Annals of the Royal College of Surgeons of England (1991) vol.
73, 13-20
Field surgery on a future conventional
battlefield: strategy and wound
management
J M Ryan MCh FRCS RAMC S M Milner BDS FRCSEd RAMC
Senior Lecturer in Surgery Senior Registrar in Surgery
G J Cooper BSc PhD
Senior Lecturer in Trauma Science
Royal Army Medical College, London
I R Haywood FRCS L/RAMC
Joint Professor of Military Surgery
Royal College of Surgeons of England and Royal Army Medical College, London
Key words: Wound ballistics; War wounds; Field surgery; Triage; War wound management
Most papers appearing in the surgical literature dealing with
wound ballistics concern themselves with wound manage-
ment in the civilian setting. The pathophysiology of modern
war wounds is contrasted with ballistic wounds commonly
encountered in peacetime, but it should be noted that even in
peacetime the modern terrorist may have access to sophisti-
cated military weaponry, and that patients injured by them
may fail within the catchment area of any civilian hospital.
Management problems associated with both wound types are
highlighted; areas of controversy are discussed. The ortho-
dox military surgical approach to ballistic wounds is
expounded and defended.
Conditions on any future conventional battlefield will
differ radically from those experienced during antiterror-
ist operations and recent short campaigns. A major war
in the future would result in the mobilisation of many
medical, surgical and nursing teams with no previous
experience of battlefield surgery. Teams drawn from the
regular arm of the Defence Medical Services (DMS) may
have had field experience gained during short campaigns;
most recently in Northern Ireland and the Falkland
Islands (1-12). However, these were unique; in most
instances casualty flow rates were low, evacuation times
were short, appropriate personnel were available and the
Present appointment and correspondence to: Lt Col J M Ryan,
Joint Professor of Military Surgery, The Department of
Military Surgery, Royal Army Medical College, London SWIP
4RJ
campaigns were of short duration. The conditions of a
future war may be assumed to be rather more testing
(13), with large numbers of wounded inundating medical
facilities. Insight may be gleaned from recent wars fought
by others (14-17).
Recent contributors to the wound ballistic literature
include surgeons, intensive care physicians, biological
scientists and weapons technologists (18-26). This has
resulted in controversy and disagreement; the areas
include not only the biophysics of ballistic injury but also
management methods (27-29). A recent editorial in
International Defence Review, entitled 'Bullet holes in
theories', commented: "When surgeons disagree on how
best to treat bullet wounds, we are all concerned" (30).
Battlefield life support and triage
The first concern in caring for battle casualties is to save
life and limb. This involves rapid access to casualties as
close as possible to the point of wounding, a primary
survey to identify life-threatening injuries and the imme-
diate institution of life-support measures. These include
securing and maintaining the airway, ensuring adequate
ventilation and the control of haemorrhage. This is
battlefield life support, the philosophy and skills of
which are taught at British Army Trauma Life Support
(BATLS) Courses which are now mandatory for all
serving regular and reserve officers.
Evacuation of casualties is staged through five medical
lines or echelons and at each, casualties are sorted into
14 M Ryan et al.
The priorities are currently defined in terms of the ability of
casualties to tolerate delay before resuscitation and sur-
gery. They do not specify type or region of injury. The
wound types below are given as examples:
Priority groups for evacuation and surgery
(for evacuation at 1 st and 2nd line; for surgery at 3rd and
4th line)
P1 Resuscitation and urgent surgery
Unable to tolerate any delay
- complicated chest injuries
- burns >15%
- internal haemorrhage
P2 Early surgery and possible resuscitation
Can withstand moderate delay (<6 h)
- visceral injuries (no P1 features)
- thoracic injury without asphyxia
- major fractures
- burn.c < 15% but involving
head/face/hands/genitalia
P3 Delayed surgery
Delay unlikely to affect outcome
- spinal injuries
- minor injuries
- burns < 15%
- closed skeletal injury
Figure 1. Military triage.
priority groups for evacuation to the next medical line.
This is triage, derived from the old French verb, trier,
meaning to sift or sort. Its concept and application has
been widely reported (12,31). The three main casualty
categories are indicated in Fig. 1. Ideally, casualties
designated PI should be stabilised and evacuated ahead of
other categories. Operational circumstances, availability
of helicopters, distances and terrain will influence the
system. PI casualties arriving at the second line are
reassessed and restabilised before re-entering the evacua-
tion chain to reach a field hospital and ultimately a
general hospital.
