Summary of the SOF Medic Meeting Presentations at the
CMC-Conference, July 2-3, 2025

Stefan Kühn^a, Florent Josse^ab

a Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy – Bundeswehrkrankenhaus Ulm

b Tactical Medicine Working Group of the German Society for Military Medicine and Military Pharmacy, Bonn

1. Session – SOF Medic Meeting

UK Adoption of TCCC, Program BLACKTHORN

Pete Hale (UK)

Colonel Pete Hale from the Royal Army Medical Corps presented the UK strategy for the comprehensive implementation of Tactical Combat Casualty Care (TCCC) through the BLACKTHORN program. The shift from a Counter Insurgency (COIN) approach to large-scale combat operations (LSCO) necessitates a more robust, decentralized casualty care system at the front lines. The British Armed Forces lag behind their NATO counterparts in TCCC, as highlighted by Ukraine‘s rejection of the British system. BLACKTHORN aims to enhance medical capability through improved training in areas such as air-to-surface missile (ASM), combat lifesaver course (CLS), and combat medical care (CMC), along with modernized equipment like individual first aid kits and blood products. Special Forces (SOF) play a leading role, serving as catalysts for the conventional forces.

The program seeks to standardize across all domains (land, air, sea) to ensure efficiency and interoperability, embedding the changes into regular operations permanently.

Key Messages

• The British Army is implementing TCCC across the board with BLACKTHORN to align with the standards of international partners.
• The transition from COIN to LSCO requires increased medical capacity at the front and simplified, interoperable structures.
• Special Forces act as role models to disseminate straightforward, effective TCCC practices throughout the defense system.

“NATO Special Operations Combat Medic (NSCOM) DEU” – Implementation and Operational Lessons

Meryem Gözalan (DEU)

Major Meryem Gözalan from the Bundeswehrkrankenhaus Ulm presented on the pilot course NATO Special Operations Combat Medics (NSOCM DEU), a strategic medical training program for German Special Forces. The goal is to create a NATO-compatible medical qualification for non-medical SOF personnel while also adhering to Germany‘s legal requirements. The course integrates civilian emergency medical technician training (according to Bavarian law) with tactical training in TCCC, Prolonged Field Care, and blood transfusion. The training includes five modules over 24 weeks, comprising theory, clinical rotations, tactical scenarios, and a state examination in Munich. Challenges include integrating German legislation, personnel shortages, and limited practice time. The course has successfully produced highly qualified SOF medics deployable in both civilian and military contexts, with a permanent establishment as a core capability of the Bundeswehr being pursued.

Key Messages

• NSOCM DEU addresses a strategic capability gap in the medical domain of Special Forces, considering both German and NATO standards.
• The training combines civilian qualifications (emergency medical technician) with operationally relevant immediate medical care (TCCC, PFC).
• The pilot course demonstrated high effectiveness, but also highlighted areas for improvement, such as training duration and resources, with plans for permanent integration.

Experience of a Paramedic at the Frontlines in UKRAINE

Michael Schumacher (DEU)

Michael Schumacher, an experienced firefighter and paramedic, shared his experiences as a Combat Medic in the Ukraine war. He was responsible for the medical care of casualties at the front lines in Pokrowsk and Lyman, conducting Case Evacuation (CASEVAC) missions and training various brigades. Most injuries are explosion-related, with approximately 90% affecting extremities and about 60% involving polytrauma with head injuries. Many complications arise from the improper use of medical equipment, such as tourniquets or thermal blankets. Drone surveillance, poor roads, and long evacuation routes severely hamper CASEVAC under wartime conditions. The current medical setup is heavy (over 40 kg), and evacuations over 8-10 km on foot are necessary in some areas. Schumacher calls up for better training, more equipment, enhanced protection against drones, and cooperation between civilian and military structures.

Key Messages

• Injury patterns: Approximately 90% extremity injuries; 60% polytrauma with head trauma; 87% facial injuries due to explosions.
• CASEVAC challenges: Drones, electronic warfare, and poor infrastructure significantly hinder evacuations; medical personnel need more time and equipment.
• Misapplications and equipment issues: Many complications result from improper use of tourniquets or thermal blankets; amputations often result from incorrect application, delayed, or no conversion of an established tourniquet.
• Future demands: More and longer training for all soldiers, intensive civilian internships, better protective equipment, anti-drone systems, and close civilian-military cooperation.

