DTIC ADA514163: Burn Hazards of the Deployed Environment in Wartime: Epidemiology of Noncombat Burns from Ongoing United States Military Operations

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Burn Hazards of the Deployed Environment
in Wartime: Epidemiology of Noncombat Burns
from Ongoing United States Military Operations
DavidSKauvar, MD,CharlesEWade, PhD,DavidGBaer,PhD
BACKGROUND: Serviceinthedeployedmilitaryenvironmentcarriesrisksforaccidental(noncombat-related)
burns.Examiningtheseriskscanassistinthedevelopmentofmilitaryburnpreventionmea-
sures. This study endeavored to examine noncombat burn epidemiology in the context of
similarciviliandata.
STUDYDESIGN: Weperformedaretrospectivecohortstudyofconsecutivecasualtiesevacuatedfromoperational
military theaters in Iraq and Afghanistan to the sole tertiary military burn center in the US.
MilitarydatawerecomparedwithdatabasesamplesoftheUSpopulationfromtheAmerican
BurnAssociationandtheCentersforDiseaseControlandPrevention.
RESULTS: Themaincausesofthe180noncombatburnsseenfromMarch2003toJune2008werewaste
burning, fuel mishaps, and unintentional ordinance detonations. Overall prevalence of non-
combatburnswas19.5burns/100,000person-yearslived.Ifcausesspecifictomilitaryopera-
tionsareremoved,militaryprevalencewas13.0/100,000.Morethanone-thirdofnoncombat
burns occurred in the first year of the study; a period of stability followed. A similar US
populationhadanaccidentalburnprevalenceof7.1/100,000from2003to2007.Burnsize,
presence of inhalation injury, and burn center mortality were not different from those in a
similarciviliancohort.
CONCLUSIONS: Deployed service members have a greater risk of unintentional burns than a similar civilian
cohortdoes.Thisisinpartbecauseofthespecificdangersofmilitaryactivities.Moreattention
todeployedmilitaryburnpreventionisneeded,especiallyearlyincombatsupportoperations.
(JAmCollSurg2009;209:453–460.©2009bytheAmericanCollegeofSurgeons)
Duringthelastcenturyandahalf,USmilitaryoperations Burnsareencounteredinasmallbutsignificantpropor-
haveproducedhundredsofthousandsofcasualties.These tionofbothcombatandnoncombatcasualtiesinmodern
casualtiescanbegroupedintothoseresultingfromhos- warfare.Inthe20thand21stcenturies,thisproportionhas
tile activity (combat or battle injuries and deaths) and beenbetween5%and20%ofallcasualties.2-4Duringthe
those resulting from nonbattle injury (noncombat cas- VietnamWar,morethanone-halfofevacuatedburncasu-
ualties).1 A combat zone is by its nature a dangerous altieswereburnedoutsideofcircumstancesresultingfrom
place,andalthoughmanyofthedangersareinherentto enemy activity, and initial reports from the ongoing con-
the task at hand—fighting in armed conflict—others are flictsinIraq(OperationIraqiFreedom[OIF])andAfghan-
relatedtothedeployedmilitaryenvironmentitself.Histor- istan(OperationEnduringFreedom[OEF])haverevealed
ically, nonbattle casualties have accounted for a varying thatmorethanone-thirdofburnsareclassifiedasnoncom-
amount of wartime mortality, but the contribution has batinjuries.5,6
alwaysbeensignificant(Table1). Austereenvironmentalconditionsandtheworkrelated
to supporting combat operations pose burn risks but are
necessary components of prosecuting and sustaining
DisclosureInformation:Nothingtodisclose.
armed conflict.Waste burning, handling of ammunition,
Theopinionsand/orassertionscontainedhereinaresolelythoseoftheau-
thorsandshouldnotbeconstruedasreflectingthoseoftheUSArmy,De- andfuelingvehiclesandgenerators,amongothers,areac-
partmentofDefense,orgovernment. tivitiesthathavebeenidentifiedasposingburnrisksinOIF
ReceivedMay21,2009;RevisedJune18,2009;AcceptedJune18,2009. and OEF, and some efforts have been made to mitigate
FromtheUnitedStatesArmyInstituteofSurgicalResearch,FortSamHous- these.6,7Thisstudywasdevisedtodescribetheepidemiol-
ton,TX.
