Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014).

INTRODUCTION: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

The character of conflict: A bioarchaeological study of violence in the Nasca highlands of Peru during the Late Intermediate Period (950-1450 C.E.).

OBJECTIVES: This study uses osteological and radiocarbon datasets combined with formal quantitative analyses to test hypotheses concerning the character of conflict in the Nasca highlands during the Late Intermediate Period (LIP, 950-1450 C.E.). We develop and test osteological expectations regarding what patterns should be observed if violence was characterized by intragroup violence, ritual conflict, intermittent raiding, or internecine warfare. MATERIALS AND METHODS: Crania (n = 267) were examined for antemortem and perimortem, overkill, and critical trauma. All age groups and both sexes are represented in the sample. One hundred twenty-four crania were AMS dated, allowing a detailed analysis of diachronic patterns in violence among various demographic groups. RESULTS: Thirty-eight percent (102/267) of crania exhibit some form of cranial trauma, a significant increase from the preceding Middle Horizon era. There are distinct trauma frequencies within the three subphases of the LIP, but Phase III (1300-1450 C.E.) exhibits the highest frequencies of all trauma types. Males exhibit significantly more antemortem trauma than females, but both exhibit similar perimortem trauma rates. DISCUSSION: There was chronic, internecine warfare throughout the Late Intermediate Period with important variations in violence throughout the three temporal phases. Evidence for heterogeneity in violent mortality shows a pattern consistent with social substitutability, whereby any and all members of the Nasca highland population were appropriate targets for lethal and sublethal violence. We argue that by testing hypotheses regarding the targets and types of conflict we are better able to explain the causes and consequences of human conflict.

Warfare in an evolutionary perspective.

The importance of warfare for human evolution is hotly debated in anthropology. Some authors hypothesize that warfare emerged at least 200,000-100,000 years BP, was frequent, and significantly shaped human social evolution. Other authors claim that warfare is a recent phenomenon, linked to the emergence of agriculture, and mostly explained by cultural rather than evolutionary forces. Here I highlight and critically evaluate six controversial points on the evolutionary bases of warfare. I argue that cultural and evolutionary explanations on the emergence of warfare are not alternative but analyze biological diversity at two distinct levels. An evolved propensity to act aggressively toward outgroup individuals may emerge irrespective of whether warfare appeared early/late during human evolution. Finally, I argue that lethal violence and aggression toward outgroup individuals are two linked but distinct phenomena, and that war and peace are complementary and should not always be treated as two mutually exclusive behavioral responses.

The Proximate Causes of Waorani Warfare.

In response to recent work on the nature of human aggression, and to shed light on the proximate, as opposed to ultimate, causes of tribal warfare, we present a record of events leading to a fatal Waorani raid on a family from another tribe, followed by a detailed first-person observation of the behavior of the raiders as they prepared themselves for war, and upon their return. We contrast this attack with other Waorani aggressions and speculate on evidence regarding their hormonal underpinnings. On-the-ground ethnographic observations are examined in light of the neuroendocrinological literature. The evidence suggests a chain of causality in launching lethal violence, beginning with a perceived injury, culminating in a massacre, and terminating in rejoicing. Although no blood or saliva samples were taken at the time of this raid, the behaviors were consistent with a deliberate initiation of the hormonal cascade characterizing the "fight-or-flight" response, along with other hormonal changes. We conclude with observations on the stratified interrelationships of the cognitive, social, emotional, and neuroendocrinological causes of aggression leading to coalitional male homicide.

Incidence of Hyperoxia in Combat Wounded in Iraq and Afghanistan: A Potential Opportunity for Oxygen Conservation.

