German Version

 

PARIS SOF CMC-Conference 2024

The Spirit of the Past, the Spirit of the Present, the Spirit of the Future – The Special Operation Forces Community Medical Strategies for Addressing New Threats

Daniela Lenard^a

^a Bundeswehr Hospital Ulm – Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy

Introduction and Background

The Paris Special Operation Forces (SOF) Combat Medical Care (CMC) Conference held its second session on October 15-16, 2024. First established in 2022 as a satellite conference of the CMC in collaboration with the SOF Medical Headquarters of the French Service de Santé des Armées, the CMC Conference Paris specifically targeted the close-knit community of medical personnel supporting the Special Forces domain.

Designed as a “small” meeting for up to 250 participants, the CMC Paris, as in 2022, once again brought together key international personnel from the tactical casualty care sector of Special Forces. This was to discuss, through lectures, workshops, a curated industry exhibition, and direct conversations in the corridors of the magnificent École du Val-de-Grâce (EVDG), the “here and now” and the future of Special Forces Operational Medicine in light of current challenges.

SOFCOM personnel – anesthesiologists, surgeons, emergency physicians, emergency nurses, intensive and anesthesia care staff, paramedics, and medics – from over 40 nations flocked to the metropolis on the Seine. The atmosphere reflected the community to which the conference was addressed: familial, direct, unconventional, informal, yet highly concentrated, always oriented towards the unifying goal of providing the best possible casualty care.

Opening of the CMC Conference 2024

The opening session took place in the stately Rouvillois Auditorium. The two leaders and hearts behind the event, Colonel Prof Dr. Pierre Pasquier and Senior Medical Officer Dr. Florent Josse, warmly and collegially welcomed their audience before handing over the microphone to Brigadier General Dr. Pierre Mahé, Major General Michel Delpit, head of the French SOF Command, General Medical Officer Dr. Jens Diehm, representative of the Central Medical Service of the Bundeswehr, and Dr. Sean Keenan, President of the Special Operations Medical Association (SOMA). The presence of these influential figures in military medicine underscored the conference’s significance for both the participants and the leadership, which, through their presence, emphasized the strategic and operational importance of effective tactical casualty care, particularly for Special Forces.

With clear and direct words, the opening speakers immediately engaged their audience with the challenges of the current political situation. They posed the crucial questions to be addressed in the coming hours and days.

• How can experiences from stabilization missions and the fight against terrorist groups be transferred to a combination of conventional and irregular warfare?
• What happens when the “golden hour” becomes a “golden day”?
• How many tactics does medicine need?
• Is there a need for new frugality in light of supply shortages?
• What options do technological advancements, industrial innovations, and telemedicine offer, or is common sense all that’s needed?

In the venerable halls of the EVDG, one of the birthplaces of field medicine, the concentrated professionalism was tasked with developing pragmatic solutions, focusing on the essentials and bypassing all the “bullshit.”

This article summarizes key messages from the numerous lectures and workshops over the two days in Paris, without claiming completeness. More information about the whole program can be found at www.cmc-conference.de.

Summaries of Selected Lectures

New Threat Scenarios: Drones, Shrapnel, and the “Death of the Golden Hour”

Mike Turconi, Canada

Mike Turconi, a Canadian by choice and a veteran of the Italian Special Forces, delivered an impressive situation report from Ukraine. At the heart of his lecture was the “Evolution of Threat”: the shift from imprecise artillery shelling to the high-precision threat posed by drones. These dramatically altered the tactical landscape, rendering classic cover structures obsolete. Turconi described the impossibility of rapid evacuation as the “Death of the Golden Hour.”

The immediate impact on casualty care involves delayed evacuations over short distances, MASCAL situations with high numbers of lightly to moderately injured individuals, which still tie up significant resources, and a new primary injury type: explosion injuries with shrapnel, which occur far more frequently than gunshot wounds (Figures 1 & 2). Turconi argued that training must go beyond the mere “how” of tourniquets, integrating reassessment, repositioning, and conversion more strongly. Particularly drastic is the so-called “epidemic of limb loss” due to inadequate follow-up care of initial life-saving measures [14][23][29].

Take-Home Message

• Precise artillery and drone attacks are targeted, among others, at medical personnel and facilities: Cover underground.
• Even short distances along the evacuation route are highly time-intensive.
• Medics are not mass-produced.
• Training scars are due to overly concise tourniquet training.

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Saving Lives With Good Data and the Joint Trauma System

Colonel Jennifer Gurney, USA

Colonel Dr. Jennifer Gurney, chair of the Joint Trauma System, emphasized in her lecture that tactics, operations, and strategy can only function medically with valid data. She further explained that data quality and communication across command and treatment levels are essential for saving lives [22].

This lecture primarily focused on the role of whole blood transfusions in the military setting. Data from the DoD Trauma Registry (DoDTR) indicated that a so-called “Futility Threshold” for the administration of blood products in the military environment may not exist, which has relevant implications for resource planning and ethics in deployment [12][17][35].

Take-Home Message

• Good Data enables Good Planning; Bad Data leads to Bad Planning.
• Medical data from civilian medical studies only allows limited conclusions about the military population.
• To improve life-saving measures, one must examine what caused the casualties to die.
• The objective determines the mission.

