MedEvac Train – Learning from the Past

Martin Bricknell (UK)

Lieutenant General (retired) Prof. Martin Bricknell (Royal Army Medical Corps) discussed the history and potential future deployment areas of the “MedEvac Train.“ This type of casualty evacuation has been used in both world wars, the Cold War, and most recently during the COVID pandemic. He sees a future need for these trains as well, as LSCO (Large-Scale Combat Operations), like the current Russian invasion of Ukraine, result in a large number of casualties that cannot all be air or ground-evacuated (road).

Prof. Bricknell highlighted the advantages of the MedEvac Train, including the reduced number of medical personnel needed per patient. Moreover, main train stations in target cities are usually more centrally located than airports, allowing for faster distribution to surrounding hospitals.

Key considerations for planning such MedEvac trains include the number of beds and logistics, focusing on oxygen and water supply, electricity, and medical equipment. Control centers are also needed to manage the distribution of casualties. Pre-programmed procedures are advantageous.

Key Messages:

• Railway MEDEVAC is a proven method for casualty transport in LSCO, especially with high patient volumes and limited air rescue.
• Historic concepts (e.g., ambulance trains in WWI and WWII) are relevant today – adapted to modern technology and logistics.
• Railways offer several advantages, including high capacity, a stable care environment, and a comparatively safe and resilient transport option.
• Designing modern ambulance trains requires comprehensive planning – bed numbers, medical equipment, personnel accommodation, power, water, oxygen.
• Good care during transport depends on the system, not just the train itself – including “casualty handling“ and “casualty regulation.“
• Networked thinking is crucial – transfer points, transport chains, medical leadership, and resource allocation must function.
• LSCO requires robust, scalable medical evacuation systems, including rail integration.
• Many countries, like Ukraine, successfully use railway MEDEVAC in wartime – this can serve as a model for NATO and EU planning.
• Integration into civil-military structures (Mil-Mil & Civ-Mil) is necessary, especially in urban centers without suitable airfields.

Conclusion: Railway MEDEVAC is more than a nostalgic look back – it is a realistic and plannable means for the casualty care of tomorrow.

Literature Recommendations

• Bricknell M, Finn A, Palmer J: For debate: health service support planning for large-scale defensive land operations (part 1). Journal of the Royal Army Medical Corps Jun 2019, 165(3): 173–175.
• Bricknell M, Finn A, Palmer J: For debate: health service support planning for large-scale defensive land operations (part 2). Journal of the Royal Army Medical Corps Jun 2019, 165(3): 176–179.
• Chavasse CCH: The Organization and Running of an Ambulance Train. BMJ Military Health 1940; 75: 227–235.
• Gerrard JJ: Notes on the Sanitary Arrangements on an Ambulance Train. BMJ Military Health 1905; 5: 265–266.
• Marble S, Barr J: Ambulance Trains – From the Crimean War to Ukraine. JAMA Network Open. 2023; 6(6): e2319687.

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Implications for Western Countries in Large-Scale Operations

John Quinn (US)

John Quinn, who has participated in volunteer missions in pre-hospital care and clinical training since 2022, shared his experiences and recommendations for Western countries based on his insights from the Ukraine conflict.

Firstly, there is a need to expand medical competencies at lower levels of care, which may increase the risk of medical errors but still improves survival rates. Additionally, the concept of Prolonged Field Care (PFC) should be viewed as the standard rather than the exception in the future. This brings moral dilemmas for medical personnel, leading to moral injury and creating gray areas in documentation. Clear clinical guidelines and decision algorithms are needed to alleviate personnel burden.

Furthermore, new blood donation concepts, such as whole blood donation or “Low-Titer 0 Whole Blood“ in the field, urgently need to be established. Quinn sees the challenge in adapting the corresponding logistics and training, and the general high need for innovation.

Lastly, medical mission planning must be adaptable to challenging environments, such as dynamic and uncertain operational spaces with extensive distances, enemy contact, and restricted communication. This challenge must be met with targeted training and improved collaboration among medical teams from various sectors.

Key Messages:

• Large-scale combat operations (LSCO) demand available, flexible, unconventional medical care.
• PFC is the rule, not the exception.
• Mid-/low-level personnel must be able to perform advanced measures safely.
• Blood supply is the pivot of modern damage control care.
• Training, standardized algorithms, and international collaboration form the foundation of modern operational medicine.
• SOF truths apply universally.

4. Session: SOF Medical Strategy – Modeling the Future

Strategic Medical Change

Michael R. Hetzler (USA)

To kick off the thematic block “Special Forces Medical Strategies – Modeling the Future,“ Michael T. Hetzler provided a fundamental impulse through a video lecture for strategic rethinking in medical missions. He advocated a change in perspective. Medical capabilities are no longer merely supportive functions but an integral part of operational planning.

Modern conflicts can no longer be captured with linear models. Instead, flexibility, interdisciplinarity, and system integration are required, especially and particularly in medical thinking. Hetzler called on the military medical community to empathize with the mindset of commanders to effectively incorporate medical expertise into leadership processes – at tactical, operational, and strategic levels.

From Hetzler‘s perspective, irregular warfare is not a fringe phenomenon but an integral part of future conflicts – whether in the form of proxy wars, asymmetric threats, or hybrid operations. Both the frontlines and the demands on military medical thinking are shifting. Hetzler, therefore, calls for explicit integration of medical expertise into the operational planning of irregular scenarios. This includes both strategic understanding and operational availability. To achieve this, the medical service structure must become more flexible, decentralized, and mission-specific. A central element is the MSIW Committee (Medical Support for Irregular Warfare), which operates within the Special Operations Medical Association (SOMA) as a strategic platform for doctrine development, research, and training. It aims to structure and strengthen the dialogue between medical practice, military leadership, and scientific analysis.

Key Messages:

• Medical capabilities are no longer merely supportive functions but an integral part of operational planning.
• Medical planning must be strategic and forward-looking.
• Offset medicine and new threat scenarios require adaptive concepts.
• Medics should consider all aspects and understand the leadership‘s situation picture.
• Interdisciplinarity, networking, and scenario competence are key competencies.
• Medicine is not a reactive tool but a strategic design factor.

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Joint Trauma System: Actual View and Saving Life with Data

Jennifer Gurney/Ashli Carlson (US)

Colonel Jennifer Gurney, head of the “Joint Trauma System“ (JTS), and Major Ashli Carlson presented the work of the JTS, which is the central medical quality assurance and development system of the US Armed Forces, to improve casualty care in the field.

Under the motto “Saving Lives with Data,“ the team demonstrated how systematic data collection and analysis lead to the development of clinical guidelines, training standards, and organizational improvements – directly impacting survival rates. Based on specific examples, it was shown how measures such as the widespread introduction of tourniquets, TXA, whole blood, or TCCC cards have directly emerged from the Medical Performance Optimization (MPO) approach of the JTS.

At the same time, the lecture addressed an often underestimated weakness: good data alone is not enough – it must be communicated strategically to have an impact on the political-military level.

The central message is:

Data saves lives – but only if it is correctly collected, interpreted, and communicated.

