Blast Injury and New Injury Patterns from Drone Warfare

In this episode of Frontline Surgery: Mastering Military Trauma Care, Drs. Joshua Dilday and Jeff Conner are joined by COL (ret) John Holcomb, MD to examine how modern drone warfare is reshaping battlefield injury patterns and the challenges facing deployed trauma teams. Drawing on recent experience working alongside Ukrainian clinicians and multinational partners, Dr. Holcomb discusses the evolving mechanisms of injury associated with drone-delivered explosives and the operational realities of providing care in contested environments.

The conversation explores how fragment injuries from aerial munitions are producing different anatomic injury patterns compared with previous conflicts, including increased head, neck, and upper extremity trauma. Dr. Holcomb highlights the importance of understanding mechanisms of injury, recognizing blast-related complications such as tympanic membrane rupture and traumatic brain injury, and managing patients with extensive fragment wounds.

The episode also addresses the operational constraints affecting casualty evacuation and resuscitation timelines in drone-dominated battlefields. With evacuation delays ranging from hours to significantly longer, frontline teams must adapt their approach to hemorrhage control, resuscitation, and resource management. Dr. Holcomb emphasizes that preparation for these environments requires both clinical readiness and system-level training, noting that high-volume trauma experience and strong team coordination remain essential for military medical teams preparing for deployment.

Keywords: Blast Injury, Drone Warfare, Military Trauma Care, Fragment Injuries, Combat Casualty Care, Damage Control Resuscitation, Battlefield Evacuation, Trauma Systems, Military Surgery, Austere Trauma Care

Transcript

SPEAKER_00 0:01

The drones are ubiquitous. There are thousands of drones in the sky every day. If it can be seen, it can be killed, is kind of what the guys are saying. And the fiber optic control drones are now going out 40-50 kilometers. So the red zone, the kill zone, extends 40 kilometers deep to the frontline.

SPEAKER_03 0:20

Enter the world of military trauma surgery with frontline surgery, where we bring you expert insights and real-world scenarios to help surgeons stay ready.

SPEAKER_01 0:29

Brought to you by the AST Military Committee. Join us as we engage in conversations with field experts to examine critical battlefield scenarios and uncover the strategies that keep surgeons ready for anything.

SPEAKER_03 0:42

Stay prepared and stay sharp with Frontline Surgery, where every episode provides key insights into mastering military trauma care. All right, welcome to Frontline Surgery, Mastering Military Trauma Care. Again, my name is Josh Trudilde. I'm joined with my co-moderator. We've done a couple episodes now. I'm joined with Jeff Connor. Jeff, how are you doing today?

SPEAKER_02 1:03

Good, excited to be here. I think we got a great episode today, but it's always good to be back on the pod with you, Josh.

SPEAKER_03 1:10

Yeah, it's right back at you. And I'm excited for this episode. You know, this series to again adjust the framework of the series, it's designed to prepare that early career military surgeon for the evolving realities of deployed trauma care. And today's episode, what Jeff alluded to, focuses on blast injury and the emerging injury patterns associated with modern drone warfare. And unfortunately, this is becoming an increasingly dominant threat in especially the large-scale combat operations which we're seeing in the shifting geopolitical climate that's affecting us today. This battlefield's changing rapidly, and so are the mechanisms. And we have to be prepared to manage those wounds and those patients that are kind of come in. And because of that, we've reached out to a repeat guest, an expert in the field, Dr. John Holcomb, who has both firsthand experience in treating these casualties and provides a system level perspective on how these injuries are reshaping modern military care. Dr. Holcomb, thank you so much for joining us again on Frontline Surgery.

SPEAKER_00 2:07

Yeah, it's great to be here. Thank you very much. Just for the group out there, anytime Josh and Jeff ask me to do something, I say yes. Well, thank you.

