TY - JOUR
AU1 - MRCS, Mark Anthony Foster, MBChB,
AU2 - MRCS, Jamil Moledina, MBBS,
AU3 - FRCS(Plast), Steve L.A. Jeffery,
AB - Abstract The authors review the etiology of U.K. military burns in light of increasing hybrid warfare. Analysis of the nature of these injured personnel will provide commanders with the evidence to plan for on-going and future operations. Case notes of all U.K. Armed Forces burn injured patients who were evacuated to the Royal Centre for Defence Medicine were reviewed. Demographics, burn severity, pattern, and mortality details were included. There were 134 U.K. military personnel with burns requiring return to the United Kingdom during 2001–2007. The median age was 27 (20–62) years. Overall, 60% of burns seen were “accidental.” Burning waste, misuse or disrespect of fuel, and scalds were the most prevalent noncombat burns. Areas commonly burned were the face, legs, and hands. During 2006–2007 in the two major conflicts, more than 59% (n = 36) of the burned patients evacuated to the United Kingdom were injured during combat. Burns sustained in combat represent 5.8% of all combat casualties and were commonly associated with other injuries. Improvised explosive device, minestrike, and rocket-propelled grenade were common causes. The mean TBSA affected for both groups was 5% (1–70). The majority of combat burn injuries have been small in size. Greater provision of flame retardant equipment and clothing may reduce the extent and number of combat burns in the future. The numbers of noncombat burns are being reduced by good military discipline. Burn injuries have been described as a consequence of battle for more than 5000 years.1 Since the great evolutionary leap when man created fire to cook and keep himself warm, he has used fire to warn off predators and to injure and kill his enemies.2,3 True incendiary warfare entails the deliberate use of fire to achieve tactical or strategic objectives, destroying defenses and materials.4 Commanders quickly realized that the slaying of men by fire was much more effective than simple arrows and shock weapons. To the present day, fire continues to terrorize both the military and civilian populace. With increasing globalization and advancing technology, Clausewitz's5 broad theory of conflict (the dynamic expression of political or ideological wills) still holds true. Attacks are being conducted using both primitive and highly sophisticated weaponry. Knowledge of the pattern, severity, and etiology of burn injuries will not only help shape the provision of burns care in the future but also the development of protective equipment. METHODS A study was designed to look at all military burns over the past 7 years who returned to the United Kingdom between January 2001 and December 2007. All military casualties have been evacuated back to the Royal Centre for Defence Medicine (RCDM) in Birmingham since its formation in January 2001. The details of all personnel returning to the United Kingdom are entered into an evacuation database (Aeromed), where demographics along with details of their injuries are recorded. This database was searched for all patients with evidence of burn injuries. The patient list was then checked against Joint Theatre Trauma Registry (JTTR) and burns ward admission books to ensure no patients were missed. Data were collected prospectively during 2007 and retrospectively for the proceeding years. Patient notes, hospital computer systems, the evacuation database, JTTR, and, where possible, interviews with patients directly were collated. The demographics, epidemiology, and the depth and extent of the burns with any associated injuries were recorded. The depth of burn was estimated using clinical acumen; Laser Doppler was not routinely used at the time of the study. The JTTR records all severe injuries and interventions. The data are collected prospectively throughout the patient journey from entry into the Emergency Department in the field hospital until discharge from RCDM in the United Kingdom. The JTTR was used to cross-reference the severely injured patients and to check their Injury Severity Score. Occasionally, casualties with large burns were transferred to other Burn Centers due to bed pressures; their details were retrieved from the evacuation database. Univariate analysis was made using two-sample Student's t-test for continuous variables and χ2 test for categorical variables. RESULTS Two hundred twelve sets of patient notes were accessed and examined. The notes revealed that 39 of these patients had not