Key Messages:

• The Joint Trauma System (JTS) improves survival rates through a data-driven process and performance optimization.
• Medical Performance Optimization (MPO) is based on documented operational medicine – without documentation, there is no learning, no improvement, no saving.
• Successes like tourniquet, TXA, and whole blood rely on systematic data evaluation – “You have lived the results.“
• “If it didn‘t get documented, it didn‘t exist.“ – Lack of documentation prevents future lifesaving.
• Good data must be strategically communicated – not only medically but in “commander speak“ (risks, ROI, timing, feasibility).
• Lack of communication creates a strategic gap, despite the presence of all necessary medical information.
• Medical teams must learn to argue operationally and politically to secure resources, platforms, and logistics.
• A data-driven trauma system not only protects lives but also directly supports the operational capability and impact of military forces.
• Scientific evidence is not enough – it must be effectively told and fed into decision-making processes.
• “Truth doesn‘t win. Truth told well does.“ – Communication is a force multiplier in military medical transformation.

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Medical Considerations in High-Risk Maritime Operations

Fredrik Granholm (SWE)

Dr. Granholm discussed the unique medical challenges in high-risk maritime operations, such as anti-terrorism, anti-smuggling missions, anti-piracy operations, and responses to hybrid threats like drone attacks or cyber-attacks.

Risk: Hypothermia

Maritime high-risk operations are generally characterized as cold, wet, dark, and inhospitable, requiring special preparation of personnel and equipment. A central medical risk he described is hypothermia, which, due to rapid temperature loss, leads to reduced physical performance, impaired decision-making, loss of fine motor skills, and decreased grip strength. Prevention through appropriate protective clothing is crucial.

Trauma care under challenging conditions

He also addressed trauma care under challenging conditions. Notable challenges include cramped spaces on multiple levels with limited access under constant movement, vibration, and moisture, which require coordinated triage, reliable casualty tracking, orderly evacuation across various levels, and maintaining performance under the harshest conditions.

Complexity of maritime operations

Additionally, the complexity of maritime operations is increasing, not only concerning hybrid threats from terrorism and organized crime but also through conventional combat combined with possible drone attacks, cyber-attacks, and chemical, biological, radiological, nuclear, and explosive (CBRNE) warfare agents.

Key Messages:

• Maritime high-risk missions are medically extremely demanding – mainly due to the environment, movement, and threat situation.
• Hypothermia is a danger that must be prevented early – e.g., through adapted clothing and protective measures.
• Cold reduces fine motor skills, decision-making ability, and grip strength, significantly hindering life-saving measures.
• Medical care at sea requires adaptation to cramped, moving, and multi-level environments – including special evacuation and triage concepts.
• Trauma care must be effective despite limited resources and logistics, even under extreme weather conditions.
• Hybrid warfare (e.g., drones, terror, cyber) places new demands on tactical casualty care at sea.
• Preparation and training must be realistic, not under idealized conditions.
• The maritime domain should not be understood as a marginal area of tactical medicine but as an independent high-risk scenario.
• Multidisciplinary collaboration and specialized SOPs are essential to be medically prepared for maritime combat situations.

Conclusion: “Don‘t get cold in the first place“ – prevention, scenario training, and adaptability determine success or failure.

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Ridge Healer: Lessons Learned from Irregular Warfare Medical Training

Jason R. Pickett (USA)

With remarkable stage presence, Lieutenant Colonel Jason Pickett presented the “Ridge Healer“ training concept used in West Virginia and South Carolina – a realistic training format designed explicitly for special operations surgical teams.

Training as Development

The goal is not only to train medical personnel under conditions of irregular warfare (IW) but also to structurally and tactically develop their capabilities further. The exercise serves as both training and an experimental field. The focus is on developing robust decision-making ability in dynamic, resource-limited operational situations – not the routine execution of medical standard procedures.

The medical events are deliberately embedded in the tactical context. Instructors withdraw early to promote individual responsibility and creativity. Roles remain flexible, and responsibility is distributed across multiple shoulders. Doctors, in particular, are prepared for the reality of a tactical situation outside their comfort zone of the clinic.

Exercise in Battle Rhythm

Unlike many exercises, the real challenge begins after surgical care. Patients must be further cared for according to intensive care principles. Establishing a battle rhythm is central – a soldierly model with precise task distribution, rotation, and checklists that also proves itself for medical teams under stress. Discipline, overview, and mastering basic soldiering skills become the foundation of medical actionability in irregular warfare.

Key Messages:

• “Ridge Healer“ is a training laboratory for realistic medical training in IW scenarios.
• The operational area is not the hospital – sterile standards, complete equipment, or specialized roles are often illusory.
• “Get the instructor out of the picture“ – teams must learn through practice and their own mistakes, not constant correction.
• Everything is a decision – medicine is only a part of the mission.
• Teams must be flexible: cross-training, role swapping, and split-team strategies are crucial.
• The driver of an evacuation vehicle has more influence on survival than the doctor – MEDEVAC is not a “medical pause button.“
• Hypothermia is an underestimated but critical factor in field operations.
• After the operation begins, the PFC phase – goal: stability, not just survival.
• Use PFC flow sheets, define goals, work with trends – not individual values.

Conclusion: Medicine under IW conditions requires adaptation, pragmatism, decisiveness, and solid basic skills – “Basic soldiering“ is as essential as medical expertise.

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Operational Security of Medical Personnel under Asymmetric Threats: A Middle East Perspective

Ufuk Sarikaya (TUR)

Ufuk Sarikaya, a former medical instructor of the Turkish Army, provided an overview of potential threats to medical personnel in asymmetric conflicts from a Middle East perspective.

Challenge: Radical Religious Terrorism

He illuminated the specific medical-operational challenges in dealing with radical religious terrorism in the Middle East, particularly from the perspective of medical personnel in asymmetric conflicts. Based on decades of experience, Ufuk Sarikaya described the motivations, tactics, and structures of radical groups, the threat posed by UAVs, IEDs, and suicide bombers, and the resulting particular risk to military medical personnel.

He also emphasized the need for detailed medical mission planning before, during, and after operations, including preventive measures, logistical preparation, personal security, telemedicine, triage, CASEVAC, and PFC.

Focus: Operational Security and Resilience of Medical Teams

He placed particular emphasis on the operational security and resilience of medical teams. His finding: Only those who know the enemy, the terrain, and cultural peculiarities can survive and effectively help in these complex environments. Medical planning for missions in the Middle East should, therefore, focus not only on the enemy but also on the terrain and climate. The better one understands the enemy, the better one can prepare for possible attacks. Connection to the local population is as essential as evacuation plans, reconnaissance, and collaboration with local hospitals.

Key Messages:

• Radical terrorism is an extreme threat to medical personnel, who are considered potential targets and operate outside the protection of international law.
• Radical groups employ a variety of asymmetric tactics, including IEDs, VBIEDs, drones, snipers, kidnappings, and psychological warfare.
• Medical personnel must be able to think, act, and plan tactically to survive and save lives in unstable environments.
• Detailed medical mission planning is essential, tailored to the mission, adversary, climate, terrain, logistics, and evacuation options.
• Each phase of operations has specific medical requirements – from physical preparation to CUF to post-mission analysis.
• Self-help, buddy aid, and immediate measures decide life and death – especially with delayed evacuation.
• Life-sustaining equipment for PFC must be robust, mobile, and resilient (e.g., against vibration, water, and magnetic fields).
• Cultural understanding, respect for the local population, and behavioral discipline are survival factors.
• The human factor often decides success or failure: mental strength, flexibility, and situational response are crucial.

