Combat casualty care: A call to action

The Military Healthcare System (MHS), a vital component of any nation's defense framework, ensures the well-being of service members during both conflict and peacetime. Nevertheless, combat casualty care remains the solemn commitment this nation makes to those who put themselves in harm's way. While the United States is currently experiencing a period of relative peace, existing global threats require military medicine to be prepared to provide combat casualty care in future conflicts. This Military Supplement of the Journal offers insights into the potential challenges we may encounter in upcoming conflicts and suggests strategies to mitigate the risks associated with these unfamiliar challenges in modern times. Military medicine faces a variety of threats, including staffing shortages, a declining health care system, and inertia in adequately preparing for these inevitabilities. Some difficulties in strategic planning stem from the substantial accomplishments of military medicine during the Global War on Terror, in contrast to potential future engagements with peer adversaries. Recent testimony to the Senate Armed Services Committee highlighted issues confronting combat casualty care to lawmakers. Military medicine's leadership must clarify the existing threats, prioritize these concerns, and present a unified voice to government and military authorities. These interrelated challenges can undermine the readiness and resilience of the armed forces, leading to serious operational consequences for mission success and troop welfare. WORKFORCE ISSUES An inexperienced medical workforce presents a significant challenge to military medicine. Unlike civilian health care, military medicine requires practitioners to operate in high-pressure, resource-constrained, and often hostile environments. Inexperience in these situations can lead to judgment errors, treatment delays, and suboptimal patient outcomes. The shortage of experienced personnel stems from several factors, including inadequate recruitment, limited mentorship opportunities, and high turnover rates because of the demanding nature of military service and the allure of a busy civilian practice. For example, Koehlmoss,1 in her 2025 article addressing the intersection of surgical volume, outcomes, and workforce, discusses the decline in surgical volume at military treatment facilities (MTFs), the increase in readmissions, and staffing challenges. Schwab,2 in his Scudder oration, highlights that 30% of military medical personnel lack prior deployment experience, resulting in knowledge gaps in trauma care and battlefield procedures. Bridging this gap requires targeted initiatives, such as military-civilian health care integration for clinical currency, managing highly complex patients, immersive simulation training to supplement clinical currency, and mentorship programs at all levels to prepare the workforce for the unique demands of combat casualty care and military medicine. Most importantly, the culture within military medicine fails to prioritize patient care over collateral responsibilities and promotion paradigms that emphasize administrative and nonclinical positions for career advancement. This neglect of clinical practice, while pursuing career goals related to fitness, professional military education, and leadership among all combat casualty care team members, in conjunction with inadequate patient volumes and a specific lack of high-acuity patients within military health care facilities, creates a formula for quality of care issues. Despite recent efforts to quantify clinical exposure for physicians, the relevance of a “community hospital” practice has not been demonstrated to apply to complex patient care that requires critical thinking.3 MILITARY HEALTH SYSTEM A downsized MHS that is no longer treating significant numbers of complex patients exacerbates the challenges of an inexperienced workforce. Systemic issues such as outdated infrastructure, inadequate and imbalanced resources, bureaucratic inefficiencies, and a lack of high-acuity patients undermine the capacity to deliver quality care. For example, reports from the US Government Accountability Office indicate that aging facilities and a lack of technological upgrades impede the ability to provide timely and effective medical services.4 Additionally, a referral system that directs more beneficiaries to the purchased care market, along with logistical delays in delivering medical supplies, further burdens the already strained health care ecosystem. These systemic failures impact the care provided to service members and discourage experienced professionals from remaining in the military health sector, perpetuating a cycle of inefficiency and attrition.3 TRAINING STRATEGY The third critical issue is the lack of a cohesive and forward-thinking strategy for training military medical personnel. Rigorous training is essential to prepare practitioners for the unpredictable and high-stakes nature of their roles. However, fragmented training approaches and inconsistent standards undermine this preparedness. There is an overreliance on simulation, along with a failure to develop clinicians' critical thinking skills. The absence of standardized curricula for military medicine training often results in uneven skill sets among personnel. For example, Bacik et al.5 emphasize the need for unified protocols in trauma care, mental health support, and emergency evacuation processes. Leadership must prioritize that members of the combat casualty care team receive hands-on experience in caring for high-acuity, complex patients, preparing them to meet the demands of time-sensitive, ill-structured problems. Without a clear strategy, efforts to cultivate a well-rounded and competent medical force remain disjointed and ineffective. These three issues—an inexperienced workforce, a failing military health system, and ineffective training strategies—are deeply interconnected. Medical personnel's inexperience often necessitates a greater reliance on robust systems and comprehensive training programs. However, when