1
Blast Overpressure
Effects
March 2019
UNCLASS IFIED
HQMC MCDAPO
2
In 2018, Headquarters Marine Corps Force Preservation Directorate
(MCDAPO), in collaboration with the Navy Marine Corps Public Health Center
(NMCPHC), initiated a longitudinal health record review of the medical encounter
data of 56 service members (SM) from Fox Battery 2/10 (F 2/10), which fired an
unusually high number of artillery rounds while deployed from April-September
2017. Initial analysis revealed that these SMs suffered a higher rate of traumatic
brain injuries (TBIs) than the rest of the artillery community. When scaled to larger
artillery units and future combat against peer/near peer adversaries, this
operational tempo could result in the artillery community suffering injuries faster
than combat replacements can be trained to replace them. Such human costs should
be incorporated into the evaluation of future programs and systems.
Subsequent analysis exploring correlations between combat and several
categories of medical conditions and procedures that might be caused by exposure to
combat revealed that artillery Marines, regardless of whether they have deployed or
not, suffer a higher rate of TBIs and Sensory injuries in comparison to Marines in
other MOSs. This difference is exacerbated the more an artillery Marine deploys.
Furthermore, in the five months prior to a combat deployment, TBIs suffered by
artillery Marines increase by a factor of 4, and once artillery Marines suffer a TBI,
they will suffer, on average, 1.2 additional TBIs per year of service after their initial
TBI and become more susceptible to spending extended periods of time on Limited
Duty. Artillery Marines and those in other combat arms MOSs require, on average, a
similar amount of medical care costs (~$600) for procedures related to BOP injuries
each year. This average cost accounts for 13% of total budgeted costs for medical
care for the average Marine ($4,471).
The characteristics of the blast wave that cause TBIs are not fully
understood at this time. As such, the Marine Corps should consolidate and fund blast
surveillance programs that monitor, record, and maintain data on blast pressure
exposure for individual Marines to inform ongoing research and the evaluation of
potential mitigation techniques and protective equipment. A 01 February 2019
memo signed by the Deputy Assistant Secretary of Defense for Health Readiness
Policy and Oversight outlines six lines of effort that should similarly guide the Marine
Corps’ efforts to improve the health and readiness of the artillery community.
Executive Summary
UNCLASSIFIED
HQMC MCDAPO
3
Background
Purpose & Scope
Methodology
Impact to the Force
Assessment of Those Most at Risk: Is Artillery
Different?
• TBIs
• Increased Vulnerability
• Sensory Injuries
• MSKIs
• Non-Deployed Injuries
• Limited Duty
• Medical Costs
Operational Significance
− Scaling to Larger Units
− Weapons and Marines
− TBI Considerations
Optimizing Warfighter Performance
− Prepare
− Prevent
− Protect
Current BOP Research
Conclusions
Table Of Contents
UNCLASSIFIED
HQMC MCDAPO
4
Background: In 2018, Headquarters Marine Corps Force
Preservation Directorate (MCDAPO), in collaboration with
the Navy Marine Corps Public Health Center (NMCPHC),
initiated a longitudinal health record review of the medical
encounter data of 56 service members (SM) from Fox
Battery 2/10 (F 2/10), which fired an unusually high
number of artillery rounds while deployed from April-
September 2017. NMCPHC found that all of these service
members experienced at least one medical encounter in
the year prior to deploying and accumulated a total of 628
outpatient records following the deployment (01 OCT
2017 to 15 MAR 2018).
− In these post-deployment records, NMCPHC found that about 25%
were for conditions or illnesses fitting into a category of
illness/injury directly related to overpressure and/or noise
exposure.
Background
Blast Overpressure (BOP) Injuries:
Injury caused by the effect of the blast wave on the body.
Primary blast injury occurs principally in the gas-filled organs
and results from extreme pressure differentials developed at
body surfaces. Organs most susceptible include the middle ear,
lung, brain, and bowel. This category of injuries includes
Traumatic Brain Injuries (TBIs). Many of the long term affects
are still not well understood.
UNCLASSIFIED
HQMC MCDAPO
5
Purpose: At the request of HQMC MCDAPO, NMCPHC conducted an initial
screening of the medical records for 56 SMs who deployed with F 2/10 to
characterize any injuries associated with a particularly high operational
tempo. This work aims to further quantify injuries associated with BOP.
It does not constitute research to establish a direct link between the cause
and effect. The primary objective is to provide a catalyst for further
research to inform risk mitigation techniques and protective equipment.