INTRODUCTION: Oxygen supplementation is frequently used in critically injured trauma casualties in the combat setting. Oxygen supplies in the deployed setting are limited so excessive use of oxygen may unnecessarily consume this limited resource. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR). METHODS: This is a subanalysis of previously published data from the DoDTR - we isolated casualties with a documented arterial blood gas (ABG) and categorized hyperoxia as an arterial oxygen >100 mmHg and extreme hyperoxia > 300 mmHg (a subset of hyperoxia). We defined serious injuries as those with an Abbreviated Injury Score (AIS) of 3 or greater. We defined a probable moderate traumatic brain injury of those with an AIS of 3 or greater for the head region and at least one Glasgow Coma Scale at 8 or less. RESULTS: Our initial search yielded 28,222 casualties, of which 10,969 had at least one ABG available. Within the 10,969, the proportion of casualties experiencing hyperoxia in this population was 20.6% (2,269) with a subset of 4.1% (452) meeting criteria for extreme hyperoxia. Among those with hyperoxia, the median age was 25 years (IQR 21-30), most were male (96.8%), most frequently US forces (41.4%), injured in Afghanistan (68.3%), injured by explosive (61.1%), with moderate injury scores (median 17, IQR 10-26), and most (93.8%) survived to hospital discharge. A total of 17.8% (1,954) of the casualties underwent endotracheal intubation: 27.5% (538 of 1,954) prior to emergency department (ED) arrival and 72.5% (1,416 of 1,954) within the ED. Among those intubated in the prehospital setting, upon ED arrival 35.1% (189) were hyperoxic, and a subset of 5.6% (30) that were extremely hyperoxic. Among those intubated in the ED, 35.4% (502) were hyperoxic, 7.9% (112) were extremely hyperoxic. Within the 1,277 with a probable TBI, 44.2% (565) experienced hyperoxia and 9.5% (122) met criteria for extreme hyperoxia. CONCLUSIONS: In our dataset, more than 1 in 5 casualties overall had documented hyperoxia on ABG measurement, 1 in 3 intubated casualties, and almost 1 in 2 TBI casualties. With limited oxygen supplies in theater and logistical challenges with oxygen resupply, efforts to avoid unnecessary oxygen supplementation may have material impact on preserving this scarce resource and avoid potential detrimental clinical effects from supraphysiologic oxygen concentrations.

Prosocial Emotion, Adolescence, and Warfare : DNA Methylation Associates with Culturally Salient Combat Variables.

Examining the costs and motivations of warfare is key to conundrums concerning the relevance of this troubling phenomenon to the evolution of social attachment and cooperation, particularly during adolescence and young adulthood-the developmental time period during which many participants are first recruited for warfare. The study focuses on Samburu, a pastoralist society of approximately 200,000 people occupying northern Kenya's semi-arid and arid lands, asking what role the emotionally sensitized, peer-driven adolescent life stage may have played in the cultural and genetic coevolution of coalitional lethal aggression. Research in small-scale societies provides unparalleled opportunities for sharply defined variables, particularly in age generation societies in which all young men are initiated into "warriorhood." Proposing an epigenetic and component behavior approach, we examine whether raiding activities such as number of raids, killing, and sparing enemy lives associate with DNA methylation in two candidate genes: MAOA, linked to mood and arousal, and NR3C1, linked to stress and immune response. We report statistically significant associations between the epigenetic variables and the combat (exposure) variables of overall raiding activity and reportedly showing mercy to enemies. In contrast, epigenetic variables did not associate with post-traumatic stress disorder (PTSD) symptom scores (a potential outcome measure), and the only combat variable associated with PTSD (but not DNA methylation) was losing one's own livestock in a raid. These findings raise important questions concerning the mechanisms driving warfare's paradoxical mix of violent and altruistic behaviors.

Social Signaling and the Warrior-Big-Man among the Western Dani : A Man Called Tibenuk.

We employ the Social Signaling Model (SSM) and life history of a Western Dani big-man, Tibenuk, to analyze a neglected curiosity in the career of the big-man type. The big-man is renowned as an economic entrepreneur, the master of material displays. In New Guinea, however, big-men had invariably first gained fame and some influence as eminent warriors. The SSM accounts for this two-part career path by proposing that small-scale social organization rests on honest, competitive signaling of individual and collective fighting strength, with leaders being those who excel in these contests. The performances for which big-men are already known, conspicuous ceremonial displays, broadcast this strength indirectly. Explicitly conceptualized as symbolic fighting, they constituted indexical proxies for their sponsors' individual and collective willingness and ability to fight. Success on the battlefield, though, signaled fighting strength more directly. Men therefore had to demonstrate strength on both the battlefield and the ceremonial ground if they were to become big-men. This was Tibenuk's achievement. When he was young and at his physical peak, he demonstrated outstanding capability in war. War is a young man's game, however, and as his physical capacities waned, he shifted to politics, an older man's game, honing his political talents and developing extensive political networks that allowed him to sponsor massive pig feasts, the principal form of conspicuous ceremonial display. Tibenuk's career also reveals synergies between warrior and political talents that hitherto have been overlooked in big-man analysis.

