In this group of patients from Mogadishu Somalia in 1993, uncontrolled hemorrhage caused 22% of the fatalities.16 Hemorrhage continued to be a major cause of battlefield death and is the leading cause of combat death when evacuation is delayed for more than 6 hours.

The soldier who slowly exsanguinated from a proximal femoral artery and vein injury despite the efforts of a medic and others to stop the bleeding is a particularly poignant example. This again illustrates the point made by Bellamy in 1984,17 when in his discussion on improving the salvage of combat casualties, he stated, “First and foremost, there is a need to improve the field management of hemorrhage.”

Clearly, the management of choice for severe extremity hemorrhage is an effective tourniquet followed by surgical repair or ligation of the injured vessels. The incidence of fatal head wounds was similar to that in Vietnam in spite of modern Kevlar helmets. Body armor reduced the number of fatal penetrating chest injuries. Penetrating wounds to the unprotected face, groin, and pelvis caused significant mortality.

But what about injuries not amenable to a tourniquet, such as those to the lower abdomen, groin, axilla, and proximal extremities? What is the optimal management for these patients on the urban battlefield of the future, where evacuation may be significantly delayed?