The advancements of modern medicine and technology create an enormous divergence between the civilian first world care and the care that is provided under the austere environment of operational and tactical medicine. One look at a the modern emergency department and the reliance on advanced monitoring and imagining technology makes the medical care practiced only a few years ago seemingly obsolete. In comparison, the austere operational and tactical environment has changed very little. Reliance solely on equipment that can be physically carried renders most modern conveniences untenable and unavailable. Looking at the casualty distribution during recent modern conflicts, several authors have discerned that seemingly simple interventions can make profound differences in survival. In this chapter, we will review some of these interventions and the applications during future operational scenarios.

The link between medicine and the tactical environment has existed since antiquity. With the advent on intravenous fluids and early antibiotics during World War II, medical care on the battlefield has become more aggressive and invasive. Insights by physicians, such as Henry K. Beecher, started to question some of the earlier believed philosophies of the time and the push for active fluid resuscitation. Although noted in several publications, many of these concepts seemed to have been lost until Dr. Ron Bellemy published his WDMED data from Vietnam in 1970 (1). Although this data identified life-saving interventions on the modern battlefield that may prevent unnecessary mortality, these concepts seemed to be eclipsed by a new and emerging advanced trauma life support (ATLS) system and certification that was coming of age. Thus, the civilian-based system worked very well in the modern established medical system of the continental United States but was not applicable to the battlefield or operational environment. This adherence to the ATLS guidelines continued even in the military environment until one day in 1996 outside FT. Bragg, North Carolina, at the Special Operations Medical Association Conference a former Navy Seal and a professor at the Uniformed Services University presented a lecture on a new concept, tactical combat casualty care (TCCC). The room was extremely skeptical about the seemingly outdated interventions Dr. Butler and Dr. Hagmann were presenting (2). These concepts were contrary to the established doctrine of ATLS. This debate continued for several years until animal data and practical operational experience provided data to validate TCCC principles. After two modern conflicts, TCCC is the currently being implemented for prehospital casualty care in the armed forces and is expanding to the civilian law enforcement community.

It is important to note that there are significant differences in civilian and military (tactical) prehospital
environments. The continuum moves from relatively safe civilian emergency medical services (EMS) through the more risky law enforcement EMS to the far forward and sometimes very high-risk military combat setting. Noting the differences within this continuum allows prehospital health care providers and tactical commanders to appreciate the different approaches that medical personnel take in these varied situations.