Scope: This study explores correlations between combat and several
categories of medical conditions and procedures that might be caused by
exposure to combat. These include bone fractures for other combat arms
and effects resulting from BOP, such as hearing loss, which is common
within the artillery community. MCDAPO examined medical data for
448,980 Active Duty Marines between FY08 – FY18:
− Deployed artillery Marines assigned to 2/10 and receiving combat pay
at the time of high intensity (103 Marines)
− In 1) Artillery, 2) Other Combat Arms, or 3) Other MOSs further
subsetted on A) having deployed and received Combat Pay, B)
deployed without receiving combat pay, or C) having not deployed in
the individual Marine’s career
Purpose & Scope
Category Artillery MOS Other Combat
Arms
Other
MOS
Combat Pay
5,289 77,070 137,136
Deployed,
no Combat
2,065 21,428 42,860
No Deployments (yet)
1,312 28,316 133,401
UNCLASSIFIED
HQMC MCDAPO
6
Due to limitations imposed by the Institutional
Review Board (IRB), the MCDAPO strips all records
of personally identifiable information. Therefore, it
is not possible to confirm that all 56 Service
Members (SMs) included in the NMCPHC study were
part of the 103 Marines deployed with 2/10 during
the specified time.
MCDAPO analysis utilizes NMCPHC health care data;
non-Navy provider care is not included.
MCDAPO uses the Civilian Health and Medical
Program of the Uniform Services (CHAMPUS)
Maximum Allowable Charge (CMAC) to estimate the
costs of procedures. Actual costs incurred by the
medical provider are very likely to be significantly
higher.
For the purposes of this study, “combat” is defined as
deploying to a combat tax exclusion (CTE) zone and
receiving imminent danger pay.
The exposure rate of BOP injuries used in this study
for illustrative purposes was derived from the 17
unique SMs out of the total 56 in the original
NMCPHC analysis who were diagnosed following
145 days of combat deployment.
Additional Assumptions
UNCLASSIFIED
HQMC MCDAPO
7
MCDAPO identifies medical diagnoses using versions 9 and 10 of the
International Statistical Classification of Diseases (ICD- 9 and ICD-10)
codes captured in:
− Comprehensive Ambulatory/Professional Encounter Record (CAPER)
− Standard Ambulatory Data Records (SADR)
− Standard Inpatient Data Record (SIDR)
− Theater Medical Data Store (TMDS)
ICD-9 and ICD-10 codes are grouped into 20+ categories, of which we give
special consideration to the following:
The MCDAPO estimates treatments for medical diagnoses from medical
procedures using the Current Procedural Terminology (CPT) codes in
CAPER and SADR and then map to the Civilian Health and Medical Program
of the Uniform Services (CHAMPUS) Maximum Allowable Charge (CMAC) in
order to understand costs.
− Note: CHAMPUS costs are maximum allowable costs and not actual costs. They are set
below the costs of providing care, resulting in underestimating the true cost of healthcare.
Similar to ICD codes, CPT codes can broadly be categorized in 10 main
areas, of which we give special consideration to (1) Digestive System, (2)
Musculoskeletal System, and (3) Endocrine, Nervous, Eye, and Auditory
(ENEA) System procedures, which broadly support the ICD groups above.
From these groups, a series of hypotheses tests and other statistical
significance tests are utilized to identify differences in medical costs
between Marines from different MOSs.
Methodology
ICD
Group
Number of Codes
Considered
Number of
Person
-Events
TBI
-Specific
31
83,606
Musculoskeletal
745
114,863
Sensory
73
143,485
UNCLASSIFIED
HQMC MCDAPO
8
Since FY15, the Marine Corps has experienced a steady
increase in TBI, Sensory, and Musculoskeletal injuries
(MSKI).
Approximately 7.5% of the force experiences at least
one TBI, and 3% experience multiple TBIs.
In FY17, there were over 39,000 unique electronic
health records (EHR) with a diagnosis of interest.
By understanding these effects, the Marine Corps can
inform its investment in materiel and non-materiel
mitigation strategies to better preserve the force and
correspondingly lower costs for both medical care and
medical separation.
Impact to the Force
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18
Percent of End Strength
Number of Distinct Medical Records
Number of Distinct Medical Records and
Percent of End Stregth with Diagnoses of Interest
Distinct Medical Records Percent of End Strength with Diagnoses of
UNCLASSIFIED
HQMC MCDAPO
9
Artillery Marines are diagnosed with TBIs at higher rates than
other MOS groups over the course of their Active Duty careers.