SOFCOM MEDAD/JMED-Update 

Mathieu David (FRA)/Tom Sharp (UK)

NATO‘s Special Operations Forces (SOF) require unified medical standards to ensure efficient and interoperable multinational operations. The SOFCOM Medical Directorate (MEDAD/JMED) coordinates medical training and development programs within NATO-SOF structures.

Over the past twelve months, numerous courses such as TCCC, SOST, and Medical Instructor Development have been conducted in various NATO countries. Central standards like SOFCOM 75.001 (minimum requirements) and 75.002 (certification) form the foundation for training combat medics and surgical teams. The development of national capacities, such as in Latvia, demonstrates successful TCCC competency building through multinational support.

In the next twelve months, further courses, training, and operational exercises like „Bold Adra“ are planned, simulating real challenges (e.g., drones or A2AD threats). Anti-Access Area Denial (A2AD) is the capability to deny or at least complicate access and/or freedom of movement in a selected area of operations to opposing forces by military means.

The goal remains to build robust, interoperable medical capabilities in the SOF sector, particularly concerning modern warfare and extended evacuation times.

Key Messages

• Unified standards: SOFCOM has established unified minimum standards and a certification system for NATO-SOF medicine with guidelines 75.001 and 75.002.
• Training and development: Numerous specialized courses (e.g., TCCC, SOST, SOMID) are conducted annually across NATO to enhance medical readiness.
• Multinational cooperation: The development of national capacities (e.g., in Latvia) demonstrates the success of international training support and ­civil-military cooperation.
• Objective: Building and securing interoperable, resilient medical support in the SOF sector.

Swedish Air Force Rangers – New Patrol Medic Course

Pierre Ströhberg (SWE)

The Swedish Air Force Rangers have developed a 35-week Patrol Medic Course tailored to the specific needs of their unit. The course comprises a 20-week academic section covering anatomy, pathophysiology, and pharmacology, alongside practical training within the unit.

The medical focus is on TCCC, PHTLS, MASCAL, and prolonged field care, with special consideration for cold climates, hypothermia, and patient prolonged care. Specialized modules like K9 medicine, CBRN-MARCH, and environmental medicine are also integrated. The highlight is the „Ex Yoda“ exercise, which realistically simulates care from the injury site to surgical treatment.

A unique feature is the combination of veterinary personnel with TCCC instructors to enhance K9 training. Long-term plans include further training such as RN training, ultrasound, and improvised medicine, with long-term capability maintenance posing a challenge.

Key Messages

• The Swedish Patrol Medic Course is practical, ­modular, and specifically adapted to the needs of Air Force Rangers.
• Broad training focuses range from TCCC, PHTLS, and MASCAL to K9, CBRN, and environmental medicine.
• Final exercises like „Ex Yoda“ and interprofessional trainer teams foster realistic, mission-oriented competencies.

2. Session – SOF Medic Meeting

Ten Points for Improvised Medicine

Aebhric O´Kelly (US)

Aebhric O’Kelly, a former critical care paramedic with the „Green Berets,“ discussed ten central principles of improvised medicine for use in remote or resource-limited environments. Simple, locally available materials are used to perform life-saving measures in cases of massive hemorrhage, airway problems, or circulatory arrest. Examples include improvised tourniquets, pelvic slings made from bedsheets, surgical airways without pens or cut tubes, and homemade chest seals with four-sided sealing. Other techniques include hypothermia wraps (including the head), rectal fluid administration in the absence of IV access (proctoclysis), and creating plaster casts with household materials.

The course aims to remain medically operational under the HITMAN model even with delayed evacuation (PFC). Correct application of the principles („If you can breathe through the tube, so can the patient“) and attention to anatomical basics are essential.

The presentation was based on the training standards of the College of Remote and Offshore Medicine (CoROM) and aims to convey practical applicability under extreme conditions.