Conclusion: “Adaptability saves lives, not planning“ – medical preparation must reflect this.

5. Session: TCCC at Sea, Desert, Mountain, and Cold

Competency and Abundance – that‘s What Might Save us

Kateryna Maslyak (UKR)

Dr. Kateryna Maslyak, a Ukrainian anesthesiologist and intensivist as well as a TCCC instructor, presented the challenges of tactical medicine in Ukraine.

Before 2022, there was little understanding of TCCC in Ukraine. Starting in 2022, structured courses like ASM, CLS, CMC, and CPP were introduced, and since 2024, a 30-hour tactical medicine course has been part of the basic training in the Ukrainian Army.

Delay in Further Care: A Central Problem

Dr. Maslyak identified care delays as a central problem, noting that it takes an average of 12 minutes from POI to CASEVAC, 5 hours from CASEVAC to Role 2 facilities, and up to 28 hours from Role 2 to Role 3. Measures such as Damage Control Surgery (DCS) and Damage Control Resuscitation (DCR) occur too late.

Competency increase as a solution

As a solution to this problem, she suggested increased competency through training all helpers as Combat Life Savers (CLS), in Combat Medic Care (CMC), En Route Care, and Prolonged Field Care (PFC), as DCR and DCS begin at POI and not just in the hospital.

She highlighted the training principles of the NGO CHEST, which focus on practical competence, learning by doing, public reflection on mistakes, training civilians as potential soldiers, and mastering CLS and DCR basics by everyone.

Equipment and Its Proper Use

The second pillar of the lecture, in addition to the competence required in the first part, was the demand for equipment. She noted that, beyond the lack of suitable equipment, a bigger problem is that existing equipment is not used. The solution, again, is training to overcome the fear of perceived waste. In Ukraine, there is simply no distinction between civilian and military medicine, as Russian missiles do not recognize such boundaries.

Key Messages:

• NGO “CHEST”: “We worship what we preach, and we practice what we teach.“
• Competence saves lives – not titles, ranks, or academic degrees.
• TCCC, CLS, DCR, DCS, and PFC must be practically mastered – from POI to definitive care.
• Evacuation delays of 5–28 hours are everyday occurrences in Ukraine – hence, damage control begins in the field.
• Many wounded die because simple measures (e.g., hemostasis) are not taken or occur too late.
• Competency-based training requires more practice and less theory – everyone must know how to save lives.
• Non-medical personnel must also be trained in DCR and DCS, as they are often alone on site.
• There is not only a lack of equipment but also of the ability to use existing equipment correctly.
• Tactical and civilian medicine blur in Ukraine – war does not distinguish between front and home.
• NGOs like “CHEST” play a crucial role because they can act quickly, independently, and flexibly.
• Conclusion: Competency + availability = survival probability.
• Every international support – whether material, personnel, or ideal – makes a difference.

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A Proposed Model for Medical Mission Specific Training

Thomas Geddes (UK)

Major Geddes from the British Army presented a modular training model to prepare medical forces for tropical environments. MAAfriC stands for Meaningful Assistance in African Conditions. It is a British military training course focused on medical care under challenging conditions and in African contexts. His focus was on realistic and country-specific content.

His course “MAAfriC“ comprises six modules:

• Module 1 deals with environmental medicine and aims to provide participants with an understanding of climatic, geographical, and hygienic risks.
• Module 2 aims to ensure that not only is survival the goal, but that actions are safe and effective. This includes adaptation strategies to heat, humidity, and resource scarcity.
• Module 3 imparts knowledge on medical care during transport and teaches how to effectively address challenges such as unstable patients, poor roads, and the pressing time factor.
• Module 4, “Enhanced Force Health Protection,“ demonstrates how to prevent infections from vectors and drinking water through measures such as maintaining appropriate vaccination status, utilizing mosquito protection, and employing malaria prophylaxis.
• Module 5, “Flora and Fauna,“ helps participants understand the correct handling of animal and plant hazards, including venomous snakes, scorpions, plant contact, and rabies.
• Module 6 “Mission-specific case studies“ prepares participants contextually for common diseases and typical emergencies.

Through a combination of location-based theory and case training, the overall concept aims to achieve better operational capability and lower morbidity and mortality.

Key Messages:

• Tropical deployment areas require specific medical training that goes beyond classic TCCC or NATO standards.
• Medical Mission Specific Training (MST) fills this gap, with modules on environmental adaptation, tropical medicine, and operational resilience.
• The goal is not just “survival,“ but “performance“ in the operational area – “Thriving, not just surviving.“
• The presented model integrates environmental influences, risk prevention strategies, transport medicine, and local disease patterns.
• A structured Medical-RSOI approach should be an integral part of multinational preparations.
• Flora, fauna, and climatic conditions influence operational capability as much as enemy impact.
• Preventive medicine and Force Health Protection (FHP) are central elements in the tropical context.
• Case studies (“environment-specific cases“) ensure practical relevance and action security.
• The MAAfriC course serves as a proven template – adaptable for other regions with similar challenges.

Conclusion: Tropical medicine in deployment requires more than a chapter in the medical textbook – it needs its own, practice-oriented training concept.

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TCCC in the Mountains – Tactical Alpine Medicine

Markus Isser (AUT)

Markus Isser, a certified anesthesiology nurse, member of the Tirol Mountain Rescue Team, and initiator of Tactical Alpine Medicine, gave a fascinating lecture on tactical medicine in the Alps. After a brief overview of the development of mountain rescue since World War I, he particularly highlighted the differences from the standard examination scheme cABCDE.

Together with colleagues, he developed the crABCDE algorithm for treating casualties in alpine terrain, which focuses not only on critical bleeding but also on hypothermia prevention and treatment. Patients should be exposed only as briefly as possible. In extreme conditions (cold/wind), a tent is erected around the patient and the treatment team.

Isser also emphasized the frequent necessity for improvisation with limited available materials. He cited the rescue blanket as an example, which, besides preventing hypothermia, can also be used as a multitool, chest seal, carrying aid, or tourniquet.

Key Messages:

• TCCC is highly relevant in alpine terrain but must be adapted to specific conditions (crABCDE with a focus on hypothermia prevention/treatment).
• Mountain operations require improvisation despite medical standards – “between doctrine and reality.“
• Extreme environmental influences such as cold, altitude, and terrain significantly complicate diagnosis and therapy.
• Materials must be multifunctional, robust, and usable under extreme conditions – e.g., rescue blankets with increased tear resistance.
• Operational times and weather windows dictate care tactics – especially during night or avalanche operations.
• “Nobody is dead until warm and dead“ – Hypothermia should never be underestimated; maintaining warmth is a priority.
• Collaboration in small, highly specialized teams is essential – communication, trust, and role distribution are vital for survival.
• Scientific studies from mountain rescue contribute significantly to the development of pre-hospital care.
• Realistic case examples and exercises are indispensable – theory must be tested under operational conditions.

