Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004–2014)

Correspondence to Capt Stacey Webster, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, United Kingdom; [email protected]

Key messages

• Eighty-seven per cent of UK deaths in Afghanistan were prehospital.

• Over half of the killed-in-action deaths were immediate, and two-thirds occurred within 10 min of injury.

• A primary injury to the head had a significantly shorter time to death compared to the abdomen and to the lower extremity.

• Significant improvement in survival can be attributed to a reduction in the prehospital case fatality rate (CFR) without an increase in the in-hospital CFR.

INTRODUCTION

Most fatalities from trauma, in civilian and military settings, die before reaching a medical treatment facility (MTF).^{1 2} Paradoxically, this is the least researched and understood phase of care. It is accepted that the sooner a patient reaches definitive medical care, the better the outcome from severe trauma.³ This has been appreciated for several decades of military conflict, and underpins the concept of MTFs being located as far forward as possible to minimise the time to definitive care. In recent conflicts, life-saving interventions such as prehospital emergency anaesthesia, blood transfusion and surgical procedures (for example thoracotomy) were pushed forward into the prehospital environment. These interventions, combined with senior decision making, were used to good effect in the recent conflict in Afghanistan.^{4 5} These advances in prehospital care have also been adopted in civilian practice, and are associated with improved early mortality.⁶

Historically, death due to trauma was thought to follow a tri-modal distribution.⁷ However, more recently this has been questioned, with many challenging the validity of this model in a modern trauma system.^8–10 Similarly, the ‘Golden Hour’ is a widely understood concept that describes the first hour following injury as the optimal period to intervene with life-saving intervention, and this has been used to drive improvement in the initial management of trauma patients and indeed the entire trauma pathway. However, the 60 min of the ‘Golden Hour’ are not based on robust evidence. It is not known how quickly life-saving intervention is needed in patients with time-critical potentially fatal injuries.

Op HERRICK was the UK’s contribution to the conflict in Afghanistan between 2002 and 2014. Survival from...