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Open-Source Data and Strategic Derivations

Lieutenant Colonel Audrey Jarrassier-Feltz, France

Lieutenant Colonel Audrey Jarrassier-Feltz highlighted the high potential of open medical data for improving tactical care. However, she warned that these programs too often rely solely on the work of volunteers out of conviction. There is a risk of lacking sustainability. In Ukraine, for example, enormous experiences and data are emerging, which, due to overarching registers, are too often lost.

A meta-analysis of 21 articles with over 11,000 patients shows the importance of promoting such data and studies. This impressively demonstrates how essential correctly indicated tourniquet application is – only 24.6% were applied appropriately (Figure 3) [16][23].

Additionally, she pointed out the critical threat of multi-resistant germs such as carbapenem-resistant Acinetobacter baumannii – a problem that intensifies along evacuation lines [16].

She also strongly warned against the danger of manipulated open-source data in hybrid warfare.

Take-Home Message

• Open-source concepts need the backing of expert committees and organizations to ensure sustainability and maintain quality standards.
• Foundations must be created to make valuable experiences from the Ukraine war available for scientific analysis in the form of registers.
• Open sources are always at risk of being used for misinformation.

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The Tragic Advantage of Experience and Knowledge in Ukraine

John Quinn, USA

Dr. John Quinn emphasized the operational flexibility of Ukrainian Role-I structures, where highly complex procedures like REBOA are sometimes performed (Figure 4), while in other places, hardly more than basic equipment is available. The training and structure are extraordinarily heterogeneous, but valuable insights arise through high personal responsibility and documented practical performance [25].

He called for stronger integration of Special Operations Forces (SOF) medicine into conventional planning processes and referred to the “Tyranny of Distance” as a central problem of casualty care in Large-Scale Combat Operations (LSCO). Standardized training (e.g., via Deployed Medicine [4–anOpen-SourcemediumoftheDHA)andpromotingthepersonalresponsibility(“ClinicalGovernance”)ofmedics[21] are essential (Figure 5).

Take-Home Message

• Open Source “Deployed Medicine” strengthens training and training concepts.
• The Ukrainian frontline shows a highly inhomogeneous care structure.
• Gained insights in LSCO of Ukraine: far ahead of the COIN experiences of NATO partners.

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“Les amateurs pensent à la tactique, les professionnels pensent à la logistique” – Strategic Change and Leadership Responsibility

Mike Hetzler, USA

Mike Hetzler, with his extensive experience in military special forces medicine, demanded a change in his lecture: the necessity of strategic change within the military medical community.

Drawing from his experiences as NATO SOF Medical Program Manager and his deep commitment to tactical medicine, he emphasized that especially special units are the driving force for change, not only in medical but also in strategic terms. Supported by quotes from General (ret.) Joseph Votel (“SOF accelerates change”), Hetzler highlighted that the SOF medical community must learn to support conventional offensive operations, and no longer exclusively vice versa. Especially considering the massive casualty numbers due to drones and shrapnel, one must ask which medic will be needed in five to ten years. He outlined the strategy of “4Ds”: Dispersion, ­Decentralization, Discipline, Deception. He called for strengthening medical leadership: From medic to strategic decision-maker (“Be a commander, accept risks”). Central skills lie in operational leadership capability and the integration of technical innovations such as AI and drone technology, for both care and logistics and evacuation. To support this change, military, academic, and industrial cooperation collaboration is necessary. The “Medical Support to Irregular Warfare” Committee (MSIW), initiated by the Standard Operating Medical Assessment (SOMA), is, according to Hetzler, an example of necessary structures that need to be created in response to irregular warfare.

Take-Home Message

• Strategic decisions for the next 5–10 years must be made now.
• Adaptation of training to LSCO experience: agile Forward Surgical Elements operating from underground, bunkers, and living rooms.
• Skills acquired by SOF must be incorporated into regular combat operations.

 

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Ad-hoc and Complex – Evacuation Missions ­without Preparation

Colonel Prof. Brice Malgras, France

Colonel Prof. Brice Malgras illustrated with an impressive experience report the reality of highly complex evacuation missions without preparation time. In spring 2023, he led a Special Operation Surgical Team (here: Surgical Life Saving Modules = SLM) on an ad-hoc mission to Sudan [18]. Over 1,000 people from over 80 nations had to be evacuated within 96 hours. In addition to classic military structures, surgical modules were used in aircraft deployment. Colonel Malgras advocated that training and education must simulate and anticipate these scenarios to make providers resilient in high-risk situations.

Take-Home Message

• Evacuation missions offer little planning time: They must be trained in training and considered in Medical Planning in advance.
• Think Outside the Box: Forward Surgical Element is also deployable and usable during flight.

 

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Prolonged Casualty Care – The Art of Endurance

Sean Keenan, USA

Dr. Sean Keenan, a long-time US military physician and leading figure in “Prolonged Field Care” (PFC) and “Prolonged Casualty Care” (PCC) development, addressed their challenges in his lecture. His goal was clear: to equip field medics mentally and professionally to care for patients over hours or days, far from established rescue chains.

Keenan says the foundation is a stable base in TCCC (Tactical Combat Casualty Care) and a functioning blood program [4]. Only regular, reality-based training can create operational decision-making security.