Key Messages

• Improvised medicine can enable life-saving interventions with simple means in resource-limited situations.
• Critical areas like hemorrhage control, airway management, and heat retention can be effectively improvised with clear rules and techniques.
• The goal is to remain medically stable even with delayed evacuation or under tactical conditions (PFC).

Food and Water Defense – Insights from the Russia-Ukraine War for (Highly) Mobile Food and Drinking Water Testing

Nicole Meier^a, Bernd Klaubert^a

^a Central Institute of the Bundeswehr Medical Service Munich

Abstract

The Russian invasion of Ukraine is currently one of the most severe conflicts in Europe, with far-reaching consequences for nature and the environment. Troop movements, extensive artillery use, infrastructure destruction, and abandoned military equipment all contribute to the release of significant amounts of environmental contaminants. Additionally, the physical, chemical, and biological properties of the soil are impaired with considerable consequences for agriculture and food quality. There is also the risk of radioactive emissions from nuclear power plants. Adverse effects (contamination) and their health impacts can be identified through the food chemical A/C protection. For this purpose, highly mobile analytical capabilities are available with the food and eco-chemical field laboratory. This review aims to identify and summarize the current literature on the release of environmental contaminants through military activities during the Russia-Ukraine War. Based on current data on water contamination levels and pollutant inputs from Ukrainian food, specific questions can be derived to expand the performance spectrum of the mobile food and eco-chemical laboratory container. The focus here is on potential challenges in national/alliance defense or comprehensive national defense. The literature review indicates that the Russia-Ukraine War has a significant impact on food and water quality, for example, through attacks on water resources and infrastructure. Water contamination with explosives, heavy metals, and radionuclides poses a real threat. Mobile field laboratories enable rapid assessment of any toxicological effects. Answering whether consumption is safe thus makes an essential contribution to preventive health protection.

Keywords: Food and water safety, food chemical A/C protection, preventive health protection, mobile analytics, Literature review

Introduction and Background

In light of insights from the war in Ukraine, it must be assumed that chemical and radiological threats significantly jeopardize food and drinking water safety. Among the most endangered areas are drinking water and the associated water infrastructure. The literature reports on both the role of water as a driving force in conflicts and the impacts of armed conflicts on water and water systems. The open-source database “Water Conflict Chronology” by the Pacific Institute currently includes over 1600 entries in three categories (Figure 1):

(1) Water as a “trigger” (control over access to water),

(2) Water as a “weapon” (water is used as a weapon),

(3) Water as a “casualty” (direct attack on water systems).

Since the start of the Ukraine-Russia War, 64 entries have already been recorded in the categories of water as a “weapon” (10 times) and as a “casualty”(54 times) (see Figure 1) [9]. Additionally, water resources are often threatened by so-called collateral damage, such as pollution from military operations. In the first three months of the war alone, reports were registered of damage to dams, flooded mines, mined areas, interruptions to water supply, water transport, wastewater treatment, surface water pollution, bacterial contamination, and the risk of radioactive contamination [13]. Impairment or contamination of drinking water and food, as well as the resulting health consequences for soldiers, can have significant impacts. Through food chemical A/C protection, such risks can be identified and assessed. For this purpose, highly mobile analytical capabilities are available with the food and eco-chemical field laboratory. The objective of this review was to identify and summarize current literature on the release of environmental contaminants due to military activities in the Russia-Ukraine War.

Method

In April 2024, a comprehensive search was conducted in relevant scientific databases for this literature review to identify and summarize existing data and publications on environmental contamination in the context of the Russia-Ukraine War. The databases used included PubMed and Google Scholar to ensure broad coverage of the relevant literature. Both original publications and review articles were considered. Additionally, publicly accessible data from Ukraine was incorporated into the discussion. Through the analysis of current literature and data from Ukraine, specific questions can be derived to expand the performance spectrum of the food and eco-chemical laboratory container. The focus is on potential challenges in national/alliance defense or comprehensive national defense.