Characteristics of Iraqi Patients Treated During Operation Inherent Resolve by a Forward Surgical Team.

INTRODUCTION: The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these "initial entry operations" experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq. MATERIALS AND METHODS: From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population. RESULTS: The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2-12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25). CONCLUSIONS: Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency.

The Impacts of Conservation and Militarization on Indigenous Peoples : A Southern African San Perspective.

There has been a long-standing debate about the roles of San in the militaries of southern Africa and the prevalence of violence among the Ju/'hoansi and other San people. The evolutionary anthropology and social anthropological debates over the contexts in which violence and warfare occurs among hunters and gatherers are considered, as is the "tribal zone theory" of warfare between states and indigenous people. This paper assesses the issues that arise from these discussions, drawing on data from San in Angola, Namibia, Botswana, and Zimbabwe. Utilizing cases of how San have been affected by military forces and wildlife conservation agencies in what became protected areas in southern Africa, this article shows that indigenous peoples have been treated differentially by state and nongovernmental organizations involved in anti-poaching, shoot-to-kill, and forced resettlement policies. Particular emphasis is placed on the !Xun and Khwe San of southern Angola and northern Namibia and the Tshwa San of western Zimbabwe and northern Botswana, who have been impacted by militarization and coercive conservation efforts since the late nineteenth century. Principal conclusions are that conservation and militarization efforts have led to a reduction in land and resources available to indigenous people, higher levels of poverty, increased socioeconomic stratification, and lower levels of physical well-being. San have responded to these trends by engaging in social activism, forming community-based institutions, and pursuing legal actions aimed at obtaining human rights and equitable treatment.

Coping resources and stress reactions among Bedouin Arab adolescents during three military operations.

This study aimed to examine coping resources (sense of coherence and hope) and stress reactions among Bedouin Arab adolescents in southern Israel during three periods of escalated political violence. Two main questions were examined: 1) Did adolescents report different coping resources and levels of stress reactions during these three different periods? 2) Were there any differences in the pattern of the associations between coping resources and stress reactions across those periods? Data were gathered from 81, 91, and 192 Bedouin Arab adolescents, who were 14-18 years old, during three periods. Participants completed self-report questionnaires including the sense of coherence (SOC) scale, a hope index, a measure or state anxiety and state anger, a measure of psychological distress, and a demographic questionnaire. Across the three periods, differences were observed in both coping resources and levels of stress reactions. Over time, SOC was found to be a significant predictor of those stress reactions; whereas the association between hope components and stress reactions weakened over time. These findings support the hypothesis that SOC is a significant component of coping with stressful political events and emphasize the importance of addressing differences in the roles of personal resources over time and transition processes.

Marital Violence During War Conflict: The Lived Experience of Syrian Refugee Women.

INTRODUCTION: Marital violence increases during times of war. This study aims to describe the lived experience of marital violence toward Syrian refugee women during the current war in Syria. DESIGN: A descriptive phenomenological research methodology was used to conduct semistructured interviews with 16 purposively selected Syrian refugee women residing in displacement centers in Jordan. Colaizzi's steps of data analysis were used. RESULTS: Four themes identified were identified: (1) Loss, insecurity, and suffering; (2) Shame and humiliation; (3) Justifying and enduring marital violence; and (4) Ways of coping with marital violence. CONCLUSION: The Syrian War conflict changed women's lifeway and created a context for marital violence. Study findings suggests addressing marital violence during wartime and allocating resources to provide care and support of victims of violence in the displaced countries.

The emergence of human warfare: Current perspectives.