“Treating a patient knowing full well they should be treated elsewhere – and for much longer than you want to” (Quote Dr. Doug Powell).

The growth of evidence-based guidelines (CPGs) must be actively promoted to make PFC/PCC not the exception, but a structured care option, both in COIN missions and in LSCO under conditions of irregular threat [27].

Take-Home Message

• The origin of the “Tyranny of Distance” remains highly relevant for PCC in both COIN and LSCO.
• The keys to good PCC care are and remain: solid TCCC training, bleeding control, sufficient blood program.
• A new version of the PCC-CPG from JTS is planned for 2025.

 

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The Operator Syndrome – The Dark Side of the Elite

Colonel Dr. Anis Duffaud, France

Colonel Dr. Anis Duffaud, a neurophysiologist at Hôpital Bégin, presented the “Operator Syndrome,” a complex syndrome constellation that goes far beyond classic PTSD. She probably spoke to many listeners’ souls through her lecture, but touched everyone deeply.

Based on up to 30 individual diagnoses – from mild traumatic brain injury to social dysfunction (Figure 6 – she described this syndrome as an expression of chronic allostasis (the organism’s ability to achieve stability through adaptation to stress) under continuous deployment conditions. The research, initiated by Dr. Christopher Frueh, shows that SOF operators, while appearing and partly being more resilient, report symptoms significantly less frequently, while simultaneously experiencing more severe forms [5][9]. Particularly in active service, a high dark figure could lead to destabilization of long-term health and operational readiness. The OPSYN-FR study presented by Duffaud aims to provide more evidence on the physical, psychological, and social stress of French Special Forces in the future.

Take-Home Message

• PTSD differs in severity between SOF personnel and regular military forces.
• SOF personnel are physically healthier and more resilient.
• The Operator Syndrome is related to the level and duration of stress.
• The Operator Syndrome is still largely unexplored but includes up to 30 different pathologies.

 

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Lighter, Faster, More Agile – Summary and ­Perspective

Colonel Dr. Yann Le Vaillant, France

Colonel Dr. Yann Le Vaillant emphasized the key themes at the end of the day:

• blurring boundaries between combatants and civilians,
• drones as a logistical resource,
• the targeted attack on medical facilities, and
• The need for operational flexibility in DCS and resuscitation modules.

Securing open-source structures through peer review and fact-based communication is a particularly emphasized challenge. NGOs must be better integrated, strategically embedded, and analyzed regarding their role in the civil-military care network. To address the challenges of irregular warfare medically, medical personnel must be increasingly empowered to think tactically and operationally, and understand international partnership as the key to success.

Take-Home Message

• DCS/DCR facilities must be lighter, more agile, and faster.
• Drones can serve as supply systems for resource-intensive materials and medications.

 

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“If you stare into the abyss...” – Humanitarian Lessons from Extreme Scenarios

Dr. Samer Attar, USA

Dr. Samer Attar, a surgeon at Médecins Sans Frontières, confronted his audience with a reality beyond military planning games (Figure 7):

• Mass casualty situations with minimal equipment, daily, permanently;
• Amputations, debridements, external fixators – all without modern imaging, without protection, under constant stress.

  

  Fig. 7: Amputation, debridement, open wound treatment, external fixator; from the presentation „War Surgery Journal: Syria, Ukraine, Gaza“ (Samer Attar, CMC Paris, October 16, 2024).

Ukraine and Gaza have taught him that it’s less about complex procedures and more about psychological resilience and sober, pragmatic surgery [10]. His demand is less focus on technology and more on decision-making strength under pressure. Acceptance of limits, training of “mental coping skills,” and a clear ethical line are essential. The goal is not the impossible but what is possible for the individual that can be saved.

Take-Home Message

• Surgical knowledge and skills are reduced to: amputation, debridement, open wound management, and external fixator.
• The main burden and challenge lie in psychological and emotional handling: continuous threat, impossibility of triage, a lack of everything, waves of helplessness, and a sense of powerlessness.
• Resilience is gained from demarcation, from acknowledging achievements, and from the strength of the community.

 

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An External Eye Sees More – Telemedicine Support for the SOF Medic

Colonel Prof. Dr. Yvain Goudard, France

Colonel Prof. Dr. Yvain Goudard’s following lecture starkly contrasted Dr. Attar’s technology-poor environment. Within the framework of the RAPACE project, his team tested various telemedicine concepts for their actual applicability in an SOF mission. RAPACE stands for “Réalité Augmentée Pour Assistance par Chirurgien Expert” [11].

Conclusion: Not yet ready for deployment, but promising. So-called pass-through systems have potential for practical application. They allow a steady flow of information about the ongoing surgical procedure while allowing support integrated into the imaging system, such as externally played skin or tissue incision guidance. Offline modes, which play a role especially in electronic reconnaissance, were also tested. Despite user-friendliness, usage comes with high demands on the user’s concentration.

Take-Home Message

• Telemedicine “Pass-Through Systems” are the most promising.
• Electric signature and offline options require further intensive research.
• Systems place high demands on concentration in application.