Results

Overview of Risks Leading to Water Pollution

The impairment of the physical, chemical, and biological properties of the soil due to military activities leads to significant consequences for agriculture and the quality of cultivated food. Physical/chemical contamination of water and food can be attributed to the following causes:

• Large-scale fires
• Destruction of critical infrastructure (e.g., energy and fuel supply, water supply and wastewater treatment facilities, waste disposal systems)
• Damage to the chemical industry and nuclear power plants (release of „toxic industrial chemicals“ [TIC] or radioactive radiation)
• Remnants of bombs, rockets, and ammunition debris, or abandoned/sunken military vehicles and equipment
• Flooding of mines and tailings storage facilities (TSF)
• Contamination with chemical warfare agents or sabotage toxins (e.g., via „unmanned armed vehicles“ [UAV])

Overall, military actions can lead to unintentional contamination and associated health hazards. This differs from deliberate contamination of water and food with chemical warfare agents (CWA) or suitable sabotage toxins.

Fig. 1: Water-related events during the Ukraine-Russia War by year and type. (Data from <https://www.worldwater.org> [9])

Decommissioned Mines and TSF

A particular example of the endangerment of Ukraine‘s water resources is decommissioned mines and tailings storage facilities (TSF), which are facilities for storing liquid waste from various industries (465 TSF in 2019 [8]). In the Donetsk and Luhansk regions alone, there are 200 TSF storing 939 million tons of industrial waste [1][8]. A pump failure or intentional destruction of the TSF systems can lead to mine flooding, resulting in the release of toxic mine water. The toxins can seep into the groundwater, affecting entire areas [11]. A particular danger exists if the Oleksandr-Zakhid mine in Horlivka, where chlorobenzene and other carcinogenic toxins have been stored since 1989, or the Yunyi-Komunar mine, where the Soviet Union detonated a 0.3-kiloton nuclear bomb in 1979, are flooded [4][6].

Pesticides

Another serious problem for Ukrainian waters is small illegal landfills with expired pesticides in the soil from the Soviet era (“pesticide burials”). Ukraine is currently one of the world‘s largest consumers of pesticides (approximately 100,000 tons per year). In 2020, an estimated 8,230 tons of expired pesticides were stored in 650 depots nationwide. Explosions caused by bombing and the intentional flooding of agricultural land through dam explosions contribute to the release of stored pesticides into the groundwater [6].

Nuclear Power Plants (NPP)

During the Ukraine-Russia War, combat actions and artillery attacks have already occurred in areas surrounding the Chernobyl (NPP Chernobyl) and Enerhodar (NPP Zaporizhzhia) nuclear power plants. Both NPPs are located near rivers and large water reservoirs. Such a location carries the risk of radionuclide emissions into the environment and their rapid transmission to surrounding ecosystems [6].

Summary of Water Monitoring Data

Despite military activities, the state agency for water resources conducts monitoring of surface waters used for drinking and household purposes at designated monitoring points, where the military situation permits. Elevated concentrations of heavy metals mercury, copper, tin, manganese, and lithium were detected. Up to an 8.5-fold exceedance of mineral oil and mercury content was also detected at locations where they were not previously detected before the invasion [1]. In the Uda River, for example, a 20- to 58-fold increase in the insecticide cypermethrin and a 1.5- to 1.7-fold increase in levels of polycyclic aromatic hydrocarbons were measured. At the surface drinking water intake points in Kharkiv, the phosphate content increased 2.4 times, and the nitrite content increased 4 times. Due to inefficient operation of wastewater treatment plants following hostilities in the region (damage, power outages, etc.), at the surface drinking water intake points in Donetsk, ammonium levels increased 2.4-fold and nitrite levels increased 2.8-fold.

Additionally, limits for pesticides, polycyclic aromatic hydrocarbons, volatile organic compounds, and heavy metals were exceeded [16]. After rocket debris damaged fertilizer tanks, ammonia and nitrate concentrations were found in river water samples east of Lviv that were 163 and 50 times above standard limits, respectively [11]. As another example, data from Strokal et al. (2023) show that, due to damaged sewer lines and wastewater treatment plants, the inputs of painkillers, antibacterial agents, and microplastics into the Dnipro River increased by 2 to 34% in 2022 [15]. Due to the military situation, state monitoring, however, does not have continuous access to all relevant sampling sites. This creates the need to close the gap with military field laboratories, including associated (highly) mobile sampling teams.