actually received a burn. This included 16 with heartburn, 5 with corneal abrasions, and 3 who had jumped from burning vehicles and sustained purely orthopedic injuries. There were two deaths at the scene due to blast injury. Although a burn had been noted, its contribution was minimal compared with other catastrophic injuries. After these had been excluded, 134 military personnel were entered into the study. Table 1 shows an increase in the number of burns over the last 2 years with 67 being evacuated from an operational theater during 2006–2007. The median age of the casualties was 27 (range, 20–62) years. Table 1. The number of burns evacuated to RCDM by year View Large Table 1. The number of burns evacuated to RCDM by year View Large The majority of burns seen were small. Seventy-five percent were under 5% TBSA. The majority were partial thickness, with only 20% being full thickness. There was no significant difference in the depth of burn when comparing combat with noncombat burns. The distribution of %TBSA and body area burnt is demonstrated in Figures 1 and 2, respectively. Figure 2 shows that the most commonly affected areas were the hands, face, and the extremities. There were five inhalation injuries of which one needed intubation. The cause of each burn was defined as combat or noncombat related. Figure 1. View largeDownload slide %TBSA of combat and noncombat burns (2001–2007). Figure 1. View largeDownload slide %TBSA of combat and noncombat burns (2001–2007). Figure 2. View largeDownload slide The distribution of body area burned (2001–2007). Figure 2. View largeDownload slide The distribution of body area burned (2001–2007). The type of burn and mechanism of injury are shown in Figure 3 and Table 2, respectively. Flash and flame was most common. Most combat burn injuries were caused by an improvised explosive device; mine strike (vehicle drives over a mine) and rocket-propelled grenade were the next most common. Figure 3. View largeDownload slide Type of burn (2001–2007). Figure 3. View largeDownload slide Type of burn (2001–2007). Table 2. The mechanism of burn separated into combat and noncombat injury during 2001–2007 View Large Table 2. The mechanism of burn separated into combat and noncombat injury during 2001–2007 View Large In the noncombat group, 16 (12%) personnel were burned while preparing hot food and drinks and 15 (11%) while burning rubbish or human excrement. There were a number of electrical burns where vehicle antennae hit aerial power lines. One electrical burn was fatal, when a soldier walked into a power line. The misuse or disrespect of hydrocarbons formed a large group, distinct from its use in burning rubbish, for example spilling fuel while refilling, using the wrong equipment to complete refuelling, leaving fuel uncovered next to open flames, or using it to burn ants. Examples of self-inflicted injuries are a case of severe sunburn and three individuals who tried to produce a regimental scar by branding a heated cap-badge on to their legs. Overall, 60% were “accidental burns” and not sustained from combat. The increased operational tempo over 2006–2007 warranted separate analysis and is shown in Figure 4. More than 59% (n = 36) of the burned patients evacuated to the United Kingdom had injuries sustained in combat. In Iraq, over the past 2 years, 296 U.K. personnel were admitted to a field hospital with a battle-related injury6; 18 (6.1%) of these patients were burned. In Afghanistan, 329 U.K. personnel were injured with 18 (5.5%) being burned.7 The combined burns sustained in combat represented 5.8% of combat casualties and were more commonly associated with other injuries. There have been no fatalities due to burns in U.K. forces where the burn was an important component of injury. A summary of these operational burns and casualty numbers is shown in Table 3. Figure 4. View largeDownload slide Subgroup analysis of burns sustained in 2006–2007. Figure 4. View largeDownload slide Subgroup analysis of burns sustained in 2006–2007. Table 3. Summary of operational burns as a reflection of casualty numbers during 2006–2007 View Large Table 3. Summary of operational burns as a reflection of casualty numbers during 2006–2007 View Large Of the 134 burn injuries, 35 (26%) required skin grafting. Infection rates were low, 5 of 134 (3.7%), despite the environmental conditions in which the burns were sustained, with no difference between injuries sustained in Iraq and Afghanistan. All wounds were initially treated with flammacerium, as per the clinical guidelines