Pattern of wounding
Civilian surgeons in the United Kingdom have exper-
ience of individual shooting and bombing incidents (32-
34); none, however, have experience of a sustained high
flow of casualties with multiple wounds from modern
antipersonnel fragments and fully jacketed bullets from
military assault rifles and machine guns. Exacerbating
this relative inexperience will be limited resources and
poor working conditions.
Wounds of modern war
Penetrating war wounds have been recognised as discrete
pathological entities for centuries (35-40). Scientific
study of these wounds was begun by Kocher towards the
end of the nineteenth century (41-42). Other valuable
contributions during this period were made by Otis
(43,44), Otis and Huntington (45), Hugier (46), Horsley
(47), Longmore (48), Woodruff (49), Stevenson (50) and
Treves (51). Contemporary research and progress is
covered extensively in the literature (18-29, 52-64).
Fragments and bullets
The pattern of wounding caused by missiles varies with
the nature of a campaign. In most conventional wars,
fragment wounds outnumber bullet wounds. Under the
special conditions of jungle warfare and urban terrorist
operations the ratio reverses (Table I). On a future
conventional battlefield, it is likely that most wounds will
be caused by modern antipersonnel fragments and mili-
tary bullets; fragments will account for the majority
(24,26). However, terrorists may use devices that are as
sophisticated as those in modern warfare.
Two antipersonnel fragment families exist; one old,
the other modern. The older fragment family is the
product of detonation of artillery shells and large calibre
mortar bombs. Natural fragmentation of the projectile
casing results in fragments varying in size from dust
particles to metal pieces of weight >20 g (Fig. 2) (65).
Initial velocities may be very high (>1500 m/s) but,
because of irregular shape, velocities decline rapidly.
Many casualties close to these exploding devices will die
immediately from multiple high energy-transfer wounds;
others will die from traumatic amputations caused by
dynamic blast overpressure (33). The majority of survi-
vors will have multiple, relatively low energy-transfer
wounds caused by fragments of variable size with low
impact velocities.
The modern fragment family arises from the incor-
poration into new munitions (modern hand-grenades,
small mortars and antipersonnel mines) of etched frag-
mentation plates, notched fragmentation coils or metal
spheres (Fig. 3). Detonation of these munitions produces
a large number of small, preformed fragments. Weapon
designers have expended considerable effort to produce a
consistent fragment size that offers the optimum com-
promise between range, velocity, probability of hit, and
terminal effectiveness. Modern, preformed fragments
weigh 0.1-0.2 g, diameter 2-3 mm and have initial
velocities which may exceed 1500 m/s; the velocities
decline rapidly with range (Fig. 4).
Table I. Distribution of wounding agents in casualties
for wars and campaigns this century
Bullets Fragments Others
World War I 39 61
World War II 10 85 5
Korea 7 92 1
Vietnam 52 44 4
Borneo 90 9 1
Northern Ireland 55 22 20
Israel 1982 11.6 53 35.5*
Falkland Islands 31.8 55.8 12.4
*
Israeli figures are complicated by the inclusion of psychiatric casual-
ties in the group designated 'other'

Figure 2. Natural fragments.
The aim is to incapacitate by inflicting multiple low
energy-transfer wounds to areas not protected by modem
helmets and body armour.
The majority of battlefield bullet wounds will be
caused by military bullets. These are fully jacketed to
prevent break-up; this is required by the Hague
Declaration of 1899. However, they may fragment at
close range or if they strike bone (21,22). The degree of
biophysical injury will be related to available kinetic
energy, wound track length, angle of yaw at impact and
along the wound track during penetration, tissue density
and propensity for deformation or fragmentation (26).
Figure 3. Types of preformed fragments.
Field surgery on a future conventional battlefteld 15
Figure 4. Types of preformed fragments.
Regional injury
Experience from past wars demonstrates a striking pre-
ponderance of limb wounds in those surviving to reach
forward surgical facilities (Table II). This is at variance
with probability calculations based on the presented area
of body regions. The preponderance is explained in part
by the use of body armour and the high lethality of torso
hits. The proportions vary statistically with the nature of
fighting and terrain. Jungle warfare and urban terrorist
conflict produce greater numbers of surviving chest and
abdominal casualties (Table II). This correlates with
close range or aimed rifle fire which characterises these
conflicts and generally reduces the incidence of limb
injuries.