This differential did not manifest itself between 2014 and 2015
when Marines went on fewer combat deployments; however, it
becomes prevalent again in 2016 when combat operations
escalated.
The 103 Marines deployed in combat from 2/10 suffered an
even higher rate of TBI than the rest of the artillery community.
Traumatic Brain Injuries
106 Artillery
870 Combat Arms
Traumatic Brain Injuries (TBI): usually result from a violent blow or jolt to the head or body.
Mild TBI may affect brain cells temporarily. More-serious TBI can result in bruising, torn
tissues, bleeding and other physical damage to the brain. These injuries can result in long-term
complications or death.
UNCLASSIFIED
HQMC MCDAPO
10
Over 25% of Marines who go
on a combat deployment will
have already been diagnosed
with a Sensory injury or TBI.
In the five months prior to a
combat deployment, TBIs
suffered by artillery Marines
increase by a factor of 4.
Once these artillery Marines
suffer a TBI, they will suffer,
on average, 1.2 additional
TBIs per year of service after
their initial TBI.
Increased Vulnerability
0%
10%
20%
30%
40%
50%
60%
70%
-10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16 18 20 22 24
First Diagnosis Relative to First Month of Combat
TBI
Sensory
MSKI
Prior to Combat
In/Post Combat
UNCLASSIFIED
HQMC MCDAPO
11
The diagnoses of interest (Sensory, TBI) vary between
occupational fields even among Marines that have never
deployed. These differences, however, do not manifest
themselves in the diagnoses of other injuries, such as MSKIs.
Artillery Marines receive a higher number of TBIs and sensory
injury diagnoses than Other MOS groups over the course of
their Active Duty careers.
Artillery Marines who have not deployed suffer MSKIs at lower
rates in comparison to Marines in Other Combat Arms MOSs
and Marines in Other MOS groups who have not deployed.
This difference remains even after less severe MSKIs (e.g.,
dislocated fingers, superficial lacerations, etc.) are eliminated
from the analysis.
Non-Deployed Injuries
Non-Deployed Marines with
Diagnosed Sensory Injuries
Non-Deployed Marines with
TBI Diagnoses
Non-Deployed Marines with
Musculoskeletal Diagnoses
Artillery Marines suffer TBIs and Sensory injuries at a higher
rate than other Marines.
UNCLASSIFIED
HQMC MCDAPO
12
Limited Duty
On average, 3.78% of the Active Component was in Limited Duty each
month in FY17, which equates to roughly $584M in personnel costs
incurred by Marines on Limited Duty who were not able to fully
perform their assigned jobs.
Of the Marines in a Limited Duty status, 75% spend less than a third
of their careers in a Limited Duty status.
However, for Marines with a history of TBI, only 66% spend less than
a third of their careers in Limited Duty status.
Approximately 14% of artillery Marines are diagnosed with BOP or
TBI related injuries at some point in their career, making them more
susceptible to spending extended periods of time on Limited Duty.
Percent of Marines Careers Spent on Limited Duty Status
75%
66%
33%
UNCLASSIFIED
HQMC MCDAPO
13
Medical Costs per Year
Between FY12-FY17, estimated medical costs for procedures to repair
Marines for certain BOP injuries (e.g. Digestive, ENEA, or
Musculoskeletal system procedures) totaled, on average, $31M/year.
However, these costs do not include Evaluation and Management
Services (includes a wide range of services), which exceed $113M per
year on average and totaled over $146M in FY17 alone.
Artillery Marines and those in other Combat Arms MOSs require, on
average, a similar amount of medical care costs (~$600) for
procedures related to BOP injuries each year. This average cost
accounts for 13% of total budgeted costs for medical care for the
average Marine ($4,471).
Marines in Other MOSs tend
accrue lower costs per year
due to MSKI and ENEA
procedures than Marines in
Combat MOSs.
Artillery Marines accrue
higher costs from ENEA
procedures, but this
difference is within the
confidence interval for
Combat and Other MOSs.
UNCLASSIFIED
HQMC MCDAPO
14
Medical Costs of Combat
Medical costs increase over time at a similar rate across the MOS
groups. As Marines get older and accrue more time in service,
total medical costs do not vary drastically between MOS groups.
As OPTEMPO (i.e., number of months in which a Marine receives
combat pay) increases, medical costs increase at a slightly higher
rate for artillery Marines than for those in non-artillery MOSs.
Medical costs for Artillery Marines increase at a higher rate
for each month they are in combat as compared all other
Marines.