ogyofthenoncombatburnhazardsthatexistinOIFand
Correspondenceaddress:DavidSKauvar,MD,USAISRClinicalDivision,
3400RawleyEChambersBldg3611,FortSamHouston,TX78234. OEFbyexaminingdatafromburncasualtiesevacuatedto
©2009bytheAmericanCollegeofSurgeons ISSN1072-7515/09/$36.00
PublishedbyElsevierInc. 453 doi:10.1016/j.jamcollsurg.2009.06.367
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1. REPORT DATE 3. DATES COVERED
18 JUN 2009 2. REPORT TYPE 00-00-2009 to 00-00-2009
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Burn Hazards of the Deployed Environment in Wartime: Epidemiology
5b. GRANT NUMBER
of Noncombat Burns from Ongoing United States Military Operations
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
U.S. Army Institute of Surgical Research (USAISR),Clinical REPORT NUMBER
Division,3400 Rawley E Chambers Bldg 3611,Fort Sam
Houston,TX,78234
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
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14. ABSTRACT

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a. REPORT b. ABSTRACT c. THIS PAGE Same as 8
unclassified unclassified unclassified Report (SAR)
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Prescribed by ANSI Std Z39-18
454 Kauvaretal EpidemiologyofNoncombatBurns JAmCollSurg
the military regional medical center in Landstuhl, Ger-
AbbreviationsandAcronyms many,andfinallytotheUSAISR.Incasesofsevereburns
LOS (cid:1)lengthofstay or critically ill burned patients, the USAISR Burn Flight
OEF (cid:1)OperationEnduringFreedom Team, consisting of specially trained and equipped burn
OIF (cid:1)OperationIraqiFreedom physicians,nurses,respiratorytherapists,andsupportstaff,
TBSA (cid:1)totalbodysurfacearea
USAISR(cid:1)USArmyInstituteofSurgicalResearch evacuatedthepatientfromGermanytotheUSAISR.8The
decisiontoevacuateapatienttotheUSAISRburncenter
wasmadebasedontheburncentertransfercriteriaofthe
American Burn Association,9 ensuring that all patients
the US Army Institute of Surgical Research (USAISR)
withsignificantburnsorwithsignificanttraumaticcomor-
burncenterinSanAntonio,TX,fromthetheatersofop-
bidities along with their burns were sent to the USAISR
erations in Southwest Asia. We aimed to characterize de-
burncenter.Durationofevacuationwascalculatedasthe
ployed military burn risks in the context of those seen in
numberofdaysbetweenthedateofwoundingandthedate
theUS’civilianpopulationinordertodetermineifandin
ofburncenteradmission.
whatwaythedeployedmilitaryenvironmentwasmoreor
Upon admission to the burn center, the circumstances
lessdangerousthanthecivilianenvironmentvis-à-visun-
under which injury occurred were garnered from transfer
intentionalburns.
medicalrecordsandfromconversationwiththepatient,if
With such epidemiologic data, we hoped to be able to
provide evidence-based recommendations for the preven- possible.Thisinformationwasmadepartoftheinpatient
tionoffurthernoncombatburnsamongdeployedservice electronic medical record. For the purposes of this study,
members.TheUSAISRfacilityisthesoleUSmilitaryburn patient demographic data and information pertaining to
referral center and, as such, receives all significant burn the wounding event and its circumstances were extracted
casualties evacuated from the combat zone. So it is fromtheinpatientmedicalrecordsofallevacuatedcasual-
uniquely suited to performing epidemiologic research on ties.Thesedatawerereviewedforthestudyandwerethen
USmilitaryburncasualties. placedintoanelectronicdatabase.Injurymechanismswere
categorized by the specific weapon used in the wounding
METHODS incidentorthenoncombatcauseoftheburninjury.From
theavailableinformation,adeterminationwasmadebythe
ThisretrospectivestudyreceivedapprovalfromtheBrooke
principalinvestigator(DSK)astowhethertheinjurywas
Army Medical Center Institutional Review Board. The
the result of enemy activity (combat-related) or was not
recordsofallactive-dutymilitarypatientsevacuatedfrom
relatedtoenemyactivity(noncombatinjury).