Controversies
It is appropriate to summarise the present state of wound
ballistics before discussing management. Although con-
troversy is widespread, this is not as critical as it might
appear. The areas of controversy include:
i. The role of velocity.
ii. Temporary cavitation.
iii. Kinetic energy formula.
iv. Energy transfer.
i. The role of velocity
Fackler, in numerous papers (27-29), criticises sur-
geons and intensive care physicians for failing to under-
stand the role of missile velocity in wounding. He is
alarmed by the proposal by some that 'high-velocity
missile' wounds always require extensive excision of
tissues from and around the permanent wound track (66-
68). This is a seriously flawed view and is rightly
challenged. The corollary that low-velocity missiles are
trivial and require little treatment is proposed by others
and is probably more dangerous (66,69,70). It is more
appropriate to consider any missile, whether of high or
low velocity, capable of causing severe injury, given
certain circumstances. Most researchers in this field now
prefer to use the terms 'high and low energy-transfer
16 J M Ryan et al.
Table II. Distribution of injuries in casualties at surgery (%)
Headlneck
World War I 17
World War II 4 8
Korea 17
Vietnam 14
Borneo 12
Northern Ireland 20
Israel 1975 13
Israel 1982 14
Falkland Islands 14
* Israeli figures are complicated by the inclusion of psychiatric casualties in the group
designated 'other'
wounding' since these more accurately describe missile
and tissue interaction (20,24-26).
ii. Temporary cavitation
The significance of this phenomenon is widely misunder-
stood. Some regard it as a tissue stretch, rarely of
importance (27,28,71). Others grant it the capacity to
destroy tissue (66-68). It is a space created transiently by
the mass movement of tissue, produced by the rapid
transfer of energy to tissue and takes place in all tissues
but to a variable degree. It is not unique to high-velocity
or high energy-transfer injury (27,63) and is not an 'all or
none' phenomenon. The size of a cavity along a wound
track can be correlated to the degree of energy transfer;
the capacity of a cavity to produce injury is an extremely
contentious issue. It occurs only slightly in lung because
of low density in contrast to liver, spleen or brain which
are very susceptible and disrupt readily. The effect on
muscle is contentious; an increasingly accepted view
holds that cavitation in muscle, particularly in the
absence of missile or bone fragmentation, may result in
modest physical injury. However, its contribution to the
pathogenesis of war wound infection by disseminating
foreign body contaminants is widely overlooked.
iii. The kinetic energy formula
A serious misconception concerns the 'kinetic energy
formula' (KE = -MV2) which some regard as the formula
for energy transfer and, therefore, wounding power.
This formula, expounded for military surgeons by
Callender and French in the 1930s, indicates the energy
available to a missile and not necessarily what is imparted
to tissue (52). For example, if a missile perforates a target
and emerges with significant residual velocity, it will
retain much of its available energy. The amount of
energy imparted to a target is related to missile mass,
velocity, tendency to deform or fragment, behaviour
(angle of yaw) in flight and at impact, and tissue features
along the wound track.
Chest Abdomen Limbs Others
4 2 70 7
4 75 9
7 7 67 2
7 5 54 20
12 20 56
15 15 50
5 7 40 35*
4 5 41 36*
7 12 67 1
iv. Energy deposit and wounding power
Ballistic scientists, mainly in Sweden, use the amount of
energy deposit as a measure of tissue damage (19). Many
of their experiments are carried out using standardised
metal spheres which do not fragment and, of course, do
not change their presented area as they progress through
a uniform tissue simulant such as gelatin. In contrast,
biological tissue varies in response to similar energy
deposits. A moderate energy deposit may disrupt liver in
a subject, an equal deposit in muscle in the same subject
may produce little injury. Missile deformation or frag-
mentation during energy transfer will significantly
increase tissue injury due to laceration by multiple sharp
fragments; additionally, temporary cavities will be larger
due to increased rates of energy transfer. The role of
missile break-up has been extensively researched by
Fackler and his colleagues in San Francisco (21).
Contamination
All war wounds are contaminated from the outset by soil,
clothing and skin. Ambroise Pare's 'Case reports and
autopsy records' provides an early description; "I will be
content with the example of a soldier from whose thigh I
remember having removed a ball. It was wrapped in the
taffeta of his breeches. . . . " (72). This method of
contamination is due to direct transfer by a missile and is
a particularly important feature of fragment injury.
Fragments have been shown experimentally to cut cloth-
ing and skin efficiently; these contaminants are then
transported into wounds (64). Raising the fragment
velocity alters the nature of clothing contamination; at
high velocity cloth is finely shredded and dispersed
widely due to the formation of a temporary cavity. Thus,
extensive foreign body contamination of uninjured areas
some distance from the permanent wound track may
result (64). Where missile perforation occurs, a resulting
low pressure, temporary cavity may withdraw contami-
nants from the exit side; this is the principal source of
contamination by high-velocity military rifle bullets.

