Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Medical care of the returning veteran

Michael J Roy, MD, MPH
Jeremy G Perkins, COL, MD, FACP
Section Editor
Mark D Aronson, MD
Deputy Editor
Daniel J Sullivan, MD, MPH


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 (TBI) 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, TBI, 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".)


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 levels 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].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 14, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Clouse WD, Rasmussen TE, Peck MA, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204:625.
  2. Landrum ML, Murray CK. Ventilator associated pneumonia in a military deployed setting: the impact of an aggressive infection control program. J Trauma 2008; 64:S123.
  3. Wojcik BE, Humphrey RJ, Czejdo B, Hassell LH. U.S. Army disease and nonbattle injury model, refined in Afghanistan and Iraq. Mil Med 2008; 173:825.
  4. Roy MJ, Koslowe PA, Kroenke K, Magruder C. Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: findings from the Comprehensive Clinical Evaluation Program. Psychosom Med 1998; 60:663.
  5. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008; 64:S38.
  6. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy revision and delayed compartment release in combat patients. J Trauma 2008; 64:S153.
  7. Minei JP, Schmicker RH, Kerby JD, et al. Severe traumatic injury: regional variation in incidence and outcome. Ann Surg 2010; 252:149.
  8. War Surgery in Afghanistan and Iraq: A Series of Cases, 2003–2007, Nessen SC, Lounsbury DE, Hetz SP (Eds), Department of the Army, Washington, DC 2008.
  9. Stansbury LG, Lalliss SJ, Branstetter JG, et al. Amputations in U.S. military personnel in the current conflicts in Afghanistan and Iraq. J Orthop Trauma 2008; 22:43.
  10. www.bordeninstitute.army.mil/published_volumes/amputee/amputee.html (Accessed on February 03, 2011).
  11. Reiber GE, McFarland LV, Hubbard S, et al. Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev 2010; 47:275.
  12. Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med 2008; 358:453.
  13. Mac Donald CL, Johnson AM, Cooper D, et al. Detection of blast-related traumatic brain injury in U.S. military personnel. N Engl J Med 2011; 364:2091.
  14. Hoge CW, Castro CA. Treatment of generalized war-related health concerns: placing TBI and PTSD in context. JAMA 2014; 312:1685.
  15. Giacino JT, Whyte J, Bagiella E, et al. Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med 2012; 366:819.
  16. Weaver FM, Burns SP, Evans CT, et al. Provider perspectives on soldiers with new spinal cord injuries returning from Iraq and Afghanistan. Arch Phys Med Rehabil 2009; 90:517.
  17. Seal KH, Metzler TJ, Gima KS, et al. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. Am J Public Health 2009; 99:1651.
  18. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J Psychiatry 2006; 163:1777.
  19. Thomas JL, Wilk JE, Riviere LA, et al. Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry 2010; 67:614.
  20. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13.
  21. Knox KL, Litts DA, Talcott GW, et al. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ 2003; 327:1376.
  22. Cohen BE, Marmar C, Ren L, et al. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA 2009; 302:489.
  23. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295:1023.
  24. Andrews B, Brewin CR, Philpott R, Stewart L. Delayed-onset posttraumatic stress disorder: a systematic review of the evidence. Am J Psychiatry 2007; 164:1319.
  25. Weathers FW, Juska JA, Keane TM. The PTSD checklist - civilian version. Boston National Center for PTSD. Boston Veterans Affairs Medical Center 1991.
  26. Keen SM, Kutter CJ, Niles BL, Krinsley KE. Psychometric properties of PTSD Checklist in sample of male veterans. J Rehabil Res Dev 2008; 45:465.
  27. Terhakopian A, Sinaii N, Engel CC, et al. Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist. J Trauma Stress 2008; 21:290.
  28. Bliese PD, Wright KM, Adler AB, et al. Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. J Consult Clin Psychol 2008; 76:272.
  29. http://www.ptsd.va.gov/professional/pages/assessments/assessment-pdf/PCL-handout.pdf (Accessed on July 30, 2015).