 

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Moon Landing in Bleeding Control – Innovation and Reality

Colonel Dr. Paul Parker, UK

Colonel Dr. Paul Parker, the highest-ranking consultant for trauma surgery and orthopedics of the British Army, focused his lecture on one of the central medical challenges of modern battlefield care: non-compressible bleeding control (Non-Compressible Torso Hemorrhage, NCTH) [8]. Looking at the rising mortality, especially in abdominal, pelvic, and junctional bleeding, exacerbated by long evacuation times under the “Tyranny of Distance”, Parker posed the groundbreaking question: Can NCTH be transformed into compressible bleeding?

He built on existing junctional tourniquets; however, he emphasized that their properties do not yet meet the requirements of an ideal device [33]. Such a device must be easy to apply, controllable, reusable, compact, tissue-­friendly, transportable, and not hinder access to the pelvis and sling.

Parker presented three central drivers for innovation:

• Shift due to successful limb tourniquets, shifting the focus of injuries to the torso and proximal junctional regions [8],
• increasing severity of injury patterns through drone use – particularly in the Ukraine war – associated with a rise in DCS-mandatory injuries [13], and
• Time factor: Every minute of uncontrolled bleeding increases mortality by up to 5% [18].

Against this backdrop, Parker outlined current research approaches to NCTH control – an endeavor seen as akin to a “moon landing” [20]. Multi-phase hemostatic foams for internal compression are particularly interesting, but they are still in the experimental stage [6].

At the center, however, was the AAJT (Abdominal Aortic and Junctional Tourniquet), whose success Parker impressively demonstrated both from preclinical research and over 60 documented applications in Ukraine [3][26]. The AAJT is considered quickly applicable, effective, and safe – even over a two-hour application duration. It was used for severe bleeding in pelvic, inguinal, and axillary areas – up to successful application in five trauma-induced cardiac arrests [1].

Colonel Parker concluded with an appeal: Time is the critical factor – both in training for the application of such devices and in their rapid, life-saving deployment on the battlefield.

Take-Home Message

• Time to bleeding control is a crucial factor for mortality reduction.
• External compression using AAJT is equivalent to Zone 3 occlusion REBOA.
• Numerous successful applications of the AAJT.
• The case-based application within TCA is successful.

 

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The Importance of Technology Transfer and Practical Training in the SOF Context

Major Dr. Jean-Charles de Schoutheete and Captain Dr. Arthur Bun, Belgium

The lectures of Major Dr. Jean-Charles de Schoutheete and Captain Dr. Arthur Bun illustrated how significant realistic surgical and anesthesiological training is for personnel of Forward Surgical Elements. The presented Belgian-Congolese cooperation offered a vivid blueprint for maintaining SOF medicine under the most challenging conditions. In Kinshasa, both basic surgical interventions (laparotomies, amputations) with limited resources (Figure 8) and regional anesthetic procedures under the most adverse circumstances (e.g., spinal anesthesia during laparotomy) were successfully performed. This underscores the value of genuine treatment experience in resource-poor settings as a complement to high-fidelity simulations.

Take-Home Message

• Resource scarcity in Third World treatment facilities offers opportunities to train DCS/DCR skills in reality-based scenarios.
• A return to simple procedures and clinical judgment is necessary.

 

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Balance Between Mobility, Quality, and Tactics

Lieutenant Colonel Dr. Matthieu David, France

Lieutenant Colonel Dr. Matthieu David bridged the past, present, and future of French SOF medicine and formulated the five medical-tactical core goals of the French SOFCOM (e.g., mobility, resilience, telemedicine) [22] (Figures 13 & 14). A key factor was once again the ability to transfuse blood under SOF conditions. It was emphasized that the modular medical deployment structure must flexibly adapt to PACE concepts (Primary, Alternate, Contingency, Emergency). It was also clear: The irregular threat situation demands a paradigm shift in training, towards tactically and operationally thinking medical personnel.

Take-Home Message

• It is not “One Size Fits All,” but medical planning adapted to the respective situation for modular medical deployment structures is required.

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Strategic Assessment and “Medical Offset Strategy”: Multinational Interoperability Instead of Singular Standards

Colonel Benjamin Ingram, USA

Colonel Benjamin Ingram, NATO SOFCOM MEDAD, highlighted the necessity of strategic qualification standards in multinational structures. Building on the Medical Offset Strategy concept, he advocated for bringing medical interventions, especially bleeding control and blood transfusion, as close as possible to the Point of Injury [2][19]. The biggest obstacle is the lack of interoperability in training and logistical systems. Training formats like PETT training (Prolonged Evacuation Transport Team) are the first steps, but unified European and NATO standards must supplement them. Blood, blood again and again, emphasized COL Ingram and posed the question of how such a mortality- and morbidity-critical medical measure lacks both European and NATO-wide interoperability.

Ingram called for using digital technologies, e.g., AI-supported logistical analyses or QR code-based patient registration, to meet the requirements of future LSCO. A central insight is “Force Medical Risk and Medical Force Risk.” Medical care must be anticipatory, resilient, and digitally transformed to meet the requirements of modern warfare.

Take-Home Message

• Establishment of true medical interoperability: cross-border, medical regulations, primarily focusing on interoperable blood programs.