Current management strategy for battlefield
wounds
Misinterpretation of terms used in the United Kingdom
wound ballistics literature has led to misunderstanding in
comparing wound management techniques. Authors in
Sweden and North America use the term 'debridement'
for the entire surgical procedure used in war wound
treatment (20,25,73,74). Debridement, as understood in
the United Kingdom and France, is merely the first stage
in the war wound operation and involves, as the term
implies, the unbridling of the wound in preparation for
formal wound excision. Desault, working at l'Hotel-Dieu
during the French Revolution, defined debridement as
laying open a wound and removing foreign material but
not excision of dead tissue (75). Desault appears to have
taught the technique to Napoleon's surgeon, Baron
Larrey. Moffat (76) and Fackler (75) have correctly
defined the term in the contemporary literature.
United Kingdom protocols for battlefield wound man-
agement have been jointly influenced by ballistic research
findings and previous battlefield experience. Existing
protocols are far-reaching and include guidelines for
resuscitation (intravenous fluids, analgesics and anti-
biotics) and early wound management in the field.
Considered by some to be rigid, conservative and didac-
tic, they nevertheless represent the best compromise
between what is available in peacetime and what will,
realistically, be suitable for use in the field during full-
scale war. They are regularly updated. Specific surgical
techniques are also reviewed as new weapons are ana-
lysed and their wounding profiles elaborated. The under-
lying principles, however, are clearly stated (77).
Adherence to these principles is being increasingly called
into question, particularly by surgeons who have
managed civilian gunshot wounds by less radical means
(69,70,73). Broome and his colleagues in Swindon have
recently described management of 14 gunshot wounds
where primary wound closure over large drains was
achieved (34). They clearly accept that this approach is
only valid where casualties can remain under static and
permanent review by the operating surgeon, who should
be prepared to perform further surgery if complications
arise. This was necessary in two of the 14 Swindon cases.
The staged approach proposed in military protocols
would prevent these complications and is probably indi-
cated even in an ideal civilian peacetime setting. Its value
in war is now beyond doubt and remains the approach in
civilian hospitals in Northern Ireland. It worked well
in the Falkland Islands where morbidity and infection
rates were significantly low and return to duty rate was
high (78).
Special aspects of management
The delivery of optimal care where surgical facilities will
be stretched to the ultimate is a difficult goal. Specific
areas of management, which are relatively free of con-
troversy in peacetime, require reassessment in the light
of battlefield conditions and include the following.
Field surgery on a future conventional battlefield 17
Use of antibiotics
Military battlefield policy specifies antibiotics for all
wounds. The protocols were formulated at a time when
the magnitude of delay before treatment was perceived to
be 6 h or less for most casualties. The specified anti-
biotics are designed to defeat the bacteria encountered in
war wounds in the pre-antibiotic era. Current research is
examining the resident skin flora of the modern British
soldier under prolonged field conditions; Fleming and
Wright have proved that this flora largely determines the
nature of subsequent wound infection.
A future war will impose delays beyond 6 h for the
majority of lightly injured (P1 and P2) casualties.
Research is examining the ability of various antibiotic
regimens to delay the onset of invasive wound infection
in infected military wound models (64). Pertinent ques-
tions include whether it may be beneficial to issue
antibiotics to individuals for 'buddy/buddy' use imme-
diately after wounding-the cost and logistic impli-
cations may be offset by a reduction in the incidence of
wound infection.
The extent of wound excision
A concern, increasingly expressed, is that inexperienced
surgeons, relying on the ballistics literature for guidance,
are misled and embark on an over-radical wound excision
when treating gunshot wounds (27,28,71). Fackler has
termed this 'a treatment worse than the malady'. Also of
concern are papers proposing the reverse; reliance on
new broad-spectrum antibiotics and minimal surgical
intervention for uncomplicated gunshot wounds to limbs
(70). These views need to be examined in the context of
the battlefield.
In ballistic wounds where bone and neurovascular
structures are spared, minimal surgical management has
been shown to be safe; contamination is typically mini-
mal and treatment is promptly delivered in well-
equipped hospitals where wounds may be carefully
observed (34). This is at variance with battlefield con-
ditions; wounds are typically heavily contaminated,
caused by multiple fragments, delays are inevitable and
treatment is delivered under poor conditions by tired,
overworked and inexperienced teams. Under these con-
ditions, inadequate or minimal surgery, based on ill-
conceived concepts would result in large numbers of
infected wounds with all their attending sequelae.
Continuing difficulty remains in distinguishing non-
viable from traumatised tissue. Historically, surgeons
have depended on clinical judgement gained from wide
experience (79). The classical criteria of colour, consist-
ency, contractility and capillary bleeding, although long
relied upon, are guidelines at best. Much research effort
is being expended aimed at accurate determination of the
extent of soft tissue death after ballistic injury and
comparing these findings with clinical assessments; an
accurate method has yet to be developed (80-84).
