Battlefield medicine made unprecedented strides during Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan, resulting in the lowest killed-in-action statistics in the history of warfare. But the wars in Southwest Asia also marked the spread of a different type of warfare – insurgencies and terrorism perpetrated by non-nation states – and expanded the definition of “battlefield” far beyond what it had been for thousands of years.

Since 9/11, “battlefield medicine” has grown beyond the Army medic or Navy corpsman treating wounded warfighters in a foreign conflict. It now includes treating the sick or wounded aboard a smuggler’s boat seized at sea by the Coast Guard, National Guard medics treating the survivors of a natural or man-made domestic disaster, or Marines helping in the fight to contain Ebola or Zika.

Today’s battlefield may be a traditional one of clashing national armies or a combination of non-uniformed armies, insurgents, and terrorists (as with the ongoing fight against the Islamic State of Iraq and the Levant), or a nightclub, train station, or other non-military facility – situations and settings in which thousands of civilians have been killed or injured since the turn of the century. It also extends to the U.S. Coast Guard’s law enforcement mission at sea against smugglers, pirates, and terrorists.

Since 9/11, “battlefield medicine” has grown beyond the Army medic or Navy corpsman treating wounded warfighters in a foreign conflict. It now includes treating the sick or wounded aboard a smuggler’s boat seized at sea by the Coast Guard, National Guard medics treating the survivors of a natural or man-made domestic disaster, or Marines helping in the fight to contain Ebola or Zika.

Those various contingencies have incorporated many of the advances made in on-site, first responder medical care in whatever battlespace or environment may be involved. Those include the latest developments related to traumatic brain injury (TBI), eye injuries, bleeding wounds, loss of limbs, facial injuries, spinal cord injuries, etc.

In 2011, Tactical Combat Casualty Care (TCCC) – a set of doctrines and procedures that had been under development and limited implementation for nearly two decades – was made the standard for combat medical procedures for all U.S. armed services. TCCC procedures and subsequent changes ordered by the Department of Defense’s (DOD) top medical authorities include:

• Before any aid is rendered, both medics and, if possible, the wounded return enemy fire in an effort to prevent additional casualties.
• Next, the medic – or, if able and without a medic immediately available, the wounded – use an aggressive approach to control bleeding through Combat Application Tourniquets (CATs) and hemostatic agents. Such “damage control” is intended to keep the wounded warfighter alive during the “golden hour” until being seen by a doctor.
• Soldiers in cold climates, such as the Afghan mountains, also now carry Hypothermia Prevention and Management Kits – chemically heated blankets and hoods.
• The fielding of small CT medical imaging machines to battlespace hospitals ended a previous mandate that front-line surgeons conduct invasive exploratory surgeries to find shrapnel embedded in the limbs of soldiers wounded by explosive blasts, such as improvised explosive devices (IEDs). By replacing surgery with non-invasive imaging, the risk of fatal complications has been greatly reduced.
• Specialized teams of vascular trauma surgeons also were deployed to in-theater hospitals after data collected in the DOD Trauma Registry, which tracks treatments given to wounded warfighters once they reach field hospitals, showed a much higher rate of injuries to veins and arteries in Southwest Asia than in previous wars.
• Since 2005, field hospitals also have employed continuous venovenous hemofiltration, a short-term emergency dialysis treatment reducing the incidence of pulmonary edema and respiratory failure among burn victims, many of whom previously had been given too much saline fluid during resuscitation.

By 2011 and nearly a decade of constant combat in Southwest Asia, every warfighter was receiving advanced first aid training, and the materials needed for emergency treatment were added to the basic kit, elevating every soldier and Marine to a level roughly equivalent to a Vietnam-era medic. While not scheduled for completion until 2017, the new generation of medics is being trained to the level of civilian emergency medical technicians (EMTs), with the ability to communicate directly, in real time, with doctors who can provide guidance until the wounded warrior can be treated by field doctors.

Unlike the rear guard MASH (Mobile Army Surgical Hospital) units of Korea and Vietnam, emergency and traumatic care doctors and surgeons advanced to the front lines, making care that previously could have taken hours or even days to reach available within the golden hour after being wounded. Once stabilized, the wounded now are immediately airlifted to the nearest permanent military hospital or hospital ship, then on to major medical care facilities, such as Landstuhl Regional Medical Center near Ramstein Air Base, Germany – often within 24 hours of being injured – and finally to the United States and the most advanced medical care available at facilities such as the Walter Reed National Military Medical Center in Bethesda, Maryland, and the Army Institute of Surgical Research Burn Center at Brooke Army Medical Center in San Antonio, Texas.