Conclusion: Alpine TCCC requires adaptation, courage for decisions, and the interplay of experience, science, and teamwork.

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The Challenges of Delivering TCCC in an Arctic Environment

Bart Van Herwijnen (UK)

Tactical Combat Casualty Care (TCCC) in Arctic environments presents unique challenges for medical forces. Cold-related complications, particularly hypothermia, develop rapidly and are a central, often underestimated cause of death under combat conditions. The classic TCCC doctrine only partially applies under these conditions. Additionally, the familiar deployment scenarios are fundamentally different from LSCO, as seen in the Ukraine war. Hypothermia prevention as a central component of the lethal diamond must be reprioritized in known concepts.

In addition to passive measures like insulation through mats, blankets, or wind protection, active heat retention strategies are essential. These include warmed infusion solutions, external heat pads, or, if necessary, internal rewarming techniques. Simultaneously, medications must be stored in a cold-protected environment to maintain their effectiveness. Monitoring and diagnostics are further complicated by limitations in thermometry, mobility, and visibility.

A holistic heat management approach that begins with mission planning is crucial: material selection, drill, team structure, and task distribution must be aligned with Arctic conditions. Only then can sufficient, tactically embedded casualty care be realized under extreme climatic conditions.

Key Messages:

• Hypothermia is a primary cause of death in Arctic environments among casualties.
• Classic TCCC models are only partially applicable in extreme cold -> MhARCH or at least MAhRCH.
• Care must occur in protected areas, not in open terrain.
• Active heat management is a central component of medical planning.
• Team drill, material choice, and mission-specific preparation determine success.

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TCCC in Large-Scale Combat Operations: Insights from the Frontline

Olha Tahirova (UKR)

As a combat medic with the Ukrainian Azov Brigade, Olha Tairova did not speak about theoretical models but showed realistic images from daily operations in Nju-Jork, Donetsk region. Her video documentation vividly demonstrated how much the nature of tactical casualty care has changed in scenarios of national and alliance defense.

As many of her Ukrainian predecessors noted:

The classic rescue chain is de facto obsolete – as is the concept of the “Golden Hour.“ The evacuation of severely injured to rear lines can take up to 36 days. Ambulances in this context are merely “expensive taxis“ – their equipment and personnel lose their effectiveness in the presence of drones and constant battlefield surveillance. Not just the severity of the injury, but the timing of the injury – morning or evening – now also determines life and death.

Tairova described how the Azov unit has adapted to this reality: Through low-threshold training, simple soldiers are trained in advanced life-saving measures – far beyond the classic “Stop the Bleed“ concept. She particularly emphasized the ability to not only apply a tourniquet but also correctly convert it into definitive bandaging.

Telemedical support allows for informed decisions even under frontline conditions. Blood products are delivered by drone to the trenches – transfusions occur shortly after enemy contact, immediately following injury.

Tairova‘s presentation strongly underscored the need to heed the warnings of Ukrainian colleagues and rethink now to save as many lives as possible in the future.

Key Messages:

• Classic evacuation chains and time windows are no longer realistic in the Ukraine war.
• Life-saving depends on time, terrain, and daylight – not just on equipment.
• Combat medics train infantry forces in advanced measures (multiplier role).
• Tourniquet conversion and trench transfusion become new realities.
• Telemedicine, drone technology, and troop-level training ensure survival chances.

6. Session – Reflections & Insights into Recent Conflicts (Part II)

Providing Medical Care in Today’s Drone-dominated Battlefield

Serhii Rotchuk (UKR)

Serhii Rotchuk from the Azov Brigade delivered an impressive presentation on the use of drones, which are employed by Russian forces for reconnaissance and combat against the Ukrainian army, but are increasingly used to support their medical care and evacuation of the wounded.

To evade reconnaissance by enemy drones, evacuations from the casualty collection point (CCP) to the nearest medical facility can only occur during the so-called “Siriak phase.“ This is the twilight period when the reconnaissance risk is lowest. This delays evacuation time, so they have equipped their CCP as best as possible, including with oxygen, blood products, and telemedicine capabilities. If needed, additional materials can be dropped near the CCP by drones.

Key adjustments include:

• Delayed evacuations during night hours (“Siriak phase“) to avoid drone surveillance.
• Setting up CCPs with enhanced care capabilities (e.g., blood products, oxygen, telemedicine).
• Tactical use of drones for safe navigation of evacuation teams or targeted material drops.
• Protective measures like electronic warfare and improvised jammers for drone defense, although their effectiveness is limited by modern, fiber-optically guided drones.

Numerous case studies in the presentation illustrated how drones can be both a threat and a rescue tool. It also became clear that conventions like marking medical vehicles no longer offer protection.

Key Messages:

• Drones fundamentally change tactical casualty care – particularly through constant surveillance, targeted attacks, and fire control.
• Daylight evacuations are highly risky – heavy losses are imminent. Night and twilight phases are strategically used.
• Delayed evacuations require new structures – e.g., casualty collection points with extended capabilities, including telemedicine.
• Rescue missions with drone support are possible and effective – e.g., for orientation, material drops, or remote consultation.
• Visually guided drones bypass electronic countermeasures – new threat from fiber-optically connected systems.
• Evacuation vehicles need their own electronic protection systems, complicating logistics, equipment, and driver management.
• Marking medical vehicles no longer offers protection – Russian forces deliberately target medical facilities with the protection emblem.

Conclusion: Technology is a double-edged sword – it can save lives but also pose targeted threats. Flexibility and creativity are crucial.

7. Session – Train as you Fight? But How Exactly?

K9 TCCC in an Operational Environment – Human Healthcare Providers

Kerri Haider/Lauren Peacock (US)

Major Kerri Heider and Captain Lauren Peacock from the US 64th Medical Detachment Veterinary Support Services and Dog Center “Flying Foxes“ in Baumholder presented the concept of “K91 Tactical Combat Casualty Care (K9TCCC),“ which is based on the principles of human TCCC and applied to military working dogs (MWD). The speakers highlighted why MWDs are indispensable “combat multipliers“ in operations and require a comparable medical care standard – especially with limited veterinary resources in deployment areas.

The focus is on integrating human health providers (HHP) into K9 care, as they are often the first or only point of contact for injured service dogs. Topics covered include anatomical peculiarities, differences in physiology, medications, injection techniques, hypothermia management, pain management, prolonged field care (PFC), and blood transfusions in dogs.

Structured Care: M3ARCH2

The structured care scheme M3ARCH2 derives from the TCCC algorithm and is adapted for dogs. The M3ARCH2 algorithm includes muzzle, massive bleeding, medications, airway, ventilation, circulation, hypothermia, head trauma, and “everything else.“

The vital signs of MWDs differ from those of human patients. Monitoring remains consistent using SpO2, MAP, and 3-channel ECG. Opioids often cause vomiting, but are necessary to enable many treatment measures. As with human patients, ondansetron should be used.