Wider variability between MOS groups
when considering months in Combat
Median Cumulative Medical Costs
by Time In Service
Median Cumulative Medical Costs
by Number of Combat Months
UNCLASSIFIED
HQMC MCDAPO
15
Operational Impacts
Estimating Similar Exposure to Larger Units
Standard Artillery
Battery
per Table of Organization
T/O 1113G
147 Personnel
6 M777 Howitzers
Estimated Full Battery
• 45 individuals with
exposure diagnoses
• 33,600 rounds fired
• 232 rounds per day
• 3,360 rounds at Zone 5
Standard Artillery
Battalion
447 Personnel
18 M777 Howitzers
Estimated Full Battalion
• 135 individuals with
exposure diagnoses
• 100,800 rounds fired
• 696 rounds per day
• 10,080 rounds at Zone 5
Standard Artillery
Regiment
800 Personnel
36 M777 Howitzers
Estimated Full Regiment
• 240 individuals with
exposure diagnoses
• 201,600 rounds fired
• 1,390 rounds per day
• 20,160 rounds at Zone 5
This OPTEMPO may result in artillery units suffering injuries
faster than combat replacements can be trained to replace
them.
Although F 2/10’s OPTEMPO is unique in recent
history, future combat against peer/near peer
adversaries may dictate operating at or above this
OPTEMPO. As such, we explore the impact this
OPTEMPO would have on larger units.
UNCLASSIFIED
HQMC MCDAPO
16
Human System Integration
Weapons and Marines
Weapon Service Life
• M776 Cannon ~ 2,650 Equivalent
Full Charges (EFC) per TM9-1000-202-14
• F 2/10 OPTEMPO: 8 EFCs per gun per day
331 Days to condemn cannon
Combat Effectiveness of Marines
• Exposure = 1 Marine every 9 days
• Exposure rate based on F 2/10’s total number of
unique diagnoses (17 SMs) and total deployment
length (145 days)
Degraded = 18 Days
Combat Ineffective = 48 Days
Given F 2/10’s OPTEMPO, an M777A2 gun crew would become combat
degraded in less than 3 weeks, which is significantly less time than it is
estimated to take the howitzer out of service for repairs.
The warfighting capability of artillery units is
based on both the equipment and the Marines. F
2/10’s high OPTEMPO resulted in cannons becoming
unserviceable and Marines being diagnosed with
service related injuries.
UNCLASSIFIED
HQMC MCDAPO
17
Major Combat Operations
TBI Considerations
In a larger scale operation, more than 90 Marines in an
Artillery Battalion could suffer a TBI in support of high
sustained rates of fire .
Based on planning estimates in an artillery battalion could
potentially fire 3x the daily average number of rounds fired
by F 2/10 in support of a major combat operation each day.
Such an OPTEMPO could result in more than 20% of the
battalion suffering a TBI.
Estimated Full Strength
Battalion operating at F
2/10 tempo
Estimated Full Battalion
• 8 individuals with TBI
a diagnosis
• 696 rounds per day
Notional OPLAN
Artillery Battalion
Estimated Full Battalion
• 91 individuals with a
TBI diagnosis
• 1,832 rounds per day
1,832 rounds per day
derived from MAGTF Staff
Training Program (MSTP)
Pamphlet 4-2 artillery
battalion Day of Supply
(DOS)
UNCLASSIFIED
HQMC MCDAPO
18
Background: Education concerning the mitigation of BOP exposure and the identification of
BOP symptoms is extremely limited in the artillery community. Current Marine Corps Orders do
not address BOP specifically in relation to risk management, and current guidance in JtRegtO
P3570.1F is somewhat misleading in implying that BOP symptoms manifest themselves
immediately. The potentially deleterious effects of sub-concussive blasts over time are
seemingly ignored. The artillery community would benefit from more education and research
concerning the human costs of BOP, as well as potential mitigation techniques and equipment.
A 01 February 2019 memo signed by the Deputy Assistant Secretary of Defense for Health
Readiness Policy and Oversight outlines the following six lines of effort that should similarly
guide the Marine Corps’ efforts to improve the health and readiness of the artillery community.
Optimizing Warfighter Performance
Prepare
Line of Effort Objective
Research
Develop a research strategy and plan of action
focused on promoting warfighter brain health and
countering TBI.
Surveillance and Prevention
Develop a health surveillance program and utilize the
established Section 734 (of the NDAA for FY 2018)
Workgroup and program structure to formulate a
strategy and action plan.