 

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Future of Blood Products – Innovation & Reality

Prof. Dr. Andrew Cap, USA

Prof. Dr. Andrew Cap presented the latest developments in freeze-dried plasma (FDP) and its significance for future deployments [24]. While glass ampoules limit current systems, new developments in plastic packaging and container solutions for freeze-drying are promising [34]. The strategic relevance arises from effectiveness and independence from conventional supply chains (Figure 10 – a decisive advantage under LSCO conditions.

Take-Home Message

• Pack freeze-dried plasma in plastic containers.
• Deployment of container-based freeze-drying facilities.
• Research on extending the shelf life of blood products is essential.

 

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CASEVAC by Drones – Science No Longer Fiction

Captain Dr. Camille Brene, France

Captain Dr. Camille Brenet cast drones in a new light: not as a threat but as an opportunity for evacuation [31]. In addition to the already implemented transport of medical products, she presented four functional UAV systems with CASEVAC potential (e.g., T-650, MERT-R). A concept of UAV and UGV evacuation in combination with AI-supported decision support was sketched – realistic in the future but with current challenges such as hypothermia, physiological stress, and triage-related limitations.

Take-Home Message

• Drones are multipurpose.
• Evacuation prototypes require further improvement.
• The indication for use plays a key role.

 

 

The Medical Response to Hybrid Warfare – Interoperability, Innovation, and Resilience

The CMC Paris 2024 impressively revealed:

Military casualty care must fundamentally adapt—technically, tactically, and conceptually. Modern conflicts require close civil-military integration, new training and education formats, modular care units, and the integration of technical innovations such as Artificial Intelligence, telemedicine, and UAV systems. SOF medicine is not only reactive but increasingly has a shaping role.

Or as Prof. Dr. Andrew Cap put it:

“If we are complacent, we will be defeated.”

Save the Date:

The CMC Conference 2025 will take place on July 2nd and 3rd in Blaubeuren. For more information, visit www.cmc-conference.de.

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Author

Lieutenant Colonel (MC) Dr. Daniela Lenard, MD
Bundeswehr Hospital Ulm
Department of Anesthesiology, Intensive Care, ­Emergency Medicine, and Pain Therapy
Oberer Eselsberg 40, D-89081 Ulm
Email: danielalendard@bundeswehr.org

 

German Version

 

Medical Insights from the War in Ukraine

Dennis Ritter^a, Christoph Czwielung^b, Willi Schmidbauer^c

^a Bundeswehr Healthcare Command, Koblenz

^b Medical Supply Center Bonn

^c Bundeswehr Central Hospital Koblenz

Summary

The war in Ukraine demonstrates how future military conflicts might impact medical services. The lessons learned can be applied to patient care from the point of injury along the rescue chain, pointing to future challenges. First responders must master the conversion of a tourniquet and receive better training on resilience and dealing with injury and death. First responders A and B must be qualified in extended care across various phases of tactical medicine. Initial medical care must be enhanced with the capability for whole blood transfusions, combined with improved tactical training. Role 1 care, as well as initial surgical stabilization, needs to be better prepared for mass casualty incidents. Strategic patient transport must be expanded to include rail-based ground transportation to handle a large number of casualties. Additionally, awareness must be raised about the critical importance of reducing electromagnetic radiation in certain frontline areas and utilizing underground supply facilities.

Keywords: Basic training for first responders, injury patterns and consequences, rescue chain, strategic patient transport

Introduction and Background

The conflict between Russia and Ukraine marks the beginning of a new era of warfare. Conventional combat, hybrid threats, and extensive use of modern technologies have significantly impacted military strategy and logistics, particularly in military medical services. New threat scenarios, high casualty numbers, and disrupted infrastructure have compounded the challenges faced by medical services. Structured analysis is difficult due to the lack of objective data. Patient numbers and injury patterns are often classified or simply unavailable, notably the absence of a “trauma registry” in Ukraine. Russian data is scarce, making interpretation even more challenging. Information comes from various sources, including individual interviews, social media, conference presentations, and NATO partners (where not classified). Additionally, there is a large volume of publications from non-governmental organizations (NGOs) that do not always undergo peer review. The authors have strived for objectivity in this analysis, acknowledging the contributions of the Lessons Learned Branch of the Military Medicine Center of Excellence (MilMedCOE) in Budapest, led by Captain (Navy) Jeff Ricks MD.

Medical care in war zones must consider several aspects: first aid on the battlefield, efficient casualty transport, medical logistics, and long-term care for injured and traumatized soldiers. The “Golden Hour”—the first hour after an injury—often determines life or death. Rapid and efficient care is a critical factor that can influence the success of military operations. This analysis reviews key medical insights from the war in Ukraine and derives future recommendations for action.

Conflict Conditions

The Russian invasion of Ukraine illustrates a new dimension of hybrid warfare. Both sides target (civilian) critical infrastructure, significantly impacting medical services. Since the invasion began in February 2022, many medical facilities have been deliberately damaged or destroyed. By December 2024, the Ukrainian Ministry of Health reported that 2,167 medical facilities had been affected, with 1,878 damaged and 289 completely destroyed [5]. The current situation shows that drone usage has created a technological “no-go area” up to 15 km behind the frontline, which was initially smaller and did not exist at night. Drone night capabilities have significantly increased, eroding the tactical advantage of darkness [9]. The ability of drones to detect electromagnetic signatures has also increased, making operations of electrical devices, especially medical equipment, easily detectable and vulnerable to countermeasures. This applies to mobile phone usage as well. Drones also locate medical waste to identify nearby medical facilities quickly. The loss of the Red Cross protection as per the Geneva Conventions by the Russian side has significantly increased the pressure on all involved in medical care.