For blood and fluid therapy, it is essential to use only canine donor blood. A dog has approximately 85 ml/kg of body weight. Tranexamic acid 0.5 g should be administered as a slow bolus no later than 30 minutes after injury. Additionally, calcium should be given after administering two blood products. In prolonged field care, fatty, protein-rich food is necessary.

For burns, particular attention must be paid to preventing hypothermia and ensuring adequate pain management. Hair in the wind area must be removed, and wounds covered. For fluid replacement, 4 ml/kg body weight/h or the percentage of burned body surface area multiplied by 10 ml per hour should be administered via an intravenous or intraosseous access.

K9 stands for service dogs in the US military. The abbreviation likely stems from the phonetic similarity of K9 with “canine,“ meaning “dog-like“ or “relating to dogs.“

Key Messages:

• MWDs are life-saving, highly skilled operatives – their medical care is essential for military effectiveness.
• K9TCCC adapts the well-known TCCC concept to the physiology and anatomy of dogs to increase survival chances in operations.
• HHP (e.g., medics, doctors, paramedics) play a crucial role, as veterinary personnel are often only available at higher levels of care.
• The M3ARCH2 care scheme (Muzzle, Massive Bleeding, Meds, Airway, Respiration, Circulation, Hypothermia, Head Injury, Everything Else) provides a straightforward, structured approach.
• K9 physiology requires modified measures – e.g., no human tourniquets, different ventilation techniques, and special intubation.
• Opioids, ketamine, and sedatives must be used discerningly – especially for pain management and chemical restraint.
• No use of human blood or colloids! Use only canine blood products, a 500 ml bolus in severe hemorrhagic shock.
• Hypothermia prevention, pain management, and burn care are also critical for dogs.
• PFC and AE (Aeromedical Evacuation) for dogs require specialized knowledge, e.g., on flight suitability, restraint, and ventilation.

Conclusion: Every medically trained soldier must have basic K9TCCC knowledge – because the dog protects human lives, and we must protect it.

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UK Developing a Tier 2 SOF Medical Training Pathway – Lessons Learned

Luke Turner (UK)

Major Luke Turner analyzed the development of a structured medical training pathway for Tier 2 SOF forces, i.e., specialized but not highly individualized forces in the field of tactical special operations. The goal is to create a training system that meets the needs of patients, troops, and medical personnel equally – flexible, realistic, and competency-based.

At the center of the training pathway are three central “lessons learned“:

1. Clear role and performance definitions (role performance statement, RPS),
2. Analysis and processing of the training foundation and
3. Questioning rigid course formats in favor of adaptive training methods.

Various training levels are presented: from the “Advanced Team Medic“ to the “NSOCM“ (NATO Special Operations Combat Medic) to the multidisciplinary “Special Operations Resuscitation Team.“

Turner called for clear goal orientation, continuous evaluation, and a flexible mix of simulation, real practice, and self-study.

Key Messages:

• SOF medicine requires specific, realistic, and adaptive training pathways – no cookie-cutter approach.
• Start with a precisely defined “Role Performance Statement (RPS)“ – what should the person specifically be able to do?
• Unclear RPS lead to ineffective courses, unclear learning objectives, and unmeasurable competence.
• Early analysis of the training foundation is crucial – what do participants really bring?
• A gap analysis identifies competence gaps and allows targeted qualification measures.
• Course concepts must be regularly critically reviewed – rigid formats cause competence loss.
• Realistic clinical placements reduce “skill fade“ and improve adaptability.
• Simulation training in variable intensity (high/low fidelity) offers controlled learning with relevance.
• A blended learning approach (self-learning, simulation, practice) is the gold standard.

Conclusion: Tailored training = effective training – good training starts with clear roles and bold course development.

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Tabletop Wargames, a Useful Tool for Training Medical Command and Control

Antoine Luft (FRA)

Colonel Dr. Antoine Luft, head of the French Medical Command and Control Training Center at the École du Val-de-Grâce in Paris, presented the “war board games“ developed in France to train medical personnel in C2 tasks (“Command and Control“).

According to Dr. Luft, the reason for their development is the necessity for medical officers not only to master medical care but also to act as planners, advisors, and participants in the command structure. This can significantly increase medical effectiveness.

The games have been integrated into military training since 2022. Advantages include their adaptability, low cost, time efficiency, and promotion of critical thinking and adaptive leadership. The core is medical planning in complex operations with tactical and/or logistical constraints, such as MASCAL scenarios.

Due to very positive experiences with this training, there are already considerations for expanding existing games and creating new ones. Currently, however, they are only available in French.

Key Messages:

• Medical effectiveness = clinical expertise x operational coordination.
• Wargaming promotes reflection, adaptability, and operational leadership.
• Advantages: cost-effective, time-efficient, usable at all levels, no real risk, and teamwork.

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AidUP – Disaster Medicine Education by Lecturio

Uwe Schneider (DEU)

Uwe Schneider presented the “AidUP“ project as part of the global educational strategy of the platform “Lecturio“ (https://lecturio.com/inst/aidup/). AidUP aims to train medical professionals, first responders, and trainers worldwide in disaster medicine. The initiative combines digital teaching content, clinical knowledge, and modern learning technologies to enable scalable, resilient, and context-sensitive training solutions – especially for conflict and crisis areas.

The program includes:

• 12,000 video lessons,
• 35,000 review questions,
• 9,800 case studies,
• 130 clinical simulations,
• Special modules on “Disaster Casualty Care (DCC)“ and “Disaster Mental Health.“

The goal is to train 10 million professionals in DCC worldwide – with a focus on deployment areas such as Ukraine, the Middle East, or fragile states. The program relies on partnerships, co-creation, local expertise, and digital dissemination to make health systems more resilient.

Key Messages:

• AidUP connects disaster medicine, military medicine, and digital learning to strengthen global emergency preparedness.
• The goal is to train 10 million medical professionals in Disaster Casualty Care (DCC).
• Lecturio offers scalable, evidence-based educational formats that are accessible anytime, anywhere – even offline.
• The system uses modern learning methods like spaced repetition, simulation-based learning, and personalized tutors.
• Disaster Mental Health is an integral part, with content from leading military psychiatrists (e.g., Jetly, Vermetten).
• AidUP targets doctors, nurses, community health workers, and first responders – tailored to their experience level.
• Content is created in collaboration with international and local experts, and we remain open to new partners and field experiences.
• Example projects, such as those in Ukraine, demonstrate applicability in active crisis areas.
• An open-access approach with co-development and knowledge exchange is explicitly desired – “Let‘s Collaborate.“

Conclusion: AidUP provides a robust, partnership-based educational model to make systems more crisis-resistant and save lives in disasters.

https://lecturio.com/inst/aidup/

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Scaling the Frontline: AI-Driven Ultrasound Adoption

Rob Arntfield (CAN)

Prof. Rob Arntfield, Western University, London, Ontario, Canada, presented a forward-looking approach to shifting diagnostic capacities to the front line. Instead of relying on centralized high-performance diagnostics, he advocates for portable, AI-supported solutions that enable reliable decisions even under field conditions – regardless of the users‘ training level.