at the time. Flammacerium is an excellent dressing for the prevention of wound infection and the “holding” of a burn wound, and as such is the dressing of choice if the evacuation time will be prolonged, as has been the case in all previous major conflicts. Evacuation times in recent conflicts have dramatically shortened. It is not unusual for soldiers to arrive back in the United Kingdom within 24 hours of injury, but typically patients arrive in Birmingham within 2 to 4 days of the injury. One disadvantage of using flammacerium is that it fixes to the dermis and makes the clinical evaluation of burn depth very difficult. The use of laser Doppler imaging can overcome this if only one or perhaps two applications of flammacerium have been applied; otherwise, it also becomes inaccurate in our experience. To overcome these challenges, clinical guidelines have subsequently been changed to reflect the shorter evacuation timelines. Acticoat is now being used as the initial dressing at the Field Hospital, which has a good antimicrobial profile, does not need daily dressing changes, and does not affect the appearance of the burn wound. Laser Doppler is now used routinely as an adjunct in burn depth assessment and, in our experience, is unaffected by the staining of tissues seen with acticoat use. The Injury Severity Score was calculated for each patient. There was a significant difference in the Injury Severity Score between combat injuries (6.5 ± 8.9) and noncombat injuries (2.4 ± 2.1) (P = <.005). DISCUSSION The RCDM provides medical support to military operational deployments. It also delivers secondary and specialist care for members of the armed forces. It is a dedicated training center for defense personnel and has an active research department. All injured military personnel from operations overseas are evacuated back to the RCDM colocated with the Birmingham Burns Centre, part of the Queen Elizabeth Hospital Birmingham. The increased operational tempo has produced a rise in the number of burn injuries, with 50% of the total number being admitted during the last 2 years. Subgroup analysis of U.K. forces combat casualties in 2006–2007 from Iraq and Afghanistan allows comparison to U.S. rates of 5.7% during 2003–2005 in similar conflicts.21 In Afghanistan, there was a lower proportion of noncombat burns compared with Iraq, which probably represents the differences in troop numbers and level of combat activity. Regardless of the device, burns in combat are sustained by two mechanisms, the heat from the initial blast or from the secondary effect of the ignition of clothing, fuel, or equipment.8 The improvised explosive device is a common weapon used by irregular or insurgent forces. This produces a blast often with shrapnel and causes the majority of combat burn injuries. Mine strike (vehicle or individual hitting a mine) and the rocket-propelled grenade were other mechanisms used to injure troops. The indirect fire group, where the weapon was not “directly sighted,” includes a small number of fratricide attacks. “Friendly fire” injuries have been an unfortunate consequence of the “fog of war” from ancient times.9 With the continued development of new systems and equipment, this number will be kept to a bare minimum. The types and proportions of accidental injuries are very similar when comparing U.S. and U.K. figures. This is nothing new; the same pattern of injuries was seen in the Vietnam War where the misuse of fuel caused the vast majority of their noncombat burn injuries. Back then, they unfortunately had a 30% fatality rate in 1005 noncombat burns.10 Particularly during the initial phases of a conflict or a “tour of duty,” the perceived immortality of the excited “battle ready” soldier can lead to risk-taking behavior. In this retrospective review, it has been impossible to identify whether the three burns caused by branding with regimental insignia resulted in any disciplinary action. Fortunately, we have not seen any more of these injuries. Anecdotally, a reduction in the number of preventable burns has been seen as details of the burn injuries are fed back through the chain of command. Education and the maintenance of good discipline are helping to limit the number of nonbattle injuries. Compared with the United States, our preventable burn injury rates are similar, 38% in U.S. forces and 40% in U.K. forces.8 The electrical burns seen were due to a lack of care and attention, primarily while driving vehicles displaying a high antenna. Contact with high-voltage power lines results in