Over the longer term, it will become increasingly unlikely that American warfighters will be engaged in a protracted counterinsurgency campaign against non-state actors whose most dangerous weapons are IEDs. They’ll more likely be organized into small, “light footprint” expeditionary units, according to Davis. “The combat zone of the future will likely take place in densely populated, cramped cityscapes where smaller, more agile teams of warfighters will replace the large contingents seen in conflicts of the past.” This battlespace, described in battle doctrine as dense urban environment, presents combat medicine with new challenges.

A warfighter who suffers a head wound in the Middle East can expect to be in a stateside hospital within 24 hours today, as the United States and its allies enjoy near-complete control of the air and seas. A forward surgical team can rely on communicating directly with experts back home, who may in some cases walk them through a difficult procedure step by step via videoconference. In multi-domain peer-to-peer battle, these advantages are likely to be challenged; air transports, including medical evacuations, may be curtailed and communications jammed, using either conventional or cyber weapons. U.S. and allied combatants likely will have to provide medical support in an anti-access/area denial environment – or prepare to do without medical support for much longer periods of time. “The ability of medical providers in the forward battlefield to engage with higher echelon support,” Davis said, “will likely be severely eroded … the mindset of the golden hour approach will have to change. In the future, instead of evacuating the casualty to another higher role of care, we’ll instead need to focus on providing medical support to the casualty at or near the point of injury.”

Today’s harbingers of multi-domain battle explain the urgency Davis and the CCCRP are applying to automated systems such as robotic vascular access and the ECLS tool. But whatever technical advances future warfighters might enjoy, multi-domain battle is likely to demand more from medics, corpsmen, and warfighters who act as first responders. Advances in telehealth and information technology, such as wearable medical sensors and secure communications technologies that can deliver virtual medical services, may also play a significant role. As the golden hour gives way to a new paradigm of prolonged field care, each of these factors – automation, greater forward expertise, and telecommunications – is likely to change the way combat medicine is practiced.

Whatever technical advances future warfighters might enjoy, multi-domain battle is likely to demand more from medics, corpsmen, and warfighters who act as first responders.

As Elster pointed out, however, the basic science of medicine remains unchanged, and military trauma medicine learns not just from war to war but also, because of the JTS, during ongoing operations. “Remember,” Elster said, “Iraq and Afghanistan evolved from the beginning, which involved more traditional armaments and injury patterns toward … dismounted IEDs becoming more prevalent. The biology is always the same. The logistics are what change, and you need to train for that.”

The JTS-enabled “learning health care system” Elster credits with boosting combat survival rates in Iraq and Afghanistan will be of critical importance in this future battlespace, Davis said, for one simple reason: No matter how accurately his program predicts the challenges multi-domain warfare might present, American combat medicine is likely to encounter something unexpected. “For this research program and, indeed, the entire military,” said Davis, “it is clear that the future battlefield will be a test of not only our current and future capabilities, but also how we apply those capabilities across new and unfamiliar terrain.”