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Medical care of the returning veteran

Authors
Michael J Roy, MD, MPH
Jeremy G Perkins, COL, MD, FACP
Section Editor
Mark D Aronson, MD
Deputy Editor
H Nancy Sokol, MD

INTRODUCTION

The nature of war-related injuries has changed considerably over time. Preventive measures, ranging from improved infection control to protective gear, have been effective in reducing military morbidity and mortality [1,2]. In addition, the rapidity of evacuation and access to higher quality care have markedly improved survival rates for battle injuries. Clinicians caring for the new generation of combat veterans from wars in Afghanistan and Iraq need to be prepared for a different distribution of injuries than from prior wars. As an example, it is more common to see survivors of traumatic brain injury and amputees who have lost multiple limbs (as the torso is often spared by body armor).

Despite the evolution of war-related injuries over time, there are three aspects of injuries that have not changed for the returning veteran. First, while non-combat injuries (eg, infections, gastrointestinal illness, and musculoskeletal problems not related to battle) have decreased dramatically in recent conflicts, they invariably outnumber combat-related injuries [3]. Second, the psychological effects of war are greater in number and duration than the physical effects over the long-term. Third, complaints in veterans presenting for care after deployment tend to be similar in distribution and frequency to those in the general primary care population [4]. Although the overall medical care of the returning veteran may be similar to that of the general population, there are certain issues (eg, traumatic brain injury, psychological sequelae, readjustment to society following deployment) that are of particular relevance to veterans.

This topic will provide an overview of medical conditions commonly encountered in returning veterans, with a particular emphasis on United States veterans returning from Afghanistan and Iraq. Specific medical conditions associated with combat are discussed in further detail elsewhere. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis" and "Unipolar depression in adults: Assessment and diagnosis" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Traumatic brain injury: Epidemiology, classification, and pathophysiology".)

PHYSICAL INJURY DUE TO COMBAT

The rate of combat-related fatalities has decreased over recent wars. This can be attributed to the use of tourniquets, modern body armor, rapid evacuation, early limb salvage, and improved hemostatic resuscitation practices [1,5,6]. Soldiers with combat injuries, which may have been fatal in previous conflicts, are arriving more rapidly to military treatment facilities in better physiologic condition and are able to receive higher level of care.

There are clear differences between military and civilian trauma populations. Whereas blunt trauma, primarily due to motor vehicle accidents and falls, represents the most common injury among civilians in the United States, penetrating injuries are more common in combat casualties [7]. The most common causes of serious penetrating injuries in civilian trauma centers are stabbings and low-velocity gunshot wounds, whereas in the military they tend to be high-velocity gunshot wounds and high-energy explosive munitions including improvised explosive devices (IEDs), mortars, and rockets which can produce varied fragmentation, concussive blast, and thermal injuries [8].

                                  

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