injuries that are often very deep, with a large amount of soft and bony tissue necrosis.11 The only U.K. fatality related to burns was in the Balkan peacekeeping efforts. The U.S. mortality rate from burns has been 3.8%. The U.K. numbers are too low to make any direct comparisons. Another area of disparity is the low number of inhalation injuries; four in combat and one noncombat burn injury. U.S. clinicians routinely perform bronchoscopy to diagnose their 13% of inhalation injuries in 2003–2005.8 The provision of protective clothing over time has reduced the depth and severity of burn injuries. The proportional increase in burns seen by the Israelis between 1967 and 1973 prompted the introduction of fire retardant clothing in their tank crews. In a later conflict in Lebanon in 1982, the proportion of burn injuries was reduced in those crews who wore flame retardant clothing and gloves.12 Burns to hands and face make up nearly one-third of all burns in combat in U.K. forces during 2001–2008. The compulsory wearing of body armor has limited the number and severity of burns to the trunk. More effort is being made to encourage the wearing of eye protection and reduce eye injuries.13,–15 This will hopefully produce a reduction in the extent of flash/flame burns to the face. The morbidity from small hand burns should not be underestimated. When a hand burn is unlikely to heal within 2 weeks, the individual is returned to the United Kingdom for assessment, debridement, and occasionally grafting. The safety of troops remaining in an operational environment who are unable to fit protective equipment or defend themselves in a timely fashion has dictated that personnel with relatively minor injuries have had to return home. The use of gloves has seen a reduction in the severity of hand burns in U.S. forces.16 Soldiers have concerns that protective clothing reduces their effectiveness; a claim once made by surgeons in relation to their wearing gloves.17 As more lightweight protective clothing becomes available, there is likely to be a reduction in burn injury. With greater availability, more equipment is now being made available earlier in training, and this will hopefully improve compliance. Many of the burned soldiers have subsequently been redeployed in Iraq or Afghanistan with sun-protection advice. Once functionally recovered, with adequate protection, the burnt soldier is able to redeploy. CONCLUSION U.K. military commanders can now estimate the number and severity of burns in the current conflict. The threat of serious injury and death from flame and incendiary device remains a real one. The proportion of accidental noncombat burn injuries remains constant. Information on the mechanism and nature of these injuries, much of which has already been fed back through the chain of command, has highlighted this and will hopefully reduce these injuries further. Although the majority of our burns have been small, medical commanders also plan for a capability to manage and evacuate large burns from operational theaters. Current deployed forces need to remain vigilant to an enemy who can use both modern weapon systems and ancient “fire ship” tactics to produce heat and flame that can be directed against military and civilian targets alike. ACKNOWLEDGMENTS We thank Flt. Lt. Judith McLeod, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, for preparing the injury severity scores. REFERENCES 1. Atiyeh BS, Gunn SWA, Hayek SN Military and Civilian Burn injuries during armed conflict. Ann Burns Fire Disasters  2007; 20: 203– 15. Google Scholar PubMed  2. Atiyeh BS, Hayek SN, Gunn SWA Armed conflict and burn injuries: a brief review. Ann Burns Fire Disasters  2005; 18: 45– 6. Google Scholar PubMed  3. Strahle WC Introduction to combustion.  Amsterdam: Taylor & Francis; 1993. 4. Sawyer RD Fire and water: the art of incendiary and aquatic warfare in China.  Boulder, CO: Westview Press; 2004. 5. Bassford C. Clausewitz and his works; available from http://www.clausewitz.com/readings/Bassford/Cworks/Works.htm; accessed May 3, 2008. 6. Operations in Iraq: British casualties; available from http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInIraqBritishCasualties.htm; accessed March 20, 2008. 7. 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TI - Epidemiology of U.K. Military Burns
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e318217fa13
DA - 2011-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/epidemiology-of-u-k-military-burns-LFCjbanzmR
SP - 415
EP - 420
VL - 32
IS - 3
DP - DeepDyve
ER -