/exit, made of medical cotton: NATO Stock number 651031162452
4. For open chest trauma, for example, an adhesive-strap film: NSN 6510015490939
5. Vacuumed gauze swabs
6. Trauma intervention reference scheme,
7. Aluminium splints (finger and limb) for example: NSN 6515014941951 and 6515015215730
8. Self-adhesive bandage, safety pin, 1 metre thin thread
9. Apparatus for opening the airway, IV sets and resuscitation fluids and medicines (for advanced cases)

Combat Injuries

The fate of the injured is in the hands of the first responder with a tampon. Dr. Nicholas Senn (1844-1908)

Losses due to uncontrollable haemorrhage reduce troop morale and have a profound impact on the armed forces, society and families. For example, one of the most important factors for the psychological trauma known as post-traumatic stress syndrome (PTSD) is losing a comrade in arms without being able to do anything. This was easily observed in both operations carried out by the Turkish Armed Forces in 1974.

• During the First Operation, a soldier from my company was shot in the head with a long-barreled gun during the attack in the direction of Kyrenia coastal defence from the White House in the Five Fingers Mountain Range in Cyprus. Since there was no medical team in my unit, I intervened myself. I intervened by taking out tampons from more than one harp pack in the harp bag I had with me, but I could not stop the bleeding. He was martyred at the front due to blood loss in the position we were in, screaming in my lap until the morning (I still hear his last words and screams in my dreams).
• In the direction of the White House Finnish Camp, Pastor’s Mansion, Kyrenia, a commando corporal in my company was shot in the crotch and his medium-sized veins were torn. I used the tampons I took from a few war bags, but I could not stop the bleeding. Since the incident happened during the attack, I had to leave the wounded. Since it was not possible to change my uniform, I carried his blood on me for 2 months.
• During the 2nd Peace Operation, I was assigned as the commander of the 2nd parachute battalion’s vanguard company in the offensive from the south of Kanlı Dere in the direction of Nicosia-Tymbou-Vatili-Lysi-Kondea-Paşaköy. I was assigned the task of taking the back security of the Ankara Tank Demonstration Regiment. With the offensive, 1 tank exploded by hitting a mine in the passage between Nicosia and Kanlı Dere. A tank non-commissioned officer’s arm was severed and he was running in my direction, holding it like a sword, shouting ‘Allah Allah Allah’. I caught him, after saving him from the psychological shock he was in, I used the tampons in the combat pack and made a tourniquet with the sleeve of his uniform. However, I could not stop the bleeding. We continued the offensive and I do not know the fate of the non-commissioned officer.

In the asymmetric warfare and GNH conditions of the current era, it is known that snipers, sabotage, mines and hot contact are among the threats to which troops in entrenched formations will be exposed. For example, an attack by a specially trained five-man team can cause unexpected losses and casualties. If this team attacks with heavy machine guns, rocket launchers or LAW weapons and sniper rifles, the casualties caused are high. At the end of the attack, the unit may lose hours to secure the perimeter. In this situation, it takes time for the nearest helicopter ambulance to arrive for initial damage assessment and triage. If the landing safety of the arriving helicopters is not ensured, casualties increase rapidly during the waiting time in the air. When we analyse the scientific studies on this subject, we obtain the following results. One of the most important elements in the combat or operational planning phase is the analysis of the risks that soldiers may be exposed to. Among these risks, the element that requires the most comprehensive planning is the knowledge of the variables required to minimise losses. To summarise briefly, the effect of the weapons to be exposed to, the cause of the injuries, their distribution on the body, the level of danger, the material and technical knowledge of the elements that can provide first aid, their competence in cases where evacuation will take a long time in a conflict environment, and the establishment of transfer channels to a hospital with advanced medical facilities or to appropriate field hospitals. The armed forces of developed countries carry out intensive studies on this subject.

When the data obtained are compared with the information of previous and potential battles, the results obtained help to take detailed measures to minimise casualties and casualties, to plan logistic support and to increase the effectiveness of the applications.