OIFandOEFtotheUSAISRwerereviewed.Datacollec-
tion began with the initial evacuations of burn casualties Theadmittingburnsurgeondeterminedthepatternand
occurring in March 2003, and collection ceased with pa- depth of burns upon burn center admission using the
tients injured in June 2008, covering a period of 64 method described by Lund and Browder.10 All patients
months.AllpatientshadbeenburnedineithertheIraqor with any suspicion of inhalation injury (oxygen require-
Afghanistan theater and received initial resuscitation and ment,facialburns)andallintubatedpatientshadthisdi-
topicaltreatmentthere,althoughnodefinitiveorsurgical agnosis confirmed or excluded with fiberoptic bronchos-
burn care was provided for any patient until arrival at copy shortly after admission. All nonburn injuries were
USAISR.Casualtieswereevacuatedbyairthroughastaged diagnosed on admission with physical examination and
system of progressively increasing patient care capability, radiologic imaging as appropriate, and Injury Severity
from combat hospitals in Iraq and Afghanistan, through Scores(ISS)werecalculatedforallpatients.
Table1. TotalandNonbattleDeathsfromMajorUSArmedConflicts
Conflict Years Totaldeaths,n Nonbattledeaths,n Nonbattle,%
CivilWar(Union) 1861–1865 364,511 224,097 61
WorldWarI 1917–1918 116,516 63,114 54
WorldWarII 1941–1946 405,399 113,842 28
Vietnam 1964–1973 58,209 10,785 19
DesertShield/Storm 1990–1991 382 235 62
OIF/OEF(throughMarch2008) 2001–present 4,492 933 21
Dataabstractedfromacongressionalresearchservicereport.1
OIF/OEF,OperationIraqiFreedom/OperationEnduringFreedom.
Vol.209,No.4,October2009 Kauvaretal EpidemiologyofNoncombatBurns 455
Mortalitywasdefinedasdeathfromanycauseoccurring Table2. ComparisonofBattleandNonbattleBurnCasualties
duringthepatient’sinitialhospitalization.Inpatientcom- Noncombat Combat
Variable (n(cid:1)180) (n(cid:1)508) pValue
plicationsweretabulatedasacategoricalvariable,andany
Totalbodysurfacearea 11(cid:2)13 19(cid:2)21 (cid:3)0.0001
complicationduringtheinitialhospitalizationwasconsid-
Full-thicknesstotalbody
ereda“positive”result.Hospitallengthofstay(LOS)was
surfacearea 5(cid:2)11 13(cid:2)21 (cid:3)0.0001
definedasthenumberofdaysfromburncenteradmission
Inhalationinjury 11(6) 97(19) (cid:3)0.0001
totheinitialdisposition,whetheritbetohomeortoan-
Nonburninjury 20(11) 272(54) (cid:3)0.0001
other inpatient or rehabilitation facility.The LOS of pa-
InjurySeverityScore 6(cid:2)8 15(cid:2)15 (cid:3)0.0001
tientswhodiedduringtheirinitialhospitalizationwasnot
Lengthofstay 17(cid:2)24 30(cid:2)50 (cid:3)0.0001
consideredincalculatinggroupLOS.
Patientswithcomplications 44(24) 208(41) (cid:3)0.0001
CivilianburndatafromtheUSwasextractedfromthe
Mortality 2(1) 41(8) 0.0009
Web-based Injury Statistics Query and Reporting System
database available from the Centers for Disease Control Dataarereportedasmean(cid:2)SDorn(%).
andPrevention11andfromdatapublishedbytheAmerican
BurnAssociationinitsannualmultiinstitutionalreport.12 mean age of 26 years (range, 18 to 52 years), and 667
The inpatient mortality and complication data garnered (97%)weremen.Ofthe688casualties,508(74%)were
fromtheAmericanBurnAssociationdatabaseareforcivil- burned in combat, leaving a noncombat burn popula-
ianburnpatientsonly,apopulationsimilartoourmilitary tion of 180 (26%).