  30. Berg AO, Breslau N, Lezak MD, et al. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence, National Academies Press, Washington, DC 2008.
  31. Nacasch N, Foa EB, Huppert JD, et al. Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: a randomized control comparison with treatment as usual. J Clin Psychiatry 2011; 72:1174.
  32. Tuerk PW, Yoder M, Grubaugh A, et al. Prolonged exposure therapy for combat-related posttraumatic stress disorder: an examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq. J Anxiety Disord 2011; 25:397.
  33. Reger GM, Holloway KM, Candy C, et al. Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic. J Trauma Stress 2011; 24:93.
  34. Roy MJ, Francis J, Friedlander J, et al. Improvement in cerebral function with treatment of posttraumatic stress disorder. Ann N Y Acad Sci 2010; 1208:142.
  35. Polusny MA, Erbes CR, Thuras P, et al. Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial. JAMA 2015; 314:456.
  36. Blore JD, Sim MR, Forbes AB, et al. Depression in Gulf War veterans: a systematic review and meta-analysis. Psychol Med 2015; 45:1565.
  37. Bonde JP, Utzon-Frank N, Bertelsen M, et al. Risk of depressive disorder following disasters and military deployment: systematic review with meta-analysis. Br J Psychiatry 2016; 208:330.
  38. Findley PA, Banerjea R, Sambamoorthi U. Excess mortality associated with mental illness and substance use disorders among veteran clinic users with spinal cord injury. Disabil Rehabil 2011; 33:1608.
  39. Scherrer JF, Chrusciel T, Zeringue A, et al. Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients. Am Heart J 2010; 159:772.
  40. Mittal D, Fortney JC, Pyne JM, Wetherell JL. Predictors of persistence of comorbid generalized anxiety disorder among veterans with major depressive disorder. J Clin Psychiatry 2011; 72:1445.
  41. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146:317.
  42. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009; 50:613.
  43. Kaplan MS, Huguet N, McFarland BH, Newsom JT. Suicide among male veterans: a prospective population-based study. J Epidemiol Community Health 2007; 61:619.
  44. Pietrzak RH, Goldstein MB, Malley JC, et al. Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord 2010; 123:102.
  45. Centers for Disease Control and Prevention (CDC). Suicide among adults aged 35-64 years--United States, 1999-2010. MMWR Morb Mortal Wkly Rep 2013; 62:321.
  46. LeardMann CA, Powell TM, Smith TC, et al. Risk factors associated with suicide in current and former US military personnel. JAMA 2013; 310:496.
  47. Gilman SE, Bromet EJ, Cox KL, et al. Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009. Psychol Med 2014; 44:2579.
  48. Bossarte RM, Claassen CA, Knox KL. Evaluating evidence of risk for suicide among veterans. Mil Med 2010; 175:703.
  49. Kessler RC, Warner CH, Ivany C, et al. Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study To Assess Risk and rEsilience in Servicemembers (Army STARRS). JAMA Psychiatry 2015; 72:49.
  50. Reger MA, Smolenski DJ, Skopp NA, et al. Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry 2015; 72:561.
  51. Schoenbaum M, Kessler RC, Gilman SE, et al. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2014; 71:493.
  52. Fonda JR, Fredman L, Brogly SB, et al. Traumatic Brain Injury and Attempted Suicide Among Veterans of the Wars in Iraq and Afghanistan. Am J Epidemiol 2017; 186:220.
  53. Conner KR, Bossarte RM, He H, et al. Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system. J Affect Disord 2014; 166:1.
  54. Sher L, Braquehais MD, Casas M. Posttraumatic stress disorder, depression, and suicide in veterans. Cleve Clin J Med 2012; 79:92.
  55. Rudd MD, Bryan CJ, Wertenberger EG, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry 2015; 172:441.
  56. Engel CC. Suicide, mental disorders, and the US military: time to focus on mental health service delivery. JAMA 2013; 310:484.