SPEAKER_03 2:14

We we ask you as often as we can because you're an expert and you've been a mentor to both of us. And specifically on this topic, can you kind of tell us what you've been doing recently in the realm of some of these injuries, whether it's drone warfare or some of these blast or explosion type injuries?

SPEAKER_00 2:32

You know, uh, guys, there's a group of us um have been in Ukraine and in Poland many, many times. And uh, as you all know, active duty guys can't go to Ukraine, which is unfortunate in some respects. And so early in the war, four years ago actually, today, got a call from some friends that were there. And uh they asked, Hey, can you send us over some PowerPoint slides about resuscitation? And I said, Well, of course. And a couple days later they said, Why don't you just come over and tell us about resuscitation? And and uh my wife said it was okay. So I went uh and and worked in western Ukraine, taking care of combat casualties, and then uh subsequently had been back in Ukraine four other times, so a total of five over the last four years of all that war. And more, probably more importantly, however, is we've had now 17 one and a half day symposia in Warsaw, where we bring Ukrainians out, uh bring US, NATO, and UK uh folks together for a day and a half, very focused, trauma systems, flood, mental health and providers, drones, et cetera, that kind of thing. 17 of those over the past three years, about every other month.

SPEAKER_02 3:43

Well, Dr. Olcom, that's that's incredible. I know that we, you know, in the in the military have used some of the things that, you know, from what you have seen and talked about at some of these conferences, have have given us really great insight into what future wars, you know, involving the U.S. may look like as well. Before we get started, I wanted to kind of run just a scenario to kind of set the stage for our talk today. Okay, so it's a late afternoon, you're at a roll to facility supporting forces in a contested environment. A small unmanned drone detonates over a patrol environment, dispersing fragments in a wide radius. And within minutes, you've got multiple casualties arriving with penetrating injuries to the head, neck, upper torso, with many small, high-velocity fragment wounds that are deceptively subtle on exam. Uh, several have altered mental status without obvious signs of hemorrhage, and your evacuation is delayed due to continued drone surveillance overhead. So just hearing that, what immediately kind of stands out to you in this scenario? And how does this differ or how does it differ from some of the blast injuries or some of the scenarios, the situations that we have dealt with in the past, maybe let's say in the Middle East?

SPEAKER_00 5:02

Yeah, Jeff, thanks. You know, number one, I just gotta say blast is like saying Xerox for all copiers, right? It's a slang phrase, and it's become uh part of almost part of doctrine, right? I mean, it's everywhere. As you guys know, there's primary, secondary, tertiary, and quaternary blasts, and some people even uh uh include a fifth part of that. But the bottom line is there's it open space explosions, which is the technically correct term, usually don't have a blast overpressure injury. If you're close enough to an explosion where you would get that blast overpressure wave, you're usually shredded and blown, literally blown to pieces. Now that's true with a 155 shell, which was the typical explosion in Iraq and Afghanistan. These smaller, usually smaller explosions from the drones at this phase of the war. Not earlier were there tanks and artillery warfare, but now the drones usually smaller. You know, you have to be really close to that one of those explosions to see the blast over pressure wave. It goes up very high and down very, very quickly when you plot that on the graph. That's been well described by the U.S. military since the end of World War II. In Korea, a lot of experiments were done that that documented this very nicely. So, in that scenario, which is all too common, you have to be aware of blast overpressure. You have to be aware of fragment injury, and you really want to know, try to find out pretty quickly, was this an open space explosion or a closed space? Did the drone fly into an underground area or or a or a trench where those that that blast wave would have reverberated back and forth, like we all learned in high school physics? The injuries that the Ukrainians are reported are different than what we saw in Iraq and Afghanistan, where predominantly saw lower extremity, chest atom pelvis, and and not minimizing the brain and tympanic membrane and that sort of thing, but less common. That's those injuries, because they now come from above, are very common on the Ukrainian battlefield. When the Ukrainians are reporting injury patterns, I would say that because of the proliferation of electronic warfare in all forms, our Ukrainian colleagues are loath to present numerators and denominators. They're loath to present exact woundy patterns from exact munitions, right? Because that informs enemy who may be listening to this podcast as we speak, the better ways to hurt Ukrainians. And so they're not going to do that, and and nor am I. I don't, I don't know that, and if I did, I wouldn't repeat it. But they have clearly said that injuries are coming from above. There's more head, there's more tympanic membrane, there's more eyes and neck and upper extremities. Lower extremity injuries are still very common, right? Um and and it, if you think about it, depends on the orientation of the soldier when they're hit by the hand grenade or mortar that falls from the sky. If they're standing upright, you have one injury pattern. If they're in a trench and laying flat, there's a different injury pattern, right? I mean, it kind of makes sense. So when people say what injuries do we need to be aware of, I would say all of them. Right? If I was a young surgeon preparing to go, or a young clinician, medic, doc, nurse to go to the battlefield today, it's my impression, having been in Ukraine multiple times and talking to lots of people, that every weapon in the arsenal is being used on the battlefield short of nuclear weapons. That's a pretty sobering statement, actually. But if I was in Yalstu, I would read and prepare for every injury.