burncenterpopulation.Thenationwideincidencedatafor Thenoncombatinjuredpopulationdifferedfromthose
civiliansfromtheCentersforDiseaseControlandPreven- injured in combat in a number of critical areas (Table 2).
tion were censored to include only civilian burn patients Both total body surface area (TBSA) burned and full-
whowereadmittedtothehospitalortransferredtoanother thicknessTBSAburnedweresmalleramongthenoncom-
hospital for care, or both.This censoring was done in an bat injured, as were the incidences of inhalation and
attempt to make the military and civilian populations as associated nonburn injuries. Correspondingly, the Injury
comparableaspossible. SeverityScorewaslowerinthenoncombatburncasualties.
Estimatedin-theatertroopstrengthdatacompiledbya As might be expected, given the less severe injury profile
privatethirdparty(thegovernmentdoesnotroutinelyre- among noncombat-injured casualties, LOS was shorter
leasenumbersofdeployedservicemembers)wereusedto andtheratesofmortalityandinpatientcomplicationswere
provide an estimate of the relative population at risk for lowerinthispopulation.
noncombatinjuryduringtheperiodoftimecoveredbyour Only2deathsoccurredamongthe180noncombatca-
review.Estimatedtroopstrengthdatawereretrievedfrom sualties,foraninpatientmortalityrateof1.1%.Thisrate
reportsontheWeb.13Thesedatawerecollatedandentered wascomparabletothe2.1%rate(236of11,338)reported
intothestudydatabase. bytheAmericanBurnAssociationforpatientsaged20to
Descriptivedataarepresentedasmeans(cid:2)standardde- 30yearsadmittedtoUSburncentersin2007(p(cid:1)0.59,
viations, with medians and ranges as appropriate. Direct Fisher’sexacttest).Therateofinpatientcomplicationswas
comparisons between population means were performed comparableamongthese2groupsaswell,at24%fornon-
witht-testsforcontinuousdataandchi-squareorFisher’s combatcasualtiesand25%forcivilians(p(cid:1)0.87),aswas
exacttestsasappropriateforproportions.Statisticalsignif- therateofinhalationinjury,at6%fornoncombatcasual-
icancewasdefinedasapvaluelessthan0.05. tiesand4%forcivilians(p(cid:1)0.16).12
Theetiologiesofthe180noncombatburnswerevaried.
The largest contributor to this population was incidents
RESULTS involving the burning of refuse (24%). Other major con-
FromMarch2003toJune2008,atotalof711casualties tributorswereincidentswithfuelingvehiclesorgenerators
from OIF and OEF were admitted to the USAISR burn (18%)andthoseinvolvingthehandlingofammunitionor
center.Ofthese,13hadnoburnsandwereexcludedfrom gunpowder(17%)orofflaresandgrenades(16%).Purely
the study. Of the remaining 698, an additional 10 had electricalburns(8%),otherincidentswithgeneratorsand
insufficientinformationintheirrecordsregardingthecir- radiators (6%), scalds (3%), and other causes (9%) ac-
cumstances under which they were injured such that no counted for the remainder of the noncombat casualties.
determination could be made about the combat or non- Othercausesincludedmotorvehicleandhelicoptercrashes
combatstatusoftheirwounding.Thesewerealsoexcluded (four patients each), barbequing incidents (two patients),
from analysis.The remaining 688 burn casualties formed unexplodedordinancedetonations(twopatients),andsin-
thestudypopulation.Militarypatientswereyoung,witha gle patients each with burns resulting from Freon spray,
456 Kauvaretal EpidemiologyofNoncombatBurns JAmCollSurg
Figure1. Incidenceofnoncombatburnsandtotal/100,000deployedtroopstrengthforOperationIraqiFreedom
andOperationEnduringFreedom(OIF/OEFTroops)for16periodsof4monthseach,fromMarch2003toJune
2008.Y-axisbreaksbetween50and150.