A particular challenge is the high number of casualties in a short time, mainly due to artillery fire and explosive injuries, which require highly specialized care. Logistical challenges due to destroyed roads, disrupted supply lines, and targeted attacks on medical facilities further complicate the situation. Reaching front-line areas is problematic as medical teams often operate under high security risks.

Lines of Insight

Insight Line 1:
Injury Patterns and Causes of Death

Injury patterns are regularly evaluated in armed conflicts. During Operation Enduring Freedom (OEF), Eastridge et al. analyzed the period from 2001 to 2011 to draw conclusions for casualty care, most of which remain relevant today [4]. The focus of this analysis was on preventable causes of death, predominantly related to massive blood loss. Hemorrhaging from extremity injuries was identified as a preventable cause of death. Other factors included airway obstruction and tension pneumothorax [1]. The lethal injury patterns were ranked as follows:

1. Severe traumatic brain injury in the group of the definitively fatal injuries at 83 %,
2. Bleeding in potentially survivable injuries in the torso (43 %), extremities (31 %), and junctional areas (neck, armpits, and groin at 21 %) [3].

Consequently, all NATO partners introduced the use of tourniquets in self and buddy aid. Relieving a tension pneumothorax, however, is reserved for trained personnel and is taught only from the level of first responder B, similar to the Combat Life Saver (CLS) program.

Injury Patterns

At the 59th COMEDS Plenary Meetings in Oslo (Norway), from April 18 to 20, 2023, the Ukrainian Surgeon General, Major General Tetiana Ostaschenko, presented the following analyses:

• 67 % of all fatalities occurred within the first ten minutes after injury; the remaining 33 % died later, without a specified timeline.
• Hemorrhaging is cited as the leading cause of death.
• 10–15 % of the injured require immediate and front-line emergency surgical stabilization to survive subsequent transport.

The injured body regions are distributed as indicated in Figure 1.

Two main focus areas emerge from the injury patterns:

• Extremity trauma and
• Head and neck injuries.

Recent insights shared by MilMedCOE indicate a focus on extremity injuries caused by shrapnel on the Ukrainian side. These injuries aim to create visibly severe wounds leading to mutilation or loss of one or more extremities, intended to demoralize the civilian population and induce war fatigue.

Care Times

Based on the care times mentioned by Major General Ostaschenko and derived from our own medical service insights [8], the average prolonged stays for the injured and sick can be estimated as follows:

Ultimately, the insufficient number of medical personnel results in disproportionately higher losses during or after combat. Reports clearly show prolonged care times and, consequently, a significantly worse medical outcome for severely injured patients.

Risk: Microbial Contamination

Examining the injury patterns of Ukrainian citizens evacuated to Germany reveals massive microbial contamination of the injured, posing significant challenges to receiving hospitals in Germany, including a lack of antibiotic treatment options. It should be noted that unnecessarily broad initial antibiotic prophylaxis promotes resistance formation, so the Tactical Combat Casualty Care (TCCC) concept, which initially recommends Carbapenem administration, should not be supported here. Instead, evidence-based initial administration of Moxifloxacin orally as part of self and buddy aid for heavily contaminated wounds, and Cefuroxime (possibly in combination with Metronidazole) from the Combat Medic Corpsman’s training level intravenously, should be implemented. Furthermore, it is crucial to emphasize the adherence to basic hygiene as a key preventive measure against these nosocomial infections, which worsen outcomes significantly and unnecessarily bind the already limited resources during treatment.

Despite unverifiable and highly differing attrition rates on both sides, Russian losses are likely significantly higher.

Insight Line 2:
Self and Buddy Aid:

Disease and Non-Battle Injuries

Future training must be based on current scientific findings in trauma research and experiences from armed conflicts. Unfortunately, Ukraine has provided little analysis of “cross-sectional,” non-battle-related diseases (so-called “Disease and Non-Battle Injuries” / DNBI) and the resulting attrition. Recent publications allow the inference that at least 65 % of all casualties (temporary or permanent) are due to diseases, showing a clear dependence on weather conditions. This would allow conclusions about necessary training needs and equipment with medical materials. However, based on available data from the professional literature, one must also expect relevant attrition due to diarrheal diseases, seasonal respiratory illnesses, and other infectious diseases in this conflict. These should be included in the individual equipment (Individual First Aid Kit, IFAK) of soldiers, as has already been done with the planned provision of Azithromycin for treating diarrhea.

Hemorrhage Control, Analgesia, Airway Management

Examining injury patterns, the care of life-threatening bleeding is clearly paramount. Training along the phases of tactical medicine must not only include the ability to tourniquet one or more extremities but, given the prolonged time until qualified medical aid arrives, also the conversion/replacement by a pressure bandage after 60 minutes. Given the significant pain burden from a tourniquet, there must be an individual, soldier-controlled analgesia available and feasible. The Central Pharmaceutical Commission of the Bundeswehr has recommended the introduction of an inhalative analgesic (Methoxyflurane), which is currently being implemented. Adequate bandages and tourniquets must be present in the IFAK to treat at least two affected extremities. Regarding head and neck injuries, training must be introduced to recognize and assess severe traumatic brain injuries and their consequences. In this context, the corresponding positioning and securing of the airway with simple aids should be part of the training. Ultimately, this leads to prolonged (tactical) casualty care. In this context, existing concepts of early antimicrobial treatment must be emphasized to minimize infection risk consistently [7].