SPEAKER_02 8:34

Absolutely. Something that you mentioned already a couple times, which I had a chance to talk to some of the Ukrainians out at UNC last year. What I didn't really think about as the trauma surgeon, always thinking about vascular injuries and penetrating injuries, was the tympanic membrane injury. Um, and they really focused on talking about that. How are they managing that, you know, downrange, or is that something that ENT is managing? How is the deployed trauma surgeon managing that?

SPEAKER_00 9:03

You know, we wrote about that, Jeff, in Iraq and Afghanistan and wrote some papers early on uh just about this. So fortunately, there's not much that needs to be done at the, I'll call it forward surgery team because I'm old, right? Because that's what we used to call it. There's not much you need to do other than, I think, diagnose it, right? Small tympanic membrane injuries heal on their own. Large tympanic membranes, 25% or more of the TM probably need 25 to 50 percent probably need some kind of tympanoplasty. Obviously, not done by general trauma surgeons, done by ENT folks back in the rear to restore their hearing somewhat to normal. I think the key is diagnosing the problem. And it reflects that blast overpressure. So when you do see a TM panic membrane rupture, then you need to go looking for other injuries, lung and bowel.

SPEAKER_03 9:50

And that's that's a great point because that comes up in the JTS guidelines, is that we should be screening all our TBIs for tympanic membrane. So that's something that we've we've identified from the coin era and before, and now we're seeing again even more in Lisco, but for a different environment, and it's drones. And you talked about the anatomic differences. What makes taking care of these patients in the drone injury era so difficult? Is it just the injury or is there more to it?

SPEAKER_00 10:16

Yeah, it's a great question, Josh. I would let's go back to the temping membang thing for just a second. Mild TBI and PTSD are really hard to differentiate. This is why you have to know where they were in relation to uh the explosion. You have to know what kind, if you can, what kind of uh munition went off, and then where there's an open space or closed space. And that really tells you what injury to go for. You know, it's kind of like the guy who falls off a three-story building and lands on his heels. You go looking for about five other injuries, right? We're all taught that in residency. Oh, by the way, we talked about it last week when I was at rounding. And and you go find those injuries. And, you know, sometimes they're they're subtle. So knowing the mechanism, if you will, of the injury and the injury patterns that are associated with this certain mechanism is really important. You know, um, I honestly don't think this individual injuries are any different. A fragment through the brain, the TM through the neck from a drone is like a fragment from an IED coming up and going through the eye, the brain, the neck that we all took care of in Iraq and Afghanistan. So the individual injuries are the same. I will tell you that the first time you see an explosion patient with a hundred holes, I don't know about you, but it knocked me back. Right? In the civilian world, you see a guy with one, two, three, four. We talk about the guy with 10 holes, but these soldiers, Satyrs, Airmen, Marines have a hundred holes. And each one has to be treated, you know, almost separately. You have to go look for the injury underneath. Wow. Wow. That hundred hole thing, I think is really important. And every time you deploy, it takes you a while to readjust to a soldier with a hundred holes. Usually, in my experience, the team needs about two weeks to switch over from civilian trauma to military trauma. And it's that guy with a hundred holes. Or, as you said, Jeff, four or five of them with a hundred holes all at once.