Central to this is the integration of point-of-care ultrasound (POCUS) in combination with artificial intelligence. The presented systems detect thoracic injuries, such as pneumothorax, more accurately than doctors in studies. With the prototype “PneumoGo,“ a portable assistance system was introduced, successfully tested under real conditions, such as with the US Marines.

Calls for a rethink: diagnostics must be advanced. Scalability and automation are indispensable in modern operational medicine.

Key Messages:

• Diagnostics must be advanced – directly into the tactical space.
• AI-based ultrasound is more accurate than manual screening in thoracic emergencies.
• Standardized systems like “PneumoGo“ enable diagnostics without on-site specialists.
• Scaling replaces centralization: technology brings decision-making authority forward.

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Ten Bullets Lessons Learned – Training in the Jungle of Brazil

Carsten Dombrowski (DEU)

Former soldier, paramedic, and TCCC instructor Hauptmann a. D. Carsten Dombrowski reported on a “training mission“ in Brazil, where a missing person was searched in the jungle. The mission planning, medical planning, and SAR (Search and Rescue) deployment were discussed. The “lessons learned“ from the mission were summarized in ten points.

Key Messages:

• Early, structured planning (PACE – Primary, Alternative, Contingency, Emergency) is essential – improvisation is no substitute.
• Precise task distribution within the team prevents chaos – roles and responsibilities must be defined.
• Information gathering beforehand is critical – about location, situation, logistics, climate, and time zone.
• Realistically assess material transport – consider time, temperature differences, and customs regulations.
• Operational readiness depends on many factors – climate, time zone, and acclimatization.
• Cross-check – control all processes and equipment.
• PPE (Personal Protective Equipment) – adapted and fully ready.
• Teamwork is a key factor – individual excellence is useless without cooperation.
• Expect the unexpected – alternative plans (B, C, D, E) are mandatory.
• Debriefing and medical checks provide valuable insights into health.
• Exit strategy is part of the plan – return path and follow-up must be considered.

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Zones in Terror Attack – Adapt to the Tactical Situation

Michael Storz (DEU)

The lecture addressed the practical challenges of the zone concept during terrorist attacks in civilian emergency services. Michael Storz, training manager for emergency services at the Munich Fire Department, argued that the theoretically sensible zone concept – dividing into red, yellow, and green zones – is often impractical, especially in the early phase of dynamic operational situations.

A central problem is that the “green zone“ is often not immediately definable. Nevertheless, there is acute pressure to act, particularly to care for critically injured individuals. The classic priority “self-protection before patient protection“ must be reevaluated in such situations – especially when the absence of early medical help has fatal consequences.

Storz called for an open, structured discussion within the emergency services about acceptable residual risks, realistic decision-making bases, and possible adaptations of existing concepts for caring for life-threateningly injured patients.

Key Messages:

• The zone concept is theoretically sensible but often practically difficult to implement – especially in the early phase of a terrorist attack.
• The green zone is frequently not immediately clear, leading to uncertainty and care delays.
• Critically injured patients cannot wait for “green zones“ – medical first aid must begin early.
• Self-protection is essential, but should not be disproportionately prioritized when no concrete danger exists.
• Rescue forces must learn to deal with residual risks, just as in other danger situations (e.g., traffic, fire, high-altitude rescue).
• Concrete danger (e.g., active shooter) justifies retreat; abstract threats (e.g., suspected explosive device) must be critically assessed.
• Operational leadership bears responsibility for balancing safety and care, not just for situation assessment.
• Standardized requirements for 100 % safe operational sites are unrealistic – they don‘t exist in everyday life either.
• LebL concepts must be adaptable and dynamic to meet the reality of complex operational situations.

Conclusion: The debate about operational boundaries, residual risks, and care tactics in terror situations is overdue and must be actively conducted within the emergency services.

8. Session – Water is for Spaghetti – Whole Blood Update

Comparison of the Lethal Triad and the Lethal Diamond:

Olivier Duranteau (FRA)

Against the backdrop of trauma-induced coagulopathy, Prof. Olivier Duranteau, Hôpital National d‘Instruction des Armées (HNIA) Percy, explained the two known concepts: the “Lethal Triad“ (hypothermia, acidosis, coagulopathy) and the extended “Lethal Diamond,“ which additionally considers hypocalcemia. In his presented retrospective multicenter study, the goal was to compare the prognostic value concerning 24-hour mortality in severely injured patients.

No significant difference was found in prognostic value between the two concepts. However, the simultaneous presence of multiple criteria – especially in the presence of hypocalcemia – was associated with increased mortality. The results raise relevant questions for future research on the role of calcium in trauma care.

Key Messages:

• No prognostic superiority of Lethal Diamond over Lethal Triad.
• Hypocalcemia + multiple triad/diamond criteria → increased 24-hour mortality.
• Calcium: risk marker or therapeutic target?
• Further research is needed on timing, dosage, and outcome of calcium administration.

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Whole Blood as a Resuscitation Fluid in the Prehospital Arena – an Update from THOR and Real-Life Experience

Elon Glassberg (ISR)

Brigadier General Prof. Dr. Elon Glassberg, Surgeon General‘s Headquarters, Israel Defense Forces (IDF), provided insight into the prehospital care of the wounded with whole blood, established by the IDF since 2018. The measure was introduced in air rescue in 2018, then in selected rescue vehicles in 2021, and since the Hamas attack, also at the front line. Whole blood is now the transfusion medium of choice for hemorrhagic shock in the Israeli army.

Advantages of Whole Blood

Compared to component therapy (red blood cells, platelet concentrate, FFP (Fresh Frozen Plasma), and cryoprecipitate), whole blood has a higher concentration of red blood cells and platelets and more clotting factors with less volume. Prof. Glassberg noted that whole blood use has been practiced in many countries for decades. In his view, risks such as transfusion reactions or infections are significantly outweighed by the benefits.

THOR Network

Additionally, Prof. Glassberg introduced the international “THOR“ network (Trauma Hemostasis and Oxygenation Research), where civilian and military special forces, experienced surgeons, and emergency physicians, as well as blood bank staff, scientists, and the industry, aim to improve the care of severe trauma and the outcomes of the wounded.

Key Messages:

• The use of whole blood has been established in Israel for decades, and since the Hamas attack, also at the front line.
• Whole blood carries risks that are outweighed by the benefits.
• Advantages over component therapy include higher red blood cell and platelet concentrations and more clotting factors with less volume.
• THOR Network: An international multidisciplinary group aiming to improve outcomes and care of severe trauma.

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Alternatives to Whole Blood: Cell Saver and Autologous Transfusion

Andreas Garcia-Bardon (DEU)

Commander (Navy MC) Dr. Andreas Garcia-Bardon from the Bundeswehr Central Hospital Koblenz, discussed the possibility of machine autotransfusion as an alternative or supplement to whole blood transfusions in Large Scale Combat Operations (LSCO) with high blood demand.

In LSCO, there is an extremely high demand for blood products, which overwhelms conventional blood logistics and emphasizes the need for resource-efficient, field-ready alternatives. In machine autotransfusion (MAT), blood is collected intraoperatively or post-traumatically, cleaned, and reinfused. Devices used include the Cell Saver Elite Plus, the CATSmart, or the Hemoclear.