welding, refilling a cigarette lighter, and a vehicle fire not nismsofburnsdiscussedabove(ammunitionhandlingand
resultingfromacrash. flare or grenade detonations) accounted for a total of 60
Review of national burn center data compiled by the (33%) of the noncombat burn casualties. If these are re-
AmericanBurnAssociationin2007revealedalargedispar- movedfromtheabovecalculation,theprevalenceofnon-
ity between the mechanisms of military noncombat and combat burns becomes 120 in 920,833 or 13.0 burns/
civilianburns.Ifallofthenoncombatmilitarymechanisms 100,000 person-years. The Centers for Disease Control
resulting in burns by fire or flame (waste burning; barbe- andPreventionreportsthatfrom2003to2007amongUS
quing; explosions of ammunition, gunpowder, and arma- civilianmenbetweentheagesof18and52years,thean-
ments; fueling; vehicle crashes; or fire) are considered to- nualprevalenceofhospitalizationortransferforuninten-
gether, as they are for civilians by the American Burn tionalburninjurywas7.1/100,000.11SofromMarch2003
Association, the resulting rate of fire or flame injuries is toJune2008,adeployedservicememberinOIForOEF
85%ofnoncombatburninjuries.Bycontrast,flameorfire had a 2 to3-fold greater chance of unintentional burn
accountsforonly44.5%ofallcivilianburncenteradmis- injurythanasimilarlyagedmaleUSpopulationcohort.
sionsamongpatientsaged20to30years.Somenoncom- Theincidenceofnoncombatburnsovertimewascalcu-
batburnshadcausesthatwere“militaryspecific,”suchas lated for each of the 16 intervals of 4 months each com-
thehandlingofammunitionorgunpowderandtheunin- prisingtheperiodofthereview.Incidencewascalculatedas
tentionaldetonationofflares,grenades,orunexplodedor- thetotalnumberofburncasualtiesadmittedper4-month
dinance.Ifweremovethesefireandflamehazardsfromthe periodandrangedfromahighof34inMarch2003toJune
noncombatburnpopulation,thefireandflameproportion 2003toalowof5forNovember2005toFebruary2006.
becomes 56% and more closely approximates the civilian IncidencewasinitiallyhighintheearlystagesofOIFand
proportion of such injuries. The same dataset demon- OEF but tapered over the first year of the conflict and
strates that among those US civilians burned, scalds remainedrelativelyconstantfortheremainderofthestudy
were more common than in the noncombat military period, even as the number of deployed service members
population,accountingfor22.9%ofburncenteradmis- fluctuated.Anexceptionwasinmid-2007,whenapproxi-
sions, but electrical injuries were less common at mately21,000additionalUSservicememberswereadded
5.2%.12 to forces in Iraq as part of the “surge” operation. During
There were an estimated monthly average of 173,742 this time, the incidence of noncombat burns increased
servicemembersdeployedwithOIFandOEFduringthe alongwiththenumberoftroopsintheater(Fig.1).
64 months (5.3 years) from March 2003 to June 2008.13 Theincidenceofnoncombatburninjuryinthecontext
Thiswereanestimatedtotalof920,833person-yearslived oftheestimatedat-riskpopulationovertimewasexamined
in the theaters of operations during this time period. So, bydividingthetotalnumberofnoncombatburncasualties
thenoncombatburnprevalenceforOIFandOEFwas180 by the estimated average number of service members de-
in 920,833, or 19.5 burns/100,000 person-years lived in ployedinOIFandOEFduringeach4-monthperiod.The
the theaters of operations.The “military-specific” mecha- resultsareexpressedasnoncombatburns/100,000service
Vol.209,No.4,October2009 Kauvaretal EpidemiologyofNoncombatBurns 457
Figure2. Noncombatburns/100,000troopsatriskfor16periodsof4-monthseach,fromMarch2003toJune
2008.