Fackler has shown experimentally that transitory con-
striction of the microvascular circulation occurs around
18 J M Ryan et al.
temporary cavities; this is followed by hyperaemia after
some hours (29). He believes that the tissues surrounding
a missile wound are in a state of constant change;
blanching of tissues should therefore not be used as a
guide for wound excision. These observations are
important but, probably, are of little relevance to the
surgeon operating on war wounds under field conditions.
Blood and fluids for resuscitation
Blood is not normally available forward of 3rd line
hospitals; at forward echelons, volume replacement is
with electrolyte or colloid solutions. The current trend is
towards new colloid solutions; smaller volumes are
required, later cross-match is not impaired and adverse
reactions are minimal (polygeline solutions were used in
large quantities during the Falklands war without ill
effect).
Blood transfusion and infusion of intravenous blood
substitutes have been shown to be life-saving since World
War I. There is, therefore, a requirement in war to
provide large quantities of blood at field and general
hospitals. There is a logistic need to provide quantities of
donated blood far in excess of those normally required in
peacetime. The collection, preparation and distribution
of blood will present colossal logistic problems on a
future battlefield. These problems will be exacerbated by
recent constraints placed upon human blood transfusion
due to the ubiquitous human immuno virus. Current
research is centred upon the provision either of blood
substitutes, such as non-biological oxygen-carrying solu-
tions like fluorocarbons or free haemoglobin solutions, or
long-term storage of human blood. At present, stock-
piling of deep frozen red cells in a plasma substitute such
as hydroxyethyl starch, which can act as a cryo-
protective, appears to be the most promising option. The
use of autologous blood, collected pre- or peroperatively,
with recycling through scavengers is not yet appropriate
for field use; encouraging developments in the United
States, however, may result in effective recycling of
heavily contaminated blood on a future battlefield.
Postoperative wound care
The achievement of limb stability and length following
missile fracture poses unique problems on battlefields.
The morbidity and mortality associated with compound
femoral shaft fractures during nineteenth-century wars
was very high. The introduction of the Thomas traction
splint to the British Army in the summer of 1916 reduced
the mortality after this type of injury from 85% to 16%
overnight (85). Current trends are towards external
fixation systems; internal fixation is, of course, contra-
indicated on account of wound contamination. The use
of external fixators in war has now been widely reported
(86-88). The British Army Medical Services have de-
veloped a simple disposable system for use by general
surgeons operating in field hospitals. The immediate
benefits are pain reduction, limb stability, protection of
vascular repairs and ease of access for wound inspection
and dressing.
The longer term benefits are reduction in amputation
rates, infection rates and improved long-term prognosis
for vascular reconstruction (88). The system was used
widely by British military surgical teams operating in
Nepal after an earthquake. Reports from these teams
have led to experiments resulting in improved pin
design, greater versatility of application and improved
frame rigidity.
Discussion
We have outlined the different patterns of ballistic
wounding that may be seen in both peace and war and
indicated how these differences affect management.
Civilian and military medical agencies have different
needs and these should be recognised and understood.
Many may be moved by the persuasive arguments of
some surgeons and ballistics research workers to abandon
the well-proven methods of debridement, formal wound
excision and delayed primary closure for contaminated
war wounds. The use of high-dose, broad-spectrum
antibiotics, administered early and coupled to minimal
surgery is conceptually appealing and has been shown to
be effective for selected wounds in a civilian setting.
Military needs are different, and should be towards a
clearer understanding of future battlefield conditions and
how this may affect patterns of wounding and manage-
ment. Military surgeons should not be unduly influenced
by what may be achieved with carefully controlled
experimental wounds using animal models. These are
important experiments and broaden our knowledge of
ballistic science but their value for the military surgeon is
limited unless they address the issues of infection and
management.
Serious and complex clinical problems that would face
surgeons on a modern conventional battlefield have not
been addressed. Burn injury is a major example; such
injury could be widespread and would characterise
engagements involving armoured vehicles. Shaffir et al.
have left excellent records of the Israeli experience (89).
Our colleagues in the Army burns unit will outline the
problems in a future paper. Recent wars have highlighted
a previously unrecognised high incidence of penetrating
ocular trauma caused by modern, small, preformed
fragments (90,91). The use of nuclear or chemical
weapons would have a profound effect on organisation,
strategy and management. These problems are the sub-
ject of current military surgical research projects and will
be reported in the future.
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Received 4 October 1990