Battle Field Casualties
The Royal Netherlands Armed Forces
2006-2010
4 years Uruzgan

INTRODUCTION
The Royal Netherlands Armed Forces (RNAF) are currently engaged in a prolonged
conflict in Afghanistan. This operation is the largest scale armed conflict for
the RNAF since the Second World War.
The experiences of all coalition combat operations in Iraq and Afghanistan have
served to highlight the need of innovations and improvement in military
medicine and combat casualty care 1. Out-of-hospital treatment of combat
casualties is a critical component of emergency medical practice on the
battlefield. Accurate understanding of battle injury (BI) is essential to
improve tactical combat casualty care (TCCC) 2,3. Earlier studies by several
authors have stated the importance of collecting casualty statistics for
research programs to improve organisation of healthcare delivery and training
of combat medics 4,5. However, prehospital medical documentation of military
combat battle injuries and subsequent transferral of this information to the
first line hospital is still insufficient or plain deficient.
In his 2009 study, Blackbourne 6 concluded, *There is currently no pre-hospital
data for the combat wounded and a system for accurate documentation of
pre-hospital care must be found.*
The Joint Theater Trauma Registry (JTTR, JTTS) has greatly enhanced the
organization of trauma care in trauma zones, especially with the advent of the
joint theater trauma registry. The JTTR, by providing us with snapshots of both
injury patterns and outcomes, has helped us to track trends over time. Our
challenge now is to complete the registry and add specific injury pattern
modules that will allow for detailed epidemiology to direct process
improvement, research, and new protective or therapeutic interventions.
An example of a specific injury pattern is the impact of Improvised Explosive
Devices (IED) on the lower extremities. Haemorrhage is the major injury
mechanism of preventable deaths.
Data on the impact of evacuation time on specific injury patterns will help
guide indications for Damage Control Resuscitation (DCR) for medics. In the
RNAF no prehospital standardized registration system for the combat wounded
exists, therefore we must find a system for standardized documentation of
prehospital care. We must also obtain short - and long term follow-up data
regarding surveillance of treatment outcomes for the unique mechanisms and
wounding patterns of combat, austere surgery, and global evacuation to help us
anticipate to unforeseen (long-term) problems after being wounded in combat 7.
Therefore we strongly recommend the use of the JTTS or a similar trauma
database within the RNAF 8 .


Because the lack of evidence and information concerning protocol, standardized
registration and demographics we propose a study. This study evaluates these
important questions that need to be answered for optimal initial pre-hospital
treatment of Battle casualties, subsequent hospital treatment and long term
follow up.
In cooperation with the Ministry of Defence, Leiden University Medical Center
(LUMC), Medical Center Haaglanden (MCH) we will conduct this study.

In this study we distinguish the following phases after a battlefield casualty.
* The actual moment of the incident and the direct combat casualty care.
* Transfer of information from the battle field to the second line hospital.
As a warning order to treat the casualty in the role 2 hospital.
* Treatment in the role 2 hospital.
* Possible treatment or rehabilitation in role 3/4 hospital either in
Afghanistan or The Netherlands.
* The long term functioning of the Battle Casualties in or outside the RNAF.

In this study the focus will be on the initial Battle Care provided up to the
role 2 (1-3) and the long-term follow up (5) of Battle Casualties.

RESEARCH QUESTIONS
* Is the currently used RNAF protocol for the acute medical care on the
Battlefield sufficient.
* What recommendation can be made to enhance this protocol, with emphasis on
the transfer of information from battle field to second line hospital
* What is the long term quality of life of the Battle Casualties.
* What recommendations can be made to enhance the quality of life of soldiers
wounded in action on the short and long term.

GOAL
The overall goal of this study is to enhance the standard and quality of care
of the battle field casualties of the RNAF.
Of specific interest is the enhancement of the information processes from the
initial battle field incident to the second line hospital.
Secondly, given the fact that both (im-)material, emotional and social
consequences of battle field casualties is high, now and in the future, this is
an area of the highest relevance for the RNAF, the individual soldier and last
but not least his/her family.
Results of this study will be submitted to peer reviewed papers, presented at
congresses and incorporated in (new) protocols, education and training of all
involved professionals.

RATIONALE AND ETHICAL CONSIDERATIONS
This study will recognise and enhance the quality of the short and long term
care of persons that perform -national- duties in the RNAF. For the general
public it will be an indication of how respectful and professional the
(political) leadership in The Netherlands approaches this subject now and more
important in the future.
For the persons (patients) involved it may give an extra indication of the
importance given to their task to perform (dangerous) missions for their
country.

Phase 1: Crossectioneel Analysis from available data
Phase 2: Observationeel Follow Up, with digital questionnaire (non invasive)
Phase3: Observationeel Follow Up, 10 year analysis

Not applicable