2.  In World War II, 30% of the Americans injured in combat died.  In Vietnam, this number dropped to 24%.  In the war in Iraq and Afghanistan, about 10 percent of those injured have died.  The reduction of deaths can be attributed to better trauma systems, timely access to medical care, and newer trauma approaches

3. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral- extremity (13.5%) hemorrhage. For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment (MTF=medical treatment facilities)

4.  Dueling began in ancient Europe as “trial by combat,” a form of “justice” in which two disputants battled it out; whoever lost was assumed to be the guilty party.  Challenging another man to a duel was not only considered a zenith of honor, but was a practice reserved for the upper-classes, those deemed by society to be true gentlemen.

5. VIOLENCE

6. 90,000 deaths and 20 million people disabled annually

7. 85 death per day3 death per hour4400 every seven weeks58000 in two years Equal to total US-Iraq war American soldiers mortality Equal to Total Mortality in Vietnam War

8. How does the trauma system respond to the civilian gunshot trauma? Is there any gap in the services.

9.  All patients during a year (n=71)  Referral Hospitals in Northeast of Iran  Transfer route,  Time intervals,  Pts Characteristics,  Clinical assessment,  Injury assessment,

10. Variable Homicide74% Male92% EMS Non-EMS Non-amb 20% 21% 59%

11. minutesD to ScA to DSc to HD to H Standard6101531 ours6.25 12.8536.4255.42

12.  Outcome was not better for non-EMS ambulance transported gunshot trauma in Iran (P=0.47) in terms of hospital stay after adjustment for the severity and age, but EMS transported individuals had slightly shorter hospital stay.

13.  The crude mortality rate was 9.3% in the non-EMS ambulance group and 4.0% in the non- ambulance group (relative risk, 2.32; P<.001) After controlling for confounding factors, the adjusted mortality among patients with ISS greater than 15 was 28.2% for the non-EMS ambulance and 17.9% for the nonambulance group (P<.001)

14.  Rapid transport rather than prolonged on- scene treatment (including maneuvers such as formal thoracolumbar immobilization) should be given the highest priority. Also, routine arteriography (another time- consuming and invasive procedure) in the treatment of gunshot wounds to the extremity is no longer the standard of care Clinical Orthopaedics & Related Research: March 2003

15. WHY IS THAT? PLEASE DO NOTHING MUCH!

16. (CMAJ, 2008)

17. Trauma Center Most severely injured Rehabilitation Interfacility Transfer Non-Trauma Center Other injured persons Prehospital Notification/EMS Access EMS response Triage Transport Ongoing Prevention Training Evaluation

19. Cost effective Optimal care Injury prevention

24. www.jammonline.com