  57. Smith EG, Kim HM, Ganoczy D, et al. Suicide risk assessment received prior to suicide death by Veterans Health Administration patients with a history of depression. J Clin Psychiatry 2013; 74:226.
  58. www.health.mil/Themes/Suicide_Prevention.aspx.
  59. Epstein RA, Heinemann AW, McFarland LV. Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev 2010; 47:373.
  60. Horgan O, MacLachlan M. Psychosocial adjustment to lower-limb amputation: a review. Disabil Rehabil 2004; 26:837.
  61. Desmond DM. Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations. J Psychosom Res 2007; 62:15.
  62. Seel RT, Kreutzer JS, Rosenthal M, et al. Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation. Arch Phys Med Rehabil 2003; 84:177.
  63. Jorge RE, Robinson RG, Moser D, et al. Major depression following traumatic brain injury. Arch Gen Psychiatry 2004; 61:42.
  64. Kennedy RE, Livingston L, Riddick A, et al. Evaluation of the Neurobehavioral Functioning Inventory as a depression screening tool after traumatic brain injury. J Head Trauma Rehabil 2005; 20:512.
  65. Schneiderman AI, Braver ER, Kang HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. Am J Epidemiol 2008; 167:1446.
  66. Spelman JF, Hunt SC, Seal KH, Burgo-Black AL. Post deployment care for returning combat veterans. J Gen Intern Med 2012; 27:1200.
  67. Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran V.A. users. Med Care 2012; 50:342.
  68. Committee on the Development of a Consensus Case Definition for Chronic Multisymptom Illness in 1990. Chronic Multisymptom Illness in Gulf War Veterans: Case Definitions Reexamined, National Academies Press, Washington 2014.
  69. Committee on Gulf War and Health: Treatment for Chronic Multisymptom Illness, Board on the Health of. Gulf War and Health: Treatment for Chronic Multisymptom Illness, National Academies Press, Washington 2013.
  70. Smith TC, Powell TM, Jacobson IG, et al. Chronic multisymptom illness: a comparison of Iraq and Afghanistan deployers with veterans of the 1991 Gulf War. Am J Epidemiol 2014; 180:1176.
  71. Kearney DJ, Simpson TL, Malte CA, et al. Mindfulness-based Stress Reduction in Addition to Usual Care Is Associated with Improvements in Pain, Fatigue, and Cognitive Failures Among Veterans with Gulf War Illness. Am J Med 2016; 129:204.
  72. Murphy LB, Helmick CG, Allen KD, et al. Arthritis among veterans - United States, 2011-2013. MMWR Morb Mortal Wkly Rep 2014; 63:999.
  73. Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA 2009; 301:1242.
  74. Bair MJ, Ang D, Wu J, et al. Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial. JAMA Intern Med 2015; 175:682.
  75. Morasco BJ, O'Hearn D, Turk DC, Dobscha SK. Associations between prescription opioid use and sleep impairment among veterans with chronic pain. Pain Med 2014; 15:1902.
  76. Edlund MJ, Austen MA, Sullivan MD, et al. Patterns of opioid use for chronic noncancer pain in the Veterans Health Administration from 2009 to 2011. Pain 2014; 155:2337.
  77. Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med 2014; 15:1911.
  78. Higgins DM, Kerns RD, Brandt CA, et al. Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/operation New Dawn veterans. Pain Med 2014; 15:782.
  79. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA 2012; 307:940.
  80. Stratton KJ, Clark SL, Hawn SE, et al. Longitudinal interactions of pain and posttraumatic stress disorder symptoms in U.S. Military service members following blast exposure. J Pain 2014; 15:1023.
  81. Bray RM, Pemberton MR, Lane ME, et al. Substance use and mental health trends among U.S. military active duty personnel: key findings from the 2008 DoD Health Behavior Survey. Mil Med 2010; 175:390.
  82. Bray RM, Hourani LL. Substance use trends among active duty military personnel: findings from the United States Department of Defense Health Related Behavior Surveys, 1980-2005. Addiction 2007; 102:1092.
  83. Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry 2007; 64:566.
