Dutch combat operation experiences in Iraq and Afghanistan: The conundrum of low surgical workload deployments

The Combined Joined Task Force - Operation Inherent Resolve is the military intervention of Iraq and Coalition Forces in the battle against Islamic State of Iraq and Syria (ISIS). Al Assad Airbase (AAAB) is one of the key airbases. It contains a Role 2 Medical Treatment Facility, primarily to perform Damage Control Surgery in Coalition Forces, Iraqi National Security Forces and Local Nationals. We present a six month medical exposure in order to provide insight into the treatment of casualties and to optimize medical planning of combat operations and (pre-/post-) deployment training.

This is a cohort study of casualties that were admitted to the Role 2 Medical Treatment Facility AAAB from November 2017 to April 2018. Their mechanisms and types of injury are described and compared to those sustained in Uruzgan, Afghanistan between 2006-2010. Additionally, they are compared to the caseload in the Dutch civilian medical centers of the medical specialist team at AAAB.

There were significant differences in both mechanism and type of injury between Coalition Forces and Iraqi Security Forces (p = 0.0001). Coalition Forces had 100% disease and non-battle injuries, where Iraqi Security Forces had 86% battle injuries and 14% non-battle casualties. The most common surgical procedures performed were debridement of wounds (38%), (exploratory) laparotomy (10%) and genital procedures (7%). The surgical caseload in Uruzgan, Afghanistan was significantly different in aspect and quantity, being 4.1 times higher. When compared to the workload at home all team members had at least a tenfold lower workload than in their civilian hospitals.

The deployed surgical teams were scarcely exposed to casualties at AAAB, Iraq. These low workload deployments could cause a decline in surgical skills. Military medical planning should be tailormade and should include adjusting length of stay, (pre-/post-)deployment refresher training and early consultation of military medical specialists. Future research should focus on optimizing this process by investigating fellowships in combat matching trauma centers, regional and international collaboration and refresher training possibilities to maintain the expertise of the acute military care provider.