SPEAKER_02 12:08

So I guess kind of changing gears a little bit more, maybe on the team-based approach, system-based approach, what are some of the, you know, I mean, this goes without saying there are increased operational challenges in the drone-dominated environments. But how, how does that change, you know, your stabilization, your resuscitation time frame? Does it just depend? Or, or what are some of the things that you've seen, you know, or heard about in Ukraine that they're dealing with now?

SPEAKER_00 12:40

Yeah, Jeff, it's it's not a great story. Um, you know, the drones are ubiquitous. There are thousands of drones in the sky every day. If it can be seen, it can be killed, is kind of what the guys are saying. And the the fiber optic control drones are now going out 40, 50 kilometers. So the red zone, the kill zone, extends 40 kilometers away from the deep to the front line. Hemorrhagic shock patients, you know, with the evacuation timelines of anywhere from two to 12 hours, two on a really good day, 12 on a normal day, and and way longer. Days on much longer, you know, the guys in hemorrhagic shock are not making it back to the surgical facilities. It's um, you know, we've worked with the Ukrainian MOD. We've worked with folks on the front lines. The KIA rate triples, KIA rate triples, case fatality rate skyrockets. And uh you know, we talked rapid evacuations, which we were used to. Does happen. There are patients who come back in hemorrhagic shock, but it's not gonna be like at least what the Ukrainians are seeing because of the drones and the lack of air superiority, which has been well discussed. Drones have really changed that so much. The last I was in uh Ukraine in Kiev at a Tourniquet symposium in November of this year, and the quote was thousands of casualties evacuated by drowned drones. Ground drones. Thousands. That's the first time I've heard that number. A year and a half ago we had a symposium that talked about drones, and it was one or two. A very senior person said thousands by ground drones, which takes hours. So I mean, just think about that compared to you know, when I deployed, which is a long time ago, guys would come you know, within 30 minutes, we're off the battlefield. And that is not happening. So physiology has not changed, hemorrhagic shock has not changed, and timelines of death have not changed. What's changed is is the drones.

SPEAKER_02 14:42

So, you know, aside from having to hold these patients, these soldiers, you know, longer in that type of scenario, I imagine the supply chain to your surgical team is is reduced or non-existent in some cases. How I mean I mean, are you seeing ways of of resource mitigation or allocation or optimization from a from just uh consumable resources?

SPEAKER_00 15:10

Yeah, you know, we have uh you know, I did a GMO year in northern Turkey in 1986 and uh operated in as a GMO, went down and operated with uh some Turkish colleagues who reused disposable gloves, who reused gauze, reused lap pads. Um you know, if if I was uh doing this again, I don't know, frontline and supply was is an issue. What is an issue, as you said. Things that are disposable in our world back here in the United States become reusable when you're out and about. It's not just in combat. I mean, it's many places around the world. And that kind of mentality, I think, is a uh it's almost a frame shift for most of most of our guys and gals.

SPEAKER_03 15:59

You know, Dr. Holcomb, you mentioned the hundred holes versus the ten holes and really, really highlight the difference between deployed, austere, expeditionary surgery, and then what we see stateside. As a lot of the military trauma surgeons are coming from these MILSIF partnerships and integration and at least CONUS-based hospital systems, what should what should the future deployable surgeon be doing? You mentioned focused on every injury, but can you break that down a little bit? I mean, how how does one in an environment that seems otherworldly prepare to be the surgical leader on the front lines in the very near future?