The origins of warfare have long been of interest for researchers across disciplines. Did our earliest ancestors engage in forms of organized violence that are appropriately viewed as approximations, forms of, or analogs for more recent forms of warfare? Assessed in this article are contrasting views that see warfare as being either a product of more recent human societies or a phenomenon with a much deeper chronology. The article provides an overview of current debates, theories, and methodological approaches, citing literature and data from archaeological, ethnographic, genetic, primatological, and paleoanthropological studies. Synthetic anthropological treatments are needed, especially in efforts to inform debates among nonacademic audiences, because the discipline's approaches are ideally suited to study the origins of warfare. Emphasized is the need to consider possible forms of violence and intergroup aggression within Pleistocene contexts, despite the methodological challenges associated with fragmentary, equivocal, or scarce data. Finally, the review concludes with an argument about the implications of the currently available data. We propose that socially cooperative violence, or "emergent warfare," became possible with the onset of symbolic thought and complex cognition. Viewing emergent warfare as a byproduct of the human capacity for symbolic thought explains how the same capacities for communication and sociality allowed for elaborate peacemaking, conflict resolution, and avoidance. Cultural institutions around war and peace are both made possible by these changes. Accordingly, we suggest that studies on warfare's origins should be tied to research on the advent of cooperation, sociality, and communication.

CAVH in the Combat Environment: A Case Report and Lessons Learned in Southern Afghanistan.

Background: Acute kidney injury is a common complication of both civilian and military trauma. The lack of dedicated resources restrict dialysis in the forward setting. We report a case of a combat polytrauma and renal failure, using continuous arteriovenous hemofiltration to clear uremia and remove volume, allowing for ventilator liberation and safe disposition. Materials and Methods: The patient presented with traumatic lower extremity injuries and abdominal wounds and developed acute post-traumatic renal failure. Using available supplies, the patient was cannulated for continuous arteriovenous hemofiltration. Aggressive fluid and electrolyte management accomplished specific goals of ventilator liberation and clearance of uremia. Results: Over 48 h, blood urea nitrogen was reduced from 101 mg/dL to 63 mg/dL. Creatinine was reduced from 8.2 mg/dL to 4.7 mg/dL. Acute respiratory distress syndrome was improved reducing P:F (PaO2:FiO2) ratio from 142 to 210. The patient was extubated and transferred safely. Conclusions: The ability to perform acute dialysis can be lifesaving. Although resource constrained, we created a dialysis system in the forward environment with a filter and universally available equipment. This represents the first described use of continuous arteriovenous hemofiltration at the NATO Role 3 hospital in Afghanistan. This technique represents another potential tool for deployed trauma teams to improve care.

Considerations for Retrograding Deployed Army Pharmacy Operations: What about Department of Defense Civilian Contractors? Lessons from Kosovo.

Background: Over the past two decades, changes in mission and expectations of deployed medical assets are requiring adaptations of pharmacy services. Specifically, the Department of Defense (DOD)-deployed contractors in theater are now eligible for varying levels of care from DOD-deployed assets. Pharmacy must now stock and maintain a complex medication footprint. This new requirement makes the attempt to retrograde a long established deployed pharmacy difficult and presents new challenges. Methods: We review the issues surrounding this quandary from the perspective of the deployed pharmacy in Kosovo, one of the longest standing theaters of deployed medical assets. Findings: Data from the 20th and 21st medical rotations in this theater demonstrate that DOD contractors consume a significant portion of pharmacy operational support. However, not only do contractors increase the volume but also pharmacy must address the use and monitoring of complex medications such as anticoagulants, antidiabetics, sleep, and psychiatric medications, as well as chronic obstructive pulmonary disease and asthma drugs, which are not typical in the deployed environment. Discussion/Impact/Recommendations: Contractors are now serving in the Balkan theater at a greater than 1:1 ratio of contractors to soldiers. Contractors are typically older than deployed soldiers and thus their pharmaceutical needs are more complex. This complicates the pharmacy operation, which on the one hand is trying to retrograde as the mission winds down, yet, on the other hand, must expand to more complex operations to support the DOD contractors in theater.