A severely wounded soldier arrives by helicopter at your Combat Support Hospital or Forward Surgical Team. Half of his abdominal wall is missing with exposed viscera and active bleeding. He arrests on arrival and you get him back with an emergency department thoracotomy and aortic cross-clamp. In the operating room, you start on his abdomen while anesthesia continues to resuscitate with blood products. He has so many injuries you don’t know where to begin, but you get to work and are finally gaining ground when the pagers go off again. Seven “urgent surgical” patients are inbound, and your anesthesiologist tells you he just hung the tenth unit of blood, which is half of your total blood supply. All eyes are on you – what are you going to do? Do you continue and exhaust your unit’s blood supply on this patient with a low probability of survival? Do you stop and make this patient “expectant,” allowing him to die so that you can tend to the other injured patients?

These are the types of decisions regarding the provision, withholding, and withdrawal of aggressive care that you are rarely faced with in civilian practice but will frequently encounter in the combat environment (Fig. 43.1). You are used to giving your all and doing everything possible for your patients until you have either won the battle or reached the point of futility. In the combat setting, you must also give equal weight to your situation, capabilities, and available resources. Are you dealing with a single casualty or are you in the middle of a mass casualty scenario? Is there another facility willing and able to provide the needed care? Do you have the medical evacuation (MEDEVAC) assets available to get that patient to a higher level of care? Do you have the required expertise, equipment, and training available at your facility to care for this patient? Is your facility at 10% occupancy or is it near capacity with already exhausted personnel? Will this patient require resources that you do not have available or resources that are scarce and needed for other patients? And finally, is this patient a US or allied service member who will be evacuated to a state-of-the-art medical facility, or is it a local national civilian who will have to rely on the scarce local health-care facilities and resources for any subsequent care? Not infrequently, the answer will be that you cannot provide aggressive care or need to cease aggressive care and manage the patient as an “expectant” casualty. The goal of this chapter is to familiarize you with the common situations and decisions you may face about the level of care to provide and some key concepts in providing compassionate and competent expectant care .