Prolonged Casualty Care and Resilience

Given the timelines, caring for casualties over hours within the framework of extended self and buddy aid presents challenges to the helpers. This is currently being taught in a separate training section in the First Responder A training as a direct consequence of the published professional insights of the medical service [6]. In the context of national defense/collective defense, the preparatory training must be adjusted for resilience enhancement, considering potentially high mortality rates. This should be done in collaboration with members of the social network, such as military chaplaincy, troop psychologists, psychotraumatologists, and palliative care physicians. Preparing for possible scenarios of caring for the dying and dealing with injury and death can significantly enhance the resilience of soldiers.

Insight Line 3:
Initial Medical Care

Considering the postulated injury patterns, the focus is on treating complex extremity and surface injuries. This involves training the care of (sub)total amputation injuries, managing reperfusion syndrome following prolonged extremity tourniquet application, and treating extensive surface injuries, bringing these competencies into the realm of non-physician personnel. Additionally, providers must ensure the care of severe traumatic brain injuries. In the comprehensive treatment of complex injury patterns, securing the airway, including infraglottic, adequately managing thoracic injuries, and providing sufficient analgesia must be ensured. Ultimately, a concept for administering blood and blood products by non-physician personnel, especially in the “pre-hospital” Role 1 area and potentially even before that, is necessary.

Transport Prioritization

In the initial medical care of casualties, it must be decided which patients can survive and which transport route must be used. Currently, there is no validated algorithm for this, indicating an urgent need for research in this area to prevent overwhelming the nearest level of care.

Provision of Medical Supplies and Equipment

The points mentioned above necessitate the provision of individual consumables (EVG) and non-consumables (NVG) medical supplies. Clear standardized supply packages are required, starting with a uniform emergency backpack, through uniformly equipped vehicles, to Role 1 facilities. The volatile market availability means these EVG/NVG medical supplies must be stocked within the Bundeswehr to ensure a robust and resilient supply of medical materials when needed. The scope of equipment must consider not only climatic peculiarities but also the supply of blood and blood products, as well as oxygen. A consistent shift from gas cylinders (as an additional explosive load) to establishing oxygen concentrators is required.

Insight Line 4:
Role 1

Given the expected complex injury patterns described above in Treatment Level 1, the troop doctor/emergency physician must be enabled to diagnose and treat these adequately. This includes performing ultrasound-guided examinations, evaluating simple laboratory parameters, securing the airway, initiating and maintaining emergency anesthesia, and treating thoracic and traumatic brain injuries. This explicitly includes initiating conservative measures to reduce intracranial pressure and stabilize circulation and administering blood and blood products in the sense of Damage Control Resuscitation.

Infection Prophylaxis

To prevent early infectious complications, the initial care of complex extremity injuries, traumatic amputations, and extensive wound surfaces must involve white sponges, surgical gauze, and stapling devices. Antimicrobial treatment should involve local application of 0.4 % polyhexanide solution combined with the administration of Cefuroxime (possibly in combination with Metronidazole).

No Amputation in Role 1

Amputations should not be performed at this level of care. They must be carried out in a treatment level suitable for initial surgical care, such as Role 2F/B/E. This is partly because only here can surgical care be provided that ensures prosthetic fitting and delivers the best possible functional outcome.

Treatment of Burn Victims

To meet the needs of this very demanding patient group, the treatment of severely burned patients must also be part of the training. Course formats like the Burn Trauma Course 48 (BTC48), developed in collaboration between the Bundeswehr Medical Service and the Occupational Accident Clinics, would be beneficial.

Handling Mass Casualty Incidents

Ultimately, an increased occurrence of mass casualties (wounded and sick) is to be expected. Strategies for triage and re-triage must be revised and incorporated into training. This includes care concepts based on the S2k “Disaster Medical Prehospital Treatment Guidelines” [2].

Insight Line 5:
Forward-, Tactical-, Strategic Medical Evacuation

The transport of casualties from the CCP towards Role 1 in Ukraine is improvised and is makeshift, not meeting the standards for qualified casualty transport. At the latest, during subsequent transport from a Role 1 facility or a Forward Surgical Element (FSE) towards Role 2/3, quality care must be ensured to maintain the treatment standard achieved up to that point, preferably optimizing it. As extensively outlined in Insight Line 4, tactical large-scale transport and strategic casualty transport are essential. Here, the personnel resources from the areas of specialist anesthesia and intensive care nursing, as well as medical officers and anesthesiology specialists, should be relieved as much as possible while maintaining professional quality standards. It is advisable to train Emergency Medical Technicians further with the civilian additional qualification “Specialist for Out-of-Hospital Ventilation” to independently care for stable ventilated patients, ultimately supervised by experienced intensive care personnel. Considerations regarding the type and scope of large-scale transport means have already been made [8].