  84. Seal KH, Cohen G, Waldrop A, et al. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug Alcohol Depend 2011; 116:93.
  85. Wagner TH, Harris KM, Federman B, et al. Prevalence of substance use disorders among veterans and comparable nonveterans from the National Survey on Drug Use and Health. Psychological Services 2007; 4:149.
  86. Hawkins EJ, Lapham GT, Kivlahan DR, Bradley KA. Recognition and management of alcohol misuse in OEF/OIF and other veterans in the VA: a cross-sectional study. Drug Alcohol Depend 2010; 109:147.
  87. McFall M, Saxon AJ, Thompson CE, et al. Improving the rates of quitting smoking for veterans with posttraumatic stress disorder. Am J Psychiatry 2005; 162:1311.
  88. McFall M, Saxon AJ, Malte CA, et al. Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. JAMA 2010; 304:2485.
  89. Santiago PN, Wilk JE, Milliken CS, et al. Screening for alcohol misuse and alcohol-related behaviors among combat veterans. Psychiatr Serv 2010; 61:575.
  90. Wilk JE, Bliese PD, Kim PY, et al. Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war. Drug Alcohol Depend 2010; 108:115.
  91. Levander XA, Overland MK. Care of women veterans. Med Clin North Am 2015; 99:651.
  92. Suris A, Lind L. Military sexual trauma: a review of prevalence and associated health consequences in veterans. Trauma Violence Abuse 2008; 9:250.
  93. Yaeger D, Himmelfarb N, Cammack A, Mintz J. DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. J Gen Intern Med 2006; 21 Suppl 3:S65.
  94. Faulde MK, Hoffmann R, Fazilat KM, Hoerauf A. Malaria reemergence in northern Afghanistan. Emerg Infect Dis 2007; 13:1402.
  95. Croft AM, Darbyshire AH, Jackson CJ, van Thiel PP. Malaria prevention measures in coalition troops in Afghanistan. JAMA 2007; 297:2197.
  96. Aronson NE, Sanders JW, Moran KA. In harm's way: infections in deployed American military forces. Clin Infect Dis 2006; 43:1045.
  97. Murray CK, Roop SA, Hospenthal DR, et al. Bacteriology of war wounds at the time of injury. Mil Med 2006; 171:826.
  98. Johnson EN, Burns TC, Hayda RA, et al. Infectious complications of open type III tibial fractures among combat casualties. Clin Infect Dis 2007; 45:409.
  99. Dallo SF, Weitao T. Insights into acinetobacter war-wound infections, biofilms, and control. Adv Skin Wound Care 2010; 23:169.
  100. Warkentien T, Rodriguez C, Lloyd B, et al. Invasive mold infections following combat-related injuries. Clin Infect Dis 2012; 55:1441.
  101. Weintrob AC, Roediger MP, Barber M, et al. Natural history of colonization with gram-negative multidrug-resistant organisms among hospitalized patients. Infect Control Hosp Epidemiol 2010; 31:330.
  102. Hospenthal DR, Crouch HK, English JF, et al. Multidrug-resistant bacterial colonization of combat-injured personnel at admission to medical centers after evacuation from Afghanistan and Iraq. J Trauma 2011; 71:S52.
  103. Keen EF 3rd, Murray CK, Robinson BJ, et al. Changes in the incidences of multidrug-resistant and extensively drug-resistant organisms isolated in a military medical center. Infect Control Hosp Epidemiol 2010; 31:728.
  104. Sensenig RA, Murray CK, Mende K, et al. Longitudinal characterization of Acinetobacter baumannii-calcoaceticus complex, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus colonizing and infecting combat casualties. Am J Infect Control 2012; 40:183.
  105. Centers for Disease Control and Prevention (CDC). Update: Cutaneous leishmaniasis in U.S. military personnel--Southwest/Central Asia, 2002-2004. MMWR Morb Mortal Wkly Rep 2004; 53:264.