members at risk for each 4-month period. Four-month burns unrelated to hostile activity constitute a significant
incidence ranged from a high of 19.4/100,000 from proportion of the total burn casualty burden, currently
March2003toJune2003toalowof2.7/100,000from 26% for OIF and OEF.This is an improvement over the
November 2005 to February 2006. Prevalence also in- Vietnam conflict, in which an in-theater burn center re-
creased during mid-2007 as additional forces were sent ported a noncombat burn rate of 51%.5 Although this
to Iraq (Fig. 2). improvement is encouraging, noncombat burns are by
Mean burn size among noncombat casualties was theirnaturepotentiallypreventable,andthereisroomfor
11 (cid:2) 13%TBSA, and the figure was heavily skewed to- further reduction.The primary goal of this article was to
ward smaller burns, with a median of 7% (interquartile describetheepidemiologyofnoncombatburnsinOIFand
range,3%to78%)TBSA.Eighty-fourpercentofnoncom- OEF in the context of US civilian burn risks in order to
bat casualties had 20%TBSA or smaller burns, and 62% determine the relative burn hazards of the deployed mili-
hadburnsof10%TBSAorsmaller.Thisisasimilardistri- taryenvironment.Throughthisevaluation,wehopedtobe
butiontothatseenincivilianburncentersin2007,where able to provide recommendations for further noncombat
89% of patients had burns of less than 20%TBSA (p (cid:1) burnpreventionmeasures.
0.33), and 69% were burned over less than 10%TBSA Itisclearfromourdatathattherearesignificantdiffer-
(p (cid:1) 0.33).12 ences in the pattern of injury between burn casualties in-
In our military population, the hands were the most juredincombatandthoseinjuredinnoncombatincidents.
frequentlyburnedbodyarea,involvedin120(67%)casu- Thisfindingreinforcesinitialcasualtydataexaminedear-
alties.Theforearmwasburnedin92(51%)andthefacein
86 (48%) (Fig. 3). Eighteen (10%) noncombat casualties
were burned solely on the hands. Six of these sustained
electrical burns, four were burned by the unintentional
dischargeofflaresorgrenades,threeeachbyburningrefuse
andammunitiondetonation,andtwoinfuelingmishaps.
Only two of the casualties with isolated hand burns had
associatednonburninjuries.Onepatientwhowasinjured
while burning refuse sustained a unilateral tympanic
membraneruptureandoneofthosewhohadanelectri-
cal burn had a partial amputation of his index finger.
DISCUSSION
Burns remain an important source of military casualties Figure 3. Anatomic distribution of burns in combat casualties by
from current operations. As noted in previous conflicts, percentageoftotalcasualtieswithspecificarea(s)involved.
458 Kauvaretal EpidemiologyofNoncombatBurns JAmCollSurg
lierinthecurrentconflict.6Noncombatburncasualtiesare ercises,eventhoseoccurringoutsideofthecombattheater.
burnedfarlessseverelyandhavefewerassociatedtraumatic Thisindicatesthatsomeoftheburnriskseeninthemili-
injuries.Their outcomes are correspondingly better, with tary population has to do with the inherent occupational
significantlylowermortality.Thesedifferencesmakethese risks of military activities and not necessarily with the
two populations distinct clinical entities, and in further deployedmilitaryenvironmentitself.Thesedatasuggest
studyofmilitaryburnstheyshouldbeexaminedindepend- thatthenoncombatburnriskinthemilitarypopulation
ently.Thespecificreasonsfortheincreasedmortalityrate may be somewhat mitigated by prevention efforts di-
among combat-wounded burn casualties require further rectedattheperformanceofhigh-riskmilitaryactivities,
study. such as explosives handling, in both the training and
Our noncombat military casualty population was very combat environments.
young and overwhelmingly male, reflecting the demo- The prevalence of noncombat burn injury in OIF and
graphicsoftheUSarmedforcesingeneral.Forthisreason OEFwas19.5patients/100,000person-yearsinthecom-
we attempted, when possible, to study our population in battheater.Thisismuchhigherthantherateof7.1unin-
thecontextofasimilarcivilianpopulation.Increasingage, tentionalburns/100,000peryearseeninaUSmalepopu-
burn size, and the presence of inhalation injury are the lationofsimilarageduringatimeperiodequivalenttothat
typicalmortalitypredictorscitedforburnpatients,14,15and covered by our review. The prevalence differential could
themilitarynoncombatpopulationhadasimilardistribu- notbeexplainedsolelybytheburnsoccurringintheper-
tionofburnsizeandrateofinhalationinjurytosimilarly formance of military-specific tasks, because the military
aged patients treated at US burn centers in 2007. So it is incidenceis12.6/100,000,evenafterpatientsburnedper-
encouragingthatournoncombatburnmortalitywascom- formingsuchtaskswereremoved.Thissuggeststhatthere
parabletothatofthecivilianburnpatientpopulation. areburnhazardsthatareinherenttothemilitaryenviron-
Althoughmortalityinthenoncombatburnpopulation mentaboveandbeyondthosethatoccurbecauseofsome
wassimilartothatwithcivilianburns,thecausesofburn of the more dangerous activities performed in support of
injurieswerenot.Militarynoncombatburnpatientswere combatoperations.