these systems falter in parallel, the overall capacity and capability to deliver quality care diminishes. POTENTIAL SOLUTIONS The confluence of these challenges and the influence of external stakeholders. such as early specialization, graduate medical education, the demand for quality care, and the military's reliance on the civilian US health care system, presents an opportunity for the services, the Department of Defense, and Defense Health Agency to adopt a novel approach to combat casualty care. To mitigate these issues, a multifaceted strategy is needed and could include the following: A unified joint medical command: There must be a single, identifiable entity that owns and oversees operational medicine and combat casualty care. The concerns of individual services losing their organizational identity must be transcended for the sake of quality care and excellence. This command should embody the characteristics of a learning organization to avoid the pitfalls of doctrine over adaptability. Enhancing recruitment and retention: Ensuring adequate clinical volumes, offering financial incentives, providing professional development opportunities, and offering mental health support can help attract and retain skilled practitioners. Expanding military civilian partnerships (MCPs): A strategic plan must be developed to identify trauma centers and burn centers in cooperation with the American College of Surgeons Military Health System Strategic Partnership, to meet the readiness needs of the combat casualty care team. This may involve unique ways of looking at partnerships that include integrated programs involving MTF, Veterans Affairs hospitals, and civilian trauma centers. We should not be limited by current paradigms when considering the future state to optimize clinical experiences across all health care systems. All critical wartime specialists and combat casualty care team members should be integrated into high-volume, adaptable civilian trauma centers. Increased integration of MCPs, along with assistance from the American College of Surgeons, will enable the identification of those MTFs that can be considered for verification as trauma centers caring for complex patients and will also prepare our civilian partners for the eventuality of repatriating wounded warriors into the civilian health care system. While optimizing the use of MCPs, the Defense Health Agency can assess where MTFs can be right-sized through primary care injects to the pipeline, resourcing, referral, recapture strategies, and where others may need to shift resources to other major centers to address staffing shortages. Developing comprehensive training programs: Standardized curricula for military-specific skills, simulation-based learning for task acquisition, formal training in critical thinking, and financially supported continuous education initiatives can ensure consistency in skill sets and preparedness. When possible, deploying teams should train together to leverage the benefits of shared mental models and psychological safety. Beyond clinical expertise, training should include resources and platforms to enhance systems expertise, allowing for the acquisition of the skills necessary to support the nonclinical aspects of the military trauma system. Encouraging research and innovation: Investing in research on battlefield medicine and using data analytics to incorporate training data can lead to evidence-based improvements in care delivery. The advancement of medical science and military conflict is inseparable, and we must continue to ensure that new knowledge and technology solutions for saving lives on the battlefield are developed, fielded, and translated to the civilian trauma community. An error-tolerant acquisition system must foster innovation and the deployment of solutions that enhance outcomes in the care of wounded warriors. LESSONS FROM CURRENT CONFLICTS To maximize opportunities for success in future large-scale combat operations, we must continue to learn from contemporary global conflicts. Many of the articles in this supplement highlight the unique military medical challenges seen in today's ongoing war in Ukraine. The rapid expansion of drone warfare, hyperbaric and hypersonic munitions, and other threats has led to challenges evacuating patients, prolonged tourniquet use, and other complications in the provision of battlefield care. As is the case in every war, military medicine has been forced to adapt and develop new solutions, such as protocols for tourniquet conversion, systems for unmanned casualty evacuation, the construction of underground medical capabilities, and the fielding of forward renal replacement. We must continue to evolve as our military medicine contemporaries learn from these hard-won lessons. CONCLUSION Experiences in modern conflicts in Ukraine and elsewhere around the world highlight the importance of maintaining continual readiness and investing in military medical preparedness. The challenges posed by an inexperienced workforce, a faltering MHS, and a lack of deliberate, resourced training present substantial risks to the effectiveness of military medicine. These shortcomings are exacerbated by service inconsistencies that fail to adopt a collaborative medical approach. This issue of the Military Supplement highlights some skills and processes necessary for the future battlefield. Addressing these problems requires coordinated efforts across recruitment, infrastructure, and training. By developing a resilient and capable medical force, our nation can ensure the health and well-being of service members, promoting operational readiness and mission success. The contributing authors and guest editors are grateful to the staff of the Journal of Trauma and Acute Care Surgery, particularly to the editor-in-chief, Dr. Raul Coimbra. Special thanks also go to American Association for the Surgery of Trauma Executive Director Sharon Gautshy and the Journal's support team. The ongoing support from American Association for the Surgery of Trauma and the Journal is essential for advancing military trauma and collaborative science.