  106. Myles O, Wortmann GW, Cummings JF, et al. Visceral leishmaniasis: clinical observations in 4 US army soldiers deployed to Afghanistan or Iraq, 2002-2004. Arch Intern Med 2007; 167:1899.
  107. Faix DJ, Harrison DJ, Riddle MS, et al. Outbreak of Q fever among US military in western Iraq, June-July 2005. Clin Infect Dis 2008; 46:e65.
  108. Weiss MM, Weiss PD, Weiss JB. Anthrax vaccine and public health policy. Am J Public Health 2007; 97:1945.
  109. LeardMann CA, Smith B, Smith TC, et al. Smallpox vaccination: comparison of self-reported and electronic vaccine records in the millennium cohort study. Hum Vaccin 2007; 3:245.
  110. Casey CG, Iskander JK, Roper MH, et al. Adverse events associated with smallpox vaccination in the United States, January-October 2003. JAMA 2005; 294:2734.
  111. Niu MT, Ball R, Woo EJ, et al. Adverse events after anthrax vaccination reported to the Vaccine Adverse Event Reporting System (VAERS), 1990-2007. Vaccine 2009; 27:290.
  112. Sulsky SI, Luippold RS, Garman P, et al. Risk of disability for US army personnel vaccinated against anthrax, 1998-2005. Vaccine 2011; 29:6035.
  113. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma 2008; 64:S21.
  114. Peng R, Chang C, Gilmore D, Bongard F. Epidemiology of immediate and early trauma deaths at an urban Level I trauma center. Am Surg 1998; 64:950.
  115. Demetriades D, Murray J, Charalambides K, et al. Trauma fatalities: time and location of hospital deaths. J Am Coll Surg 2004; 198:20.
  116. Kauvar DS, Holcomb JB, Norris GC, Hess JR. Fresh whole blood transfusion: a controversial military practice. J Trauma 2006; 61:181.
  117. Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. J Trauma 2006; 60:S59.
  118. Perkins JG, Cap AP, Spinella PC, et al. Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME). Transfusion 2011; 51:242.
  119. Spinella PC, Perkins JG, Grathwohl KW, et al. Risks associated with fresh whole blood and red blood cell transfusions in a combat support hospital. Crit Care Med 2007; 35:2576.
  120. Office of the Assistant Secretary of Defense. Policy on the Use of Non-U.S. Food and Drug Administration Compliant Blood Products. US Department of Defense, Washington, DC 2010.
  121. http://www.health.mil/libraries/HA_Policies_and_Guidelines/10-002.pdf (Accessed on March 21, 2012).
  122. Veterans Benefits Administration Annual Benefits Report Fiscal Year 2013. http://www.benefits.va.gov/REPORTS/abr/ABR-Combined-FY13-09262014.pdf (Accessed on July 30, 2015).
  123. Veterans Benefits Administration. VBA Annual Benefits Report Fiscal Year 2016. US Department of Veterans Affairs, 2016.
  124. Saunders GH, Vachhani JJ, Galvez G, Griest SE. Formative evaluation of a multimedia self-administered computerized hearing loss prevention program. Int J Audiol 2015; 54:234.
  125. https://www.ncrar.research.va.gov/aboutus/index.asp (Accessed on August 17, 2017).
  126. http://www.ncrar.research.va.gov/aboutus/index.asp (Accessed on February 28, 2011).
  127. Bullman TA, Kang HK. The effects of mustard gas, ionizing radiation, herbicides, trauma, and oil smoke on US military personnel: the results of veteran studies. Annu Rev Public Health 1994; 15:69.
  128. Bullman T, Kang H. A fifty year mortality follow-up study of veterans exposed to low level chemical warfare agent, mustard gGas. Ann Epidemiol 2000; 10:333.
  129. Bullman TA, Mahan CM, Kang HK, Page WF. Mortality in US Army Gulf War veterans exposed to 1991 Khamisiyah chemical munitions destruction. Am J Public Health 2005; 95:1382.
  130. Kang HK, Bullman T. Mortality follow-up of veterans who participated in military chemical and biological warfare agent testing between 1962 and 1972. J Toxicol Environ Health A 2009; 72:1550.