far more likely to be burned by fire or flame than their Acluetothereasonfortheincreasedprevalenceofun-
similarlyagedciviliancounterparts.Thisdisparityinflame intentionalburnsamongservicemembersinthedeployed
burnpercentageappearstobeprincipallytheresultofpar- environment can come from examining the incidence of
ticipationinhazardousactivitiesrelatedspecificallytomil- suchburnsovertime.Morethanone-thirdoftheOIFand
itary operations in the combat zone. These activities in- OEF noncombat burn casualties (64 of 180) occurred in
clude the handling of explosives, such as ammunition, the first 12 months of our data collection period. If the
flares, and grenades, all of which resulted in fire or flame initial12monthsofnoncombatburncasualtiesareomit-
burns in our noncombat population.The other causes of tedfromthedata,representingthoseburnsthatoccurredin
noncombat burns are similar to those seen in a civilian the combat theater after the high incidence seen initially
working-agepopulation:burningofrefuse,incidentsinvolv- during the expeditionary phase of the OIF conflict, the
ingmisuseormishapswithvolatilefuels,incidentswithgen- prevalence decreases to 15.4 casualties/100,000 person-
erators, and motor vehicle and helicopter crashes.16 The years. This more accurately reflects the “baseline” preva-
military-specifictasksnotedareallassociatedwithcombat lenceofnoncombatburnsinthematurecombattheater.If
operations,andtheincidenceofburnsresultingfrommis- allofthemilitary-specificactivityburnsareremovedfrom
hapsoccurringwhileperformingthesewouldbeexpected thiscalculation,thentheprevalencedecreasesto10.2burn
toincreasealongwiththeoperationaltempo.Thisisinfact casualties/100,000 person-years in theater, which more
whatwenoted,withanincreaseinnoncombatburnsdur- closelyapproximatesthecivilianprevalenceof7.1uninten-
ingthe“surge”oftroopsinmid-2007intotheIraqtheater tionalburns/100,000person-yearslivedintheUSamong
ofoperations. youngmenfrom2003to2007.
But the risk of burns from munitions is not limited to During the initial phases of large military operations
the deployed combat environment. In a 2001 report on such as OIF and OEF, not only is there a high pace of
noncombatmunitionsinjuriesintheUSArmy,Kopchin- combat operations with attendant increased burn risks as
skiandLein17found261burnsamong894injuredsoldiers noted above, but service members also live and work in
frommunitionsincidentsoveran86-monthperiod,which austere conditions, a situation that comes with its own
included Operations Desert Shield and Desert Storm. burnhazards.Theclearestoftheseisthehazardsencoun-
Burns were the most common mechanism of injury and tered during the incineration of refuse and human waste,
weremostcommonlyassociatedwithcombattrainingex- which was the most frequent source of our noncombat
Vol.209,No.4,October2009 Kauvaretal EpidemiologyofNoncombatBurns 459
burncasualties.Incinerationisastandardmilitarypractice ing to OIF and OEF are issued gloves, yet 10% of our
forwastedisposalandhasbeenidentifiedasacontributor noncombat burn casualties received burns only to the
tounintentionalburnmorbidityinpreviousconflicts.5In hands.Allofthesehand-onlyinjuriesoccurredduringthe
OIFandOEF,thepracticeinitiallyledtohighnumbersof performanceofhigh-riskactivities,suggestingthatthese18
noncombat burn casualties in OIF and OEF and drew burns could have been completely prevented had the pa-
attentionfromtheburncareprovidersattheUSAISR.4A tientsbeenwearingtheirglovesatthetimeoftheirinjury.
