Introduction: Medical teams were extremely successful in saving lives during the war in Afghanistan. However, this war was a counterinsurgency (COIN) operation where Allied forces enjoyed air superiority and complete unhampered communications. A future war against a peer adversary may present differently. A narrative review was conducted to make recommendations about how medical support to large-scale combat operations may need to be modified from current doctrine, which was developed for COIN operations. Methods: This narrative review examined the evolution of pre-hospital (tactical combat casualty care [TCCC]) and hospital (NATO echelons of care) doctrine underlying medical support to land operations developed during operations in Afghanistan and Iraq. It analyzed the outcomes of several battles from the current Russo-Ukrainian conflict and considered the implications of how medical support should be provided to large-scale combat operations. Results: Military planners should expect that timely medical evacuation to surgical care cannot be assumed in a peer-to-peer war, as air superiority and reliable communications cannot be assured. As well, modern munitions are likely to cause substantially more casualties than previous COIN operations, with a higher proportion of burns and primary blast injuries. Discussion: Canadian Forces Health Services should actively review its TCCC guidelines and doctrine for providing medical support to land operations. As air superiority and constant communication cannot be assured during peer-to-peer large-scale combat operations, there may be a need to focus on prolonged tactical field care and smaller, more mobile surgical teams. LAY SUMMARY Assumptions for how the Canadian Armed Forces cares for injured soldiers on the battlefield may no longer hold true. Previous treatments were designed for counterinsurgency operations where Allied forces dominated the air and land during operations. However, the recent fighting in Ukraine highlights the need to develop a doctrine for pre-hospital care on the battlefield for large-scale combat operations. In these operations, modern weapons are extremely lethal, and the casualty rate is extremely high. This review examines the development of tactical combat casualty care and the assumptions behind its treatment algorithms. It suggests changes need to be made to better support Canadian soldiers if fighting in large-scale combat operations.