The Hemoclear, in particular, seems suitable for use in low-resource settings due to its simple design.

Independent (especially) clinical studies to evaluate the effectiveness, safety, and practicality of the system in real-world scenarios are still pending. Early results indicate that the device can increase the hemoglobin value of a solution to be filtered by up to one and a half times compared to the starting value.

Key Messages:

• LSCO requires new blood supply concepts.
• Machine autotransfusion (MAT) is a practical, near-deployment solution.
• MAT offers clinically relevant hemoglobin concentrations.
• MAT reduces dependence on blood banks and transfusion logistics.

9. Session – Wounded Warrior – Backside of the Coin

Sub-PTSD Detection and the D-STRESS Project

Dr. Fanny Levy (FRA)

Dr. Fanny Levy presented the D-STRESS project, a French research program aimed at detecting subclinical PTSD symptoms. The goal is to objectively and non-stigmatically identify stressed soldiers through physiological and behavioral data.

In a virtual-reality (VR)-supported study, heart rate variability, skin conductance, and respiratory rate during conditioned fear reactions were analyzed. A risk score developed from this could identify sub-PTSD with high accuracy.

Key Messages:

• Sub-PTSD affects up to 65 % of experienced soldiers.
• The VR paradigm allows for objective assessment of stress reactions.
• HRV and SCR values are reliable predictors of sub-PTSD.
• EEG and behavioral data add little to the model.
• Goal: a mass-applicable, automated detection method for prevention.

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Ganglion-stellatum Blockade (GSB) in PTSD

Alan Peterson (USA) & Peter Christensen (DAN)

Professor Alan Peterson, University of Texas San Antonio (USA), and Dr. Peter Christensen (Denmark) presented a combined therapy approach for treating post-traumatic stress disorder (PTSD) – particularly in soldiers and veterans.

The combination of ganglion-stellatum blockade (GSB) and prolonged exposure therapy (PE) aims to enhance therapeutic effectiveness by simultaneously reducing the physiological stress response and cognitively processing traumatic experiences.

GSB Method

The GSB is an ultrasound-guided, invasive procedure in which a local anesthetic is applied to sympathetic nerve fibers in the C4 and C6 regions (first right, then left) in two sessions. These fibers have connections to the amygdala, a central center of fear processing. The goal is to inhibit the “fight or flight“ response temporarily. The effect sets in quickly, lasts three to twelve months, and has a low side effect profile (e.g., Horner‘s syndrome, hoarseness).

Study situation

In a pilot study with twelve active US soldiers undergoing PE and additionally receiving a GSB, there was an average reduction of 32 points in the PCL-5 score (a decrease of ten points is considered significant). After three months, 89 % of participants no longer met PTSD criteria. A multicenter follow-up study with 140 soldiers worldwide is currently underway.

Key Messages:

• PTSD is highly prevalent among soldiers and veterans and requires specific treatment strategies.
• GSB is a safe, cost-effective, and time-efficient procedure with minimal side effect risk.
• Mechanism of action: blockade of sympathetic nerve fibers → inhibition of the amygdala → dampening of the stress response.
• Treatment protocol: two sessions within 48 hours, bilateral cervical, at C4 and C6 levels.
• Combination with PE (evidence-based cognitive behavioral therapy) shows significantly improved therapy effects.
• GSB can reduce emotional overarousal, facilitating access to cognitive therapy elements.
• Initial studies show high efficacy, especially in previously difficult-to-treat patient groups.
• Further international studies are ongoing, including with online-supported data collection.

Conclusion: GSB is a promising addition to classical psychotherapy for PTSD, especially in the military context.

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Beyond PTSD: Addressing Shame and Moral Injury in Combat Veterans

Caroline Diekmann (DEU)

Major (MC) Caroline Diekmann, Psychotraumazentrum der Bundeswehr am Bundeswehrkrankenhaus Berlin, addressed the previously little-discussed phenomenon of “Moral Injury.“ Unlike PTSD, shame, guilt, and moral disorientation after boundary transgressions are at the center. Using deployment examples, she described three primary sources of moral injury:

• Misconduct by others,
• one‘s actions, and
• experiences of betrayal.

A therapeutic, three-week group concept with psychotherapeutic and pastoral elements showed significant effectiveness in reducing dysfunctional strategies for dealing with shame. The concept encompasses reconstructing moral integrity through rituals, narrative procedures, and symbolic reconciliation.

Key Messages:

• Moral injury is based on shame, guilt, and value conflicts – not fear.
• Causes include omission of assistance, one‘s misconduct, and betrayal.
• Psychotherapy addresses values, identity, and moral reconstruction.
• Rituals and symbolic procedures (e.g., stone ritual, letters) promote healing.
• Leaders should be sensitized to moral injury preventively.

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Medical Challenges in the Warzone Ukraine

Iryna Rybinkina (UKR)

Dr. Iryna Rybinkina, herself a native Ukrainian and a UK-trained anesthetist, gave an impressive insight into the medical realities in Ukraine‘s frontline areas, particularly in Donetsk and Zaporizhzhia. The stark contrast between modern Western clinical standards (e.g., King‘s College Hospital London) and makeshift operating rooms and stabilization points at the frontline took center stage.

Medical facilities are daily targets of attacks – civilian and military casualties, children and adults, are jointly cared for under the harshest conditions. This involves not just medical care but primarily logistical, technical, and infrastructural challenges: power supply, device standardization, lack of spare parts, consumables, and insufficient training.

Paradigm Shift Demanded

Dr. Rybinkina called for a paradigm shift from “Deploy & Donate“ to “Sustain & Support“: Only through thoughtful, compatible, and serviceable systems can long-term supply security be established in war zones. This requires strategic thinking, on-site training, and clear communication and repair paths.

Key Messages:

• War changes everything – especially medical standards and priorities.
• Devices must be compatible, robust, and maintenance-friendly – simple troubleshooting guides and spare parts are more critical than high-tech.
• Turbine-based ventilators (independent of the central gas system) are crucial for front-line operation.
• Standardization reduces complexity – same systems, same spare parts, same training.
• Consumables are often more expensive than the device itself – planning must reflect ongoing costs.
• Charities and NGOs need access to spare parts, which are currently often not sold.
• Planning must consider maintenance, logistics, and long-term supply – not just equipment delivery.
• Training is critical: Devices can save lives – but only if they are operated correctly.
• Digital communication channels (e.g., WhatsApp) enable remote support – simple solutions are often the most effective.

Conclusion: In a war where medical infrastructure is deliberately destroyed, not just technology saves lives, but above all, thoughtful, sustainable system design.

10. Session – Surgical & Anesthesiological Lessons Learned of Combat-Related Injuries

MOF Persistence in Shock Relevant in Large-Scale Combat Operations

Pierre-Louis Quere (FRA)

In his presentation, Dr. Pierre-Louis Quere, from Sainte Anne Military Hospital in Toulon, examined multi-organ failure in severely injured soldiers in light of insights into future Large Scale Combat Operations (LSCO).