preventionprogramwasimplementedinthecombatthe- Hand burns are particularly morbid injuries,22 and from
ater and has been somewhat effective in mitigating this ourdatawestronglyadvocatethewearingofglovesduring
risk.7 high-riskactivitiesandcontinuedemphasisonthisaspect
As the OIF and OEF combat theater matured from ofpreventativemedicinebymilitarymedicalauthorities.23
2003to2004,thepaceofinitialcombatoperationsslowed, TheUSAISR,asthesoleUSmilitaryburncenter,hasbeen
and more permanent facilities and procedures were ac- heavilyinvolvedinadvocacyandpolicymattersregarding
quired and constructed for sanitation and other burn- the provision and use of flame-retardant garments and
otherequipmenttopreventbothcombatandnoncombat
prone tasks. There was a corresponding decrease in the
burns.Currently,allservicemembersdeployinginsupport
incidence of noncombat burns to between 2 and 6 per
of OIF and OEF are issued gloves and flame retardant
100,000troopsintheater,which,aftertheinitialhighin-
uniforms before arrival in the combat theater. The real-
cidence, represented the “baseline” incidence for the the-
worldeffectivenessoftheseshouldbethesubjectoffurther
aterofoperations(Fig.2).Thisfairlyconstantbaselineof
researchintotheepidemiologyofmilitaryburncasualties.
noncombatburnsinthefaceoffluctuatinglevelsoftroops
We have demonstrated that service members deployed
meansthatthetheaterhadmaturedproperlyafterthefirst
totheOIFandOEFtheatermilitaryenvironmentinsup-
year of operations.The observed increase in incidence to
port of combat operations have a baseline risk of burn
8/100,000 at risk with the addition of about 21,000
injurythatexceedsbyafactoroftwotothreetheriskfaced
“surge” troops in 2007 indicates that there is room for
byasimilarpopulationintheUS.Thisincreasedriskap-
improvementinnoncombatburnprevention.Ifthecom-
pears to be somewhat mitigated by the specific require-
battheaterweretrulyatabaselineminimalriskdetermined
mentsoftheirenvironment.Resourcesdevelopedinama-
by living and operating conditions, we would have ex-
turingcombattheaterseemtoresultinreducednoncombat
pectedtheburnincidencetoremainthesameregardlessof
burn risks.These include the development of centralized
theadditionaltroopsinthetheater.Itisinterestingtonote
powerplantstoreplaceportablefueledgeneratorsandthe
that noncombat burn incidence decreased even as the
useofchemicaltoiletsorthedevelopmentofsanitarysewer
“surge”troopsremainedinthetheater.Thisismostlikely
systems to eliminate waste burning. Such developments
fromacombinationofdecreasingoperationaltempo(and
can further reduce the incidence of noncombat burn in-
associated combat-support tasks as noted earlier) and the
jury.Emphasisonsafeproceduresandthewearingofpro-
evolutionofthecombattheatertoprovideasafernoncom-
tectivegarmentsduringhigh-risk,andespeciallymilitary-
batenvironmentfortheadditionalservicemembers.Mil-
specific, activities, such as handling explosives, generator
itary commanders should expect a transient increase in
fueling, and maintenance, and during vehicle-fueling ac-
noncombat burn casualties whenever a large number of
tivities, remains indicated in attempts to reduce the inci-
troopsareaddedtoevenamaturecombattheater.
denceandimpactofnoncombatmilitaryburninjuries.
Noncombat burns sustained in the deployed military
environment remain an important source of combat the-
Author Contributions
ater morbidity, and many of these injuries are potentially
preventable.Ahighincidenceofhandburnsisuniversally
Studyconceptionanddesign:Kauvar,Wade,Baer
reportedfrommilitaryoperations,5,18,19andtheincidence
Acquisitionofdata:Kauvar,Wade
of burns to the hands has been found to be significantly
Analysisandinterpretationofdata:Kauvar,Wade,Baer
higher among military burn patients from OIF and OEF
Draftingofmanuscript:Kauvar,Wade,Baer
than in the civilian burn population.20 Wearing of gloves
Criticalrevision:Kauvar,Wade,Baer
canbeveryeffectiveinthepreventionofburnstothehands
inmilitaryoperationalsituations,especiallywhentheyare
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