Diagnosis, Treatment,
Rehabilitation,
and
Reintegration
Assess and improve the TBI standard of care, the
translation and implementation of research findings
into healthcare practices and health policy, access to
and improvement of TBI care, and the rehabilitation
and reintegration of service members who have
sustained a TBI.
Outreach, Education, and
Training
Assess and improve communications
about, and
promoting awareness of, warfighter brain health and
surveillance initiatives.
Long Term Effects of TBI
Synthesize current knowledge related to long term
and late effects of TBI, as well as mitigation and
countermeasures
to reduce or eliminate them.
Section 734, NDAA FY 18
Coordinate with established
working groups to
successfully implement
a strategy for the
development of a longitudinal medical study on blast
pressure exposure of service members in combat and
training.
UNCLASSIFIED
HQMC MCDAPO
19
Optimizing Warfighter Performance
Prevent/Protect
Category Status Future Assessments Estimated Savings
Hearing
Enhancement/
Protection
Headsets
PM ICE will buy 2,640 hearing
enhancement/protection
headsets for artillery Marines
in July 2019 and expects
deliveries
to begin around
October 2019.
a Marine’s
do not improve
-related
Marines with
a history
of BOP related injuries
on average incur nearly
$10M more annually on
Auditory Procedures as
compared to those
without BOP injuries. A
10% reduction in these
procedures could save
$1.6M per year in costs.
BOP Software
Upgrade
PM TAS will field a software
upgrade that incorporates a
BOP feature that counts BOP
points based upon what
round/propellant combination
is fired. The software provides
warnings when the operators
reach 80% and 100% of the
maximum allowable points in a
24
-hour period. This upgrade
will be implemented this fall to
synch with an AFATDS update.
and BOP is
terrain and weather,
. Fund and
-of-care.
BrainScope is FDA
-
approved medical
device which aids in the
diagnosis of both
concussions
and TBIs.
The commercial cost of
each device is less than
$20,000 (the one
-time-
use disposable EEG net
costs less than $200),
and the results can be
determined by a medical
professional with
minimal training. In
contrast, CT scanners
cost between $50,000 to
$80,000 and MRI
scanners cost at least
$150,000.
Evaluate Non-
Development
Item Purchase of
Wheeled
Systems
Recently,
many foreign
militaries have developed and
acquired wheeled, self
-
propelled howitzers due to
their mobility, transportability,
and reduced maintenance
costs. These wheeled systems
require fewer
operators.
wheeled systems will
these
Transitioning to a
wheeled system would
save approximately
$200K
-250K 18FYD per
gun crew
in manpower
costs.
UNCLASSIFIED
HQMC MCDAPO
20
In April 2018, the DoD Blast Injury Research
Program Coordinating Office published an
information paper in response to an RFI on wearable
blast sensory. The Marine Corps should use this
information paper to justify the acquisition of TRL 9
and MIL-STD-810 compliant devices (e.g., the B3
Wearable Blast Sensor) that can monitor an
individual Marine’s blast exposure level and thus
inform ongoing research.
On 14 February 2018, the FDA approved a blood-
based biomarker test for TBI; however, no TRL 9 and
MIL-STD-810 compliant devices capable of
measuring these biomarkers exist at this time.
Most recently, on 2 January 2019, the FDA approved
the medical device BrainScope (and EEG-based
monitor) for multi-modal, multi-parameter
concussion assessment. Acquiring and deploying
this device to Marines in theater could reduce rates
of TBI-related MEDEVACs and Limited Duty status.
Current BOP Research
UNCLASSIFIED
HQMC MCDAPO
21
Conclusions
F 2/10 fired an unusually high number of rounds during its
April-September 2017 deployment, resulting in a TBI rate
exceeding the rest of the artillery community.
Further analysis revealed that artillery Marines, regardless of
whether they have deployed or not, suffer a higher rate of TBIs
and Sensory injuries in comparison to Marines in other MOSs.
This difference is exacerbated the more an artillery Marine
deploys.
The characteristics of the blast wave that cause TBIs are not
fully understood at this time. As such, the Marine Corps should
consolidate and fund blast surveillance programs that monitor,
record, and maintain data on blast pressure exposure for
individual Marines to inform ongoing research and the
evaluation of potential mitigation techniques and protective
equipment.
Develop a more robust POI concerning the effects of BOP
exposure, the identification of BOP symptoms, and potential
mitigation techniques.
Ensure human costs are incorporated into the evaluation of
programs and systems.
UNCLASSIFIED
HQMC MCDAPO
Questions
22
UNCLASSIFIED