Fig. 2: The Kakhovka Hydroelectric Power Plant and its associated dam on the Dnipro River were destroyed by an explosion early on June 6, 2023. Downstream, four cities and several dozen villages were largely flooded, resulting in numerous fatalities, and industrial and urban infrastructure was destroyed or damaged. Bacterial and chemical pollution, including mineral oil residues, heavy metals, and polychlorinated biphenyls, was detected in both the downstream area and the northwestern part of the Black Sea. The water supply to extensive agricultural areas, several large cities, and towns, as well as essential energy facilities, including the Zaporizhzhia Nuclear Power Plant, was interrupted [17]. Satellite images of the lower Dnipro River, taken by the Landsat-9 satellite on (a) June 1, 2023, and (b) June 9, 2023. (Source: https://earthexplorer.usgs.gov/)

Health-Relevant Parameters for the Food and Eco-Chemical Laboratory Container

Numerous reports exist on the contamination of water with various chemical compounds. The following list provides an overview of the relevant physical and chemical parameters. References/sources are given in square brackets.

• Ammonium [3][4][7][11][13][15]
• Pharmaceuticals (e.g., Diclofenac) [15]
• Chemical Warfare Agents (CWA) [4][14]
• Chlorobenzothiophen [10]
• Dioxins [7][10]
• Volatile organic compounds (e.g., chloroform) [7]
• Macro-/Microplastics [15]
• Mycotoxins [5]
• Nitrate [3][7][11][15]
• Nitrite [4][7][13][15]
• Oil/fuel residues [1][7][11][13][14][17]
• Perchlorate [10][11]
• Per- and polyfluorinated alkyl substances (PFAS)
• Pesticides (e.g., Triclosan) [6][7][13][15]
• Phosphate [15]
• Polycyclic aromatic hydrocarbons (PAH) [4][7][10][13]
• Polychlorinated biphenyls (PCB) [10][17]
• (Poly)chlorinated naphthalenes [10]
• Radioactive compounds [1][3][6][10][14]
• Heavy metals [1–5][7][10][11][13][14][17]
• Explosives (nitroaromatics, e.g., TNT) [1][3][4][6][10][11][14]
• Sulfate [7][13]
• Toxic industry chemicals (TIC) [6][7][11]

Relevance of the Food and Eco-Chemical Laboratory Container

The current literature indicates that the Russia-Ukraine War has a significant impact on food and water quality, for example, through targeted attacks on water resources and infrastructure, or unintentional contamination resulting from military activities. The benefit of the food and eco-chemical laboratory container lies in the rapid assessment of potential acute toxicological effects from consuming water and food. The highly mobile sampling teams can also operate armed and close the gaps in civilian official surveillance. Due to high mobility and rapid deployability, statements about edibility or potential health hazards can be made directly on site. For the food and eco-chemical laboratory container, parameters not typically covered by civilian surveillance, such as explosive residues or CWA, are of particular interest. Based on the obtained information, the performance spectrum should be adapted to include the determination of TIC or pesticide residues. Additionally, data from satellite images („remote sensing data“) [12][14] or open-source tools can be utilized (Figure 3) to identify potential hazards and derive parameters for analysis.

Conclusion

The review offers insights into the contamination situation of water, food, and the environment in Ukraine, as well as its health impacts on daily life. Furthermore, the summary forms a basis for further developing the performance spectrum of the (highly) mobile food and eco-chemical laboratory container for future deployments within the framework of a national and alliance defense scenario or comprehensive national defense. The highly mobile field laboratories thus make an essential contribution to the preventive health protection of soldiers and ensure a health-safe supply for the troops.

References

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Manuscript Data

Citation

Meier N, Klaubert B: Food and Water Defense – Insights from the Russia-Ukraine War for (Highly) Mobile Food and Drinking Water Testing. WMM 2025; 69(10-11E): 7.

DOI: https://doi.org/10.48701/opus4-763

For the Authors

Captain (MC Pharm) Dr. Nicole Meier

Central Institute of the Bundeswehr Medical Service Munich

Ingolstädter Landstraße 102, D-85748 Garching

E-Mail: nicole1meier@bundeswehr.org