MOF Study from 2023

Dr. Quere referred to a retrospective, monocentric study from 2023, which included soldiers wounded in action with a Modified Injury Severity Score (MISS) ≥ 9. Multi-organ failure (MOF) was defined as the failure of more than two organ systems and a SOFA score over four on the fourth day in the clinic.

Study Results

22 % of patients developed persistent MOF on day four, with MOF correlating with more thoracic injuries, more blood transfusions, more intubations, higher vasopressor needs, a higher number of surgeries in the first week, and often with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI).

Patients with MOF had significantly poorer outcomes. Compared to the civilian setting, MOF often began immediately after injury, transport time to a Role 4 was usually longer than a day, and causes were frequently multiple and complex injuries.

Conclusions for LSCO

For LSCO, these insights mean that the risk of MOF increases with severe combination injuries and traumatic brain injury (TBI) and hemorrhage, and evacuation delays exacerbate the problem. Early recognition of MOF is crucial and raises the question of early care using high-end systems, such as ECMO or renal replacement therapy (RRT).

Key Messages:

• MOF is a leading cause of death in wounded patients with severe combination injuries.
• Early MOF detection is crucial but challenging under LSCO conditions.
• Extended evacuation times without air superiority worsen the prognosis.
• TBI and massive transfusions are essential indicators of MOF.
• LSCO requires strategic resource planning for organ-supportive therapies (ECMO, RRT).

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Regional Anesthesia in Austere Locations

Tristan Alie (CAN)

Major Dr. Tristan Alie, Royal Canadian Medical Service, Ottawa, emphasized the value of regional anesthesia procedures in resource-limited deployments. Especially in extremity injuries – the most common injury pattern – regional anesthesia allows effective and longer-lasting pain management with minimal monitoring effort.

Besides the benefits, he also highlighted risks and necessary skills: coagulopathy, LA toxicity, and lack of expertise can cause severe complications. He called for targeted training, clear protocols, and context sensitivity in procedure selection.

Key Messages:

• Regional anesthesia is a “force multiplier“ in extremity injuries.
• Pain reduction with simultaneously reduced monitoring needs.
• Knowledge of anatomy, coagulopathy, and ultrasound guidance is crucial.
• LA toxicity and misplacements are central risks.
• There is a need for structured training concepts and the selection of suitable block techniques.

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Surgical Lessons Learned from Gaza, Syria, and Ukraine

Samer Attar (USA)

Dr. Samer Attar, Northwestern University, Chicago, has been volunteering as a US trauma and emergency surgeon in crisis areas of Syria, the Gaza Strip, and Ukraine for years. He shared impactful images and stories from his missions.

Severe Trauma, Lack of Resources

The injury patterns are very similar in all deployments: massive amputations, soft tissue and head injuries, malnutrition, and many child patients. The images he presented showed the harshest conditions under which the injured had to be treated. For 100 patients, there are only three nurses and hardly any beds, so treatment often takes place on the floor. There is no monitoring, no medical equipment, no imaging.

Open Wound Treatment is Essential

An important lesson he has learned from his many deployments is the importance of open wound care for at least five days. Otherwise, it cannot be assumed that muscle cells are viable (and remain so). Subsequently, a secondary wound closure, possibly with flap plasty, can be performed.

Great Psychological Burden

The psychological burden is enormous, not only due to the constantly looming threat of an attack on the medical facility but also because of the often very young patients and the helplessness of being unable to treat many of them with the available means. Dealing with death is routine. However, Dr. Attar also emphasized the incredible teamwork and the immense gratitude of the patients saved by the team.

Key Messages:

• “Killing a medic is like killing 100 soldiers.“
• Open wound care for at least five days to assess tissue viability.
• Enormous burden on nurses and doctors due to lack of materials, constant need for patient triage, and severity of injuries.

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Guideline for Traumatic Brain Injury under LV/BV Conditions

Magnus Scheer (DEU)

Lieutenent Colonel (MC) Dr. Magnus Scheer from the Bundeswehr Hospital Ulm presented the clinical practice guideline for managing traumatic brain injuries under national and alliance defense (LV/BV) conditions.

Discrepancy between demand and resources

The starting point was the drastic discrepancy between the expected neurotraumatological care demand and the realistically available resources. A calculation example illustrates this impressively:

In a scenario of large-scale combat, up to 250 penetrating traumatic brain injuries would be expected daily – compared to only about 20 neurosurgeons in the Bundes­wehr.

Guideline with indication-based recommendations

To enable scalable and structured care in such a scenario, a guideline was formulated. It defines indication-based recommendations for operative and conservative treatment – especially by non-neurosurgeons – and recommendations for limiting therapy in hopeless situations.

Key Messages:

• Daily care reality in LV/BV could mean 250 penetrating TBI with only 20 neurosurgeons.
• The guideline ensures scalable and practical action security.
• Main target group: non-neurosurgeons in Role 2/3 structures.
• Indication-based recommendations for craniotomy, ICP measurement, EVD, conservative therapy.
• Consideration of telemedical support and clearly defined limits.

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Non-Compressible Hemorrhage Control

John Croushorn USA

John Croushorn, emergency physician and Major (retired) of the US Army, presented options for controlling non-compressible hemorrhages in his lecture.

The Non-Compressible Torso Hemorrhage (NCTH) has been the most common preventable cause of death in military casualties for over ten years. For junctional bleeding in the groin/axilla, so-called junctional tourniquets can be used, or alternatively, the wound can be packed.

Similarly, for junctional bleeding/pelvic or post-partum hemorrhages, AAJT-s (Abdominal Aortic and Junctional Tourniquet-Stabilized) can be used. These have a high success rate even with inexperienced users and can increase the mean arterial pressure (MAP) comparable to a Zone 3 REBOA. An application of fewer than two hours has also not led to tissue damage in pig models.

AAJT-s have also been studied in pig model studies for use in resuscitation. Here, an increased ROSC and survival rate were observed.

AAJT-s have already been successfully applied in Ukraine. However, given the four-hour application duration, tissue damage cannot be avoided, and patients should receive intensive care.

Key Messages:

• Non-compressible hemorrhages (NCTH) are the leading cause of preventable deaths in military operations – tourniquets are ineffective here.
• AAJT-S is a practical, quickly applicable solution to stop arterial bleeding in areas like the pelvis, axilla, and abdomen.
• Studies show comparable effects to REBOA but with less invasiveness and faster application by non-specialized forces.
• Protocols for prolonged application (up to four hours) exist; complications are manageable, especially with transport or delayed access to definitive care.
• The application is already CoTCCC-recommended, FDA-/CE-approved, and gaining worldwide importance. Goal: Integration of AAJT-S as a “basic standard“ in every tactical casualty care and CASEVAC structure.

For the Authors

Major (MC) Dr. Katharina Beck
Department of Anesthesia, Intensive Care, Emergency Medicine, and Pain Therapy (AINS)
Bundeswehr Hospital Ulm
Oberer Eselsberg 40, 89081 Ulm
E-Mail: kathatrina2beck@bundeswehr.org

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¹ K9 stands for service dogs in the US military. The abbreviation likely stems from the phonetic similarity of K9 with “canine,“ meaning “dog-like“ or “relating to dogs.“