Ahead of the curve: Sustained innovation for future combat casualty care.

T figure on the cover of this issue of the Journal of Trauma and Acute Care Surgery illustrates concluding casualty statistics from the wars in Afghanistan and Iraq. While various reports on morbidity and mortality among US service personnel have been provided during earlier phases of the wars, this analysis represents the first since the conclusion of combat operations in December 2014. The percentage of died of wounds, killed in action, and overall case-fatality rate are based on data from the Defense Casualty Analysis System and calculated using accepted definitions of each of these percentages. The percentage of died of wounds, killed in action, and case-fatality rate of 2.4%, 7.1%, and 9.3%, respectively, provide important information for the Department of Defense Combat Casualty Care Research Program (CCCRP) and offer compelling context for the nation and its volunteer force. Results from this analysis also show that, as a percentage of all combat-related deaths during the course of the wars, 76% were in the prehospital setting. Although substantial, this value is less than the burden of prehospital mortality in Korea (91% of combat deaths) and Vietnam (88% of combat deaths) as well as that reported by Eastridge et al. in a 2011 analysis (87%). These new findings provide evidence that efforts to research and develop knowledge and materiel solutions, combined with an appropriately postured force structure and an integrated Joint Trauma System, are having an effect on mitigating prehospital mortality. These data also show that the work is not doneVthe gaps in combat casualty care are not resolvedVand further progress must be made to improve prehospital care and alleviate the burden of survivorship (i.e., in-hospital morbidity and mortality), resulting from effective lifesaving efforts. As the analysis of concluding statistics from the recent wars continues, the Department of Defense CCCRP enters a new era, one that has it endeavoring to stay ahead of the curve and spur innovation to support future andmore complex operational scenarios. Evenwith the end of combat operations in Afghanistan, the United States maintains a significant number of troops in the country to participate in Operation Resolute Support, a North Atlantic Treaty OrganizationYled mission to provide training and support to local institutions and forces. Simultaneously, the United States and partner nations have initiated Operation Inherent Resolve in northern Iraq and Syria, while continuing small-unit surveillance and targeted operations in parts of Africa. Finally, strategic guidanceVincluding the so-called pivot or rebalance of policy toward the Asia Pacific region as well as the Army Operating Concept ‘‘Force 2025 and Beyond’’ (AOC 2025B)Vinforms the research program working to develop solutions to support combat scenarios over large-distance operations in the Pacific and in highly populated urban areas (i.e., megacities). Although the scale and conduct of these operations are likely to be different from those of the past 14 years, US personnel will continue to serve in hostile and unpredictable environments around the world. In many ways, future operational scenarios may present greater challenges to casualty care than those of the past. In this context, future combat casualty caremay be tested by longer prehospital times requiring a reappraisal of the traditional ‘‘GoldenHour.’’ During the past decade, the GoldenHour has existed as a lifesaving and resuscitation capability based on predictable and enabled levels of care. However, future scenarios, including prolonged field care (PFC) and long-distance air-, landor sea-based