  131. Ryu H, Han JK, Jung JW, et al. Human health risk assessment of explosives and heavy metals at a military gunnery range. Environ Geochem Health 2007; 29:259.
  132. Stellman JM, Stellman SD, Christian R, et al. The extent and patterns of usage of Agent Orange and other herbicides in Vietnam. Nature 2003; 422:681.
  133. Schecter A, Needham L, Pavuk M, et al. Agent Orange exposure, Vietnam war veterans, and the risk of prostate cancer. Cancer 2009; 115:3369.
  134. Uzych L. Agent Orange, the Vietnam War, and lasting health effects. Environ Health Perspect 1991; 95:211.
  135. Kroenke K, Koslowe P, Roy M. Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures. J Occup Environ Med 1998; 40:520.
  136. Roy MJ, Kraus PL, Seegers CA, et al. Pyridostigmine, diethyltoluamide, permethrin, and stress: a double-blind, randomized, placebo-controlled trial to assess safety. Mayo Clin Proc 2006; 81:1303.
  137. Schmidt CW. Soldiers and oil well smoke. Respiratory connection remains hazy. Environ Health Perspect 2002; 110:A690.
  138. Gronseth GS. Gulf war syndrome: a toxic exposure? A systematic review. Neurol Clin 2005; 23:523.
  139. Chronic multisymptom illness in Gulf War veterans: Case definitions reexamined. Institute of Medicine. March 2014. http://www.iom.edu/Reports/2014/Chronic-Multisymptom-Illness-in-Gulf-War-Veterans-Case-Definitions-Reexamined.aspx (Accessed on April 24, 2014).
  140. Ismail K. A review of the evidence for a "Gulf War syndrome". Occup Environ Med 2001; 58:754.
  141. Fukuda K, Nisenbaum R, Stewart G, et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA 1998; 280:981.
  142. Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. Am J Epidemiol 2000; 152:992.
  143. Robbins PJ, Cherniack MG. Review of the biodistribution and toxicity of the insect repellent N,N-diethyl-m-toluamide (DEET). J Toxicol Environ Health 1986; 18:503.
  144. Franz TJ, Lehman PA, Franz SF, Guin JD. Comparative percutaneous absorption of lindane and permethrin. Arch Dermatol 1996; 132:901.
  145. Haley RW, Kurt TL. Self-reported exposure to neurotoxic chemical combinations in the Gulf War. A cross-sectional epidemiologic study. JAMA 1997; 277:231.
  146. Roy MJ, Kraus PL, Seegers CA, et al. Pyridostigmine, diethyltoluamide, permethrin, and stress: a double-blind, randomized, placebo-controlled trial to assess safety. Mayo Clin Proc 2006; 81:1303.
  147. Tables 522 and 524. In: Statistical Abstract of the United States: 2012. Available at: http://www.census.gov/prod/2011pubs/12statab/defense.pdf (Accessed on August 17, 2017).
  148. Medical Services. Standards of Medical Fitness. AR 40-501, US Department of the Army, Washington, DC 2017.
  149. www.benefits.va.gov/warms/bookc.asp#h (Accessed on August 17, 2017).
  150. Finley EP, Zeber JE, Pugh MJ, et al. Postdeployment health care for returning OEF/OIF military personnel and their social networks: a qualitative approach. Mil Med 2010; 175:953.
  151. McFarlane AC. Military deployment: the impact on children and family adjustment and the need for care. Curr Opin Psychiatry 2009; 22:369.
  152. Flake EM, Davis BE, Johnson PL, Middleton LS. The psychosocial effects of deployment on military children. J Dev Behav Pediatr 2009; 30:271.
  153. Walker S. Assessing the mental health consequences of military combat in Iraq and Afghanistan: a literature review. J Psychiatr Ment Health Nurs 2010; 17:790.
  154. Sayer NA, Noorbaloochi S, Frazier P, et al. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatr Serv 2010; 61:589.