This is an epidemiological description of the physical injuries sustained by Norwegian soldiers during combat in Afghanistan. We found that most of the deaths had been caused by exploding IEDs, and that most of the combat-related injuries were slight. The extremities were most frequently affected. Our absolute figures for combat injuries and casualties in Afghanistan are so low that a statistical comparison with figures from the US is impossible. As of 16 November 2011, a total of 1 439 combat-related deaths and 14 837 combat-related injuries had been registered among US soldiers in Afghanistan since 2001 (11). We found that the mechanisms and locations of injuries among Norwegian soldiers were identical to those previously reported for US soldiers (12, 13, 14).
The Revised Trauma Score, which is a weighted estimate of respiration frequency, systolic blood pressure and the Glasgow Coma Scale (7), showed that these values were relatively low at arrival at the surgical facility. The TRISS values indicated that the probability of survival was not significantly reduced for most of them, while one soldier had an approximately 30 per cent reduced probability of survival. Commonly, a patient is classified as severely injured if the ISS exceeds 15, and traffic-accident victims with an ISS of 16 and higher have a considerably increased mortality (15). We chose to include three patients with ISS scores of 5, 10 and 11 respectively in a group described as severely injured soldiers. The remaining soldiers in this group had ISS scores above 26. To describe whether a patient was severely injured or not, we used values such as physiological observations and degree of haemorrhaging, in addition to an anatomical classification. It has been documented that the ISS system is not equally well suited to describe the degree of severity and prognosis for penetrating trauma as it is for blunt trauma (16). We have described how 28 patients sustained lighter injuries with an ISS score under 5 and no reduced probability of survival. We have not examined how many of these were able to return to duty within 72 hours, since Norway follows a practice of not returning soldiers to duty immediately after having been injured. Our group of slight injuries will therefore not correspond to the American concept of RTD.
US figures show that the proportion of soldiers who are killed in action but potentially could have survived amounts to 20 – 30 per cent. Of these, approximately 75 per cent die before arrival at a surgical facility, and 25 per cent after arrival (12). The concept of «potentially survivable» is used in military traumatology, and is comparable to the civilian «preventable death». In addition to a medical assessment of whether the injury in theory could be survivable, it also includes an assessment of whether local combat circumstances have rendered treatment or evacuation impossible (10). Any registered death after a potentially survivable injury should give rise to a critical review of the initial treatment of the patient. If the death occurs after arrival at a surgical facility, this facility should also be made subject to review. No Norwegian soldiers died of injuries that were potentially survivable. Approximately five per cent of all soldiers who fall in combat die after arrival at a surgical facility (9). All fallen Norwegian soldiers died before arriving at a surgical facility.
There are many reasons for undertaking medical research during wars. HSE efforts for soldiers in combat may appear impossible, but detailed registration of injuries has proven to help produce innovations that improve the protective gear and general combat tactics of soldiers (17). The JTTR registry continuously collects all data concerning mechanisms of injury, physiological findings, diagnostic studies, therapeutic measures and treatment outcomes for all injured and fallen soldiers. As of November 2011, a search in PubMed using the search term «combat injury» results in more than 2 000 hits, whereof approximately 1 250 publications are related to Afghanistan or Iraq. In the majority of these, the data are taken from the JTTR registry. Registration of patient pathways and outcomes of treatment of soldiers have provided new knowledge which is directly transferable to the treatment of civilian trauma patients. Knowledge from this registry has given rise to changes in the principles of fluid therapy for severe burn victims and to the introduction of protocols for massive blood transfusion in cases of severe injury in the civilian health services (18). In addition, registration of medical data is necessary for the monitoring and quality assurance of large and complex trauma systems (19).
This study illustrates a weakness in the Norwegian Defence Forces’ system for documentation of war injuries to date: all the data were collected in a retrospective review of medical records, and not from a prospective trauma registry. A Norwegian implementation in the existing JTTR registry could provide better quality control of medical evacuation and treatment (20). As regards our reported findings, the information is relatively reliable, because the records contain all medical information assembled from the initial assessment and treatment, including notes from the various elements of the treatment chain, to patient histories from civilian Norwegian hospitals that have been responsible for the final treatment of the soldiers.