SPEAKER_00 16:40

Josh, I think it I honestly think it's a very simple answer. And all I know is my personal experience. You know, I I I trained at a place, William Beaumont, El Paso, Texas. You know, not a not a lot of high fancy medicine was done there, but we did a lot of surgery. And then I went to Fort Bragg, and at that time it was it was I mean, we did just about everything. I honestly think that in training to prepare to go to the battlefield, that this crawl, walk, run, sprint paradigm that people talk about all the time, right? To me, the sprint is deployed combat casual care. That's the sprint. It's not easy. It requires a frame shift from a run, right? But the run, in my opinion, is at our MILSIP partnerships. That's the run. I've been back to multiple MTFs to visit. And outside of one, right? The MTFs are not busy. And there's not a lot of running going on. Now I I I've worked for the past six years in a MILSIP partnership in Alabama. You guys both work at MILSIP partnerships right now. When you're on call, you're running. I mean, literally, not just figuratively, but but literally when you're on trauma call. That is the best preparation today for going downrange and sprinting. No question in my mind. That's that's excellent.

SPEAKER_03 18:07

I mean, we both obviously support the military civilian partnership and in all the opportunities for the military engagement from the community, whether that's being trained in the MTF or partnerships in in whatever fit form or fashion, but I think that incorporating some of that running in those in those training environments is key to make sure that you can can hit that sprint as fast as you can when you get in that environment. Well, Dr. Holcomb, this was phenomenal. We had no expectation other than the fact that it was going to be phenomenal because we know what it's like for you to be a repeat guest on us. And for those listeners, we hope today was informative. Jeff, I think that this episode is just quite alarming. And we knew it would be, but it seems like every episode we do, especially as we start going into multiple seasons, the realities become more and more, more and more scary. I don't know what you're thinking where you are, but it it's a reality that we're not excited about facing, but we have a duty to do so.

SPEAKER_02 18:56

I totally agree. You know, I I love what you said, Dr. Holcomb, about the walk, run, sprint. Um, I don't think that they're, and we're fortunate, there is nowhere in the U.S. that we have to sprint and deal with hundreds and hundreds of holes and hundreds and hundreds of patients. That's a good thing, right? However, we've got to be prepared to handle that in the battlefield. And like you said, at some of these military-civilian partnerships, I also agree. I think that's the answer. Um, so I appreciate you you saying that. I appreciate all of your wisdom through this through this talk. It was it was great again. Um, and thanks for coming on.

SPEAKER_03 19:33

Well, there you go.

unknown 19:34

Dr.

SPEAKER_03 19:34

Olcom, thank you so much for joining us here on Frontline Surgery, Mastery in Military Trauma Care. Again, modern drone warfare is redefining the injury patterns that we see on the battlefield. You talked about the injury patterns, the anatomic differences, the resource allocation, the logistical issues, and you talked about how to prepare that we must evolve and fight and treat, take care of patients, and that being able to run as quickly as we can.

SPEAKER_00 19:56

Okay, just gonna make one last comment. Can we one last comment? The mic is yours. Go ahead, sir. It's quite interrupting. We've talked a lot about surgeons, but you know, it goes without saying that the team has to be ready to sprint, right? The team, the nurses, the medics, the CRNAs, the NFC, I mean, the whole team, right? Emergency medicine guys have to be ready to sprint. And no, it goes, it has to be said. It goes without saying, but it has to be said. The team is important. I'm glad you hit on that.

SPEAKER_03 20:25

And I think that's a phenomenal point to end on. This is a team, it takes an entire team to take care of these patients, especially in the the evolving battlefield. And with that, I don't think we have anything else to say, Jeff, except we'll end the way we end every podcast is stay sharp and stay ready. Thank you so much. We'll tune in next time.

SPEAKER_01 20:43

Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care. Be sure to join us next time for more expert perspectives and battlefield ready knowledge.

SPEAKER_03 20:55

Until then, stay ready.