The most important of these studies, WDMET (Wound Data and Munitions Effectiveness Team) started with the recording of 7898 cases of casualty and wounded statistics obtained from 3000 conflicts in 1965-67. These records covered only 4-5 per cent of the total casualties and losses of the US army. Later, by combining with the data banks of the British and Israeli armed forces and adding the US operations in Somalia and Panama, more than 4100 contemporary combat casualty statistics were created. Since then, all armies and military medical scientists have been working intensively to collect and analyse existing cases. In our country, this work is carried out within GATA. In order to approach the subject from a scientific perspective, it is essential to analyse the models obtained from the available statistics. With the WDMET data, it is known that the most detailed statistical studies available on combat casualties, injury models and how to minimise losses if the wounds are treated in the most effective way are carried out. In the light of these models, the armed forces of developed countries have provided full military medical response logistics (well-equipped field hospitals, response levels, transport systems, rehabilitation services, etc.), which constitute one of the pillars of the logistical preparations they make before the operation, and first aid training on a continental basis and the simplest, fastest and most effective use of materials in the first response. Looking briefly at the concept of combat injuries and casualties with WDMET data, it is useful to recall that D. D. Trunkey’s 1983 report on accidents and fatalities to civilians analysed deaths in the first hour, early (2-3 hours later) and late (several weeks after injury). Scientific observations of accidents involving civilians show that 50 per cent of deaths occur in the first hour, 30 per cent in the early hours and 20 per cent in the late hours. In the light of this distribution of injuries and deaths, the ‘Golden Hour’ concept has gained importance and has been accepted by the emergency medicine departments of almost all countries of the world. For this reason, it is known that how soon the ambulance services arrive at the scene of the incident and the correct and effective intervention they make to the injured is more important than the injured who is delivered to a full-fledged hospital hours later. However, the injury model is a very important issue in this study. The fact that the wound model of the civilian population examined later increased from blunt wounds to penetrating wounds, and that 80-90% of the wounded exited in the first 5 minutes in all injuries actually determined that the ‘Golden Hour’ concept is the ‘Golden First 5 Minutes’10: For this reason, WDMET data shows how many wounded can be saved by performing the first intervention in the first 5 minutes in the field of military medicine today. (Fig 1)

Fig. 1. %70 of the total casualties are lost in the first 5 minutes and %85 of the total casualties are lost in the first 30 minutes.

In this context, the scientific approach did not neglect to categorise the causes of death on the battlefield. At the same time, in the study published by Arnold and Cutting11 , when we analyse the pathophysiology of the deaths of the wounded in the WDMET data, the most common cause of death is bleeding (Fig.2). In addition, studies on the mechanism of injury (Fig.3) show the characteristics of the Vietnam War.

Fig.2 Causes of loss, CNS refers to the destruction of the central nervous system and the second CNS refers to deaths occurring after the wound. Shock is also a condition caused by bleeding that cannot be stopped after medical intervention.

When analysed in itself, 20% of the above-mentioned deaths from haemorrhage are arterial/vein ruptures. If appropriate first aid was given on time, many of them could have been saved. In addition, according to WDMET data, although no bleeding shock was observed in the hospital, 10% of the injured group was found to be in bleeding shock at the first hospital admissions. The remaining 80 per cent were injured in about 10 different anatomical regions and lived for about 10 minutes. The assistance that can be provided to these injured people is based on stabilisation with advanced first aid and keeping the metabolism stable until surgical intervention with advanced biotechnology-based systems.

Fig 3. Mechanisms of Injury

Combat Injuries – 2

In today’s asymmetric warfare, these injury data show percentage changes between fragmentation and projectile wounds. In Lebanese urban warfare, there has been a %36 reduction in projectile wounds and a %57 reduction in shrapnel wounds. Deaths due to hemorrhage increased from %41 to 56. Scientific studies on the subject, which have been conducted and are being conducted, show the following table when analyzed in terms of the percentage distribution of injuries to the body:

* Flesh and back wounds, fragmentation wounds are not included
+ Multiple traumas
**80% fragmentation injuries, between 1-45 and an average of 9

Generally, conventional combat injuries from small fragmentation weapons are most commonly observed in the limbs. In the above ratios, it is evident that the highest number of injuries have consistently been concentrated in the head and limbs throughout the history of World Warfare. Moreover, due to the asymmetric threat, the injury patterns caused by threat elements are increasing in favour of haemorrhagic injuries. In areas such as Ireland, Somalia and Iraq, where urban conflicts and terrorist incidents occur, the number of deaths from unstoppable bleeding has almost doubled compared to more conventional wars such as Korea and Vietnam. Among these injuries, mines, remote-controlled mines and booby-trapped explosives are more common according to today’s combat characteristics. Especially anti-personnel mines, the most common ones are fragmentation mines, pressure mines, bouncing mines and mines placed by remote launching. In addition, explosives made of all kinds of flammable, explosive and toxic chemicals or existing bombs and mines, activated by a sensor or electromagnetic field emitting control (mobile phone etc.) are classified as booby traps. The following findings were obtained in the study on these types of explosives. In light of these findings, controlling the bleeding, opening the airway, resutation, splinting and fixation with traction kits should be performed in the first 5 minutes. If bleeding is considered to be intense, haemostatic plugs, emergency trauma bandages for limb ruptures and a tourniquet if necessary should be used. If we encounter a second-class situation, it is necessary to use almost 2 times the materials we have. Without these procedures, it is difficult to control the bleeding only with the tampons in the classical war package. In addition, if we calculate the time it takes for helicopter ambulances to evacuate the wounded without landing safety, and the arrival and departure times, the reasons for the casualties caused by mines can be easily understood. In conclusion, first aid in the field of conflict will save more lives under all circumstances than the measures taken by wounded soldiers on their own, by their comrades who are fighting with them or by the first aid physician in a fully equipped surgical hospital.