Insight Line 6:
Initial Emergency Surgical Care/FSE/Role 2B

Pathophysiological Necessity: Adhering to the Golden Hour

The NATO and Bundeswehr Medical Service timelines for casualty care are based on medical research foundations. These show that the survival chances of an injured or wounded person decrease significantly if they are not provided with emergency medical care within an hour (the so-called “Golden Hour”). Thus, the timelines are not scenario-dependent but dictated by the human body’s physiological processes.

Timeline 10 + 1 + 2 (+ 2)

The operational principles of the Bundeswehr Medical Service are designed to enable casualty care within the NATO-prescribed timelines. The necessary resource requirements are formulated and must be implemented promptly for the sake of the deployed soldiers. The aim remains to ensure that after injury:

• Within 10 minutes, initial qualified assistance is provided.
• After one hour, Damage Control Resuscitation (DCR) measures are initiated, and
• Within a maximum of two hours, initial emergency surgical care in the sense of Damage Control Surgery (DCS) is provided.
• After an additional two hours, treatment in a Role 2 E or higher treatment level should be ensured.

Thus, the 10+1+2(+2) approach as a timeline is to be demanded. Deviating from this, regardless of the reason, whether due to planning considerations or uncontrollable factors during implementation, will inevitably lead to a significantly worse outcome in care and survival rate of the casualties.

Frontline Surgical Initial Capability

The need for a surgical initial capability placed as close to the combat area as possible has long been recognized as necessary by all established Western medical services, not just since the current war. The provision of surgical instruments and their processing must also be considered. Based on the efforts of the US-based non-governmental organization Global Surgical and Medical Support Group (GSMSG), this surgical support is provided in Ukraine up to the front lines shortly after the war began. This NGO operates from a consortium that draws its personnel from the American College of Surgeons structure. With over 80,000 members in renowned clinics and other American healthcare organizations, this NGO possesses extensive expertise and corresponding experience. This example confirms the German position and targeted efforts to expand and implement this capability in the forward combat area.

Conclusion at Present

Along the outlined lines of insight, explosive and shrapnel injuries are the most common causes of trauma. The extremities and the head and neck area are primarily affected. Bleeding and severe traumatic brain injury are the most frequent causes of death.

These insights necessitate adjustments to the training content for First Responder A, focusing on hemorrhage control (application and replacement of tourniquets), analgesia, and thermal maintenance, as well as enhancing soldiers’ psychological resilience. However, DNBI, with about 65 %, remains the most common cause of (temporary) soldier attrition. From the First Responder B level, additional qualifications such as early, evidence-based antibiotic administration and basic knowledge of relieving tension pneumothorax and prolonged battlefield care are to be pursued.

Insight Line 3 (initial medical care) focuses on strengthening trauma care competencies, early administration of blood and blood products by medical personnel, MASCAL training, researching a new triage algorithm, and transitioning to concentrator-based oxygen production.

Insight Line 4 results in the requirement to strengthen emergency medical competencies at the Role 1 level, focusing on ultrasound diagnostics, managing complex thermomechanical combination injuries, including (partial) amputations, and managing MASCAL situations.

Another requirement is to enhance intensive care competencies during large-scale transports by Emergency Medical Technicians with the additional qualification “Specialist for Out-of-Hospital Ventilation.” Insight Line 6 highlights the importance of the treatment timelines 10 + 1 + 2 (+ 2) for soldiers’ survival through consistent application of DCR and DCS. Additionally, the treatment of DNBI remains a significant part of all medical care, as this will be where most patient numbers are concentrated.

Final Assessment

The Bundeswehr Medical Service is already planned, conceptually aligned, and professionally prepared to support the German military and its partners in a national and collective defense scenario. This is repeatedly confirmed concerning training, equipment, and medical and non-medical personnel operational principles. The identified needs must be addressed promptly, and the relevant professional qualifications must be acquired.

Observations from the war in Ukraine underscore the necessity to make the demanded quickly and urgently needed resources, including materials for the Bundeswehr Medical Service, available in the interest of balanced force development and the responsibility for the life and health of the entrusted soldiers. Mitigation opportunities must be consistently identified and pursued, as the medical service will also be affected by the increasing shortage of skilled workers in the healthcare sector.

The insights presented must now be operationalized and implemented by the respective responsible bodies in the Bundeswehr Support Command, Bundeswehr Healthcare Command, Bundeswehr Medical Academy, and advisory groups to further improve medical support for the Bundeswehr in a national and collective defense scenario.

Key Points

• Tactical medicine is the foundation for medical action on the battlefield.
• Diseases remain the primary cause of combat power loss in troops.
• Preparation for mass sick and/or injured casualties is crucial.
• Blood, blood products, standardization of equipment and medications, and the use of oxygen concentrators are challenges for the near future.
• Regular evaluation and adaptation to current insights in all areas are the basis for further actions.

References

1. Anderson DE, Kocik VI, Rizzo JA, et al.: A Narrative Review of Traumatic Pneumothorax Diagnoses and Management. Med J (Ft Sam Houst Tex). 2023 Jan-Mar; (Per 23-1/2/3): 3-10. read more
2. Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI e. V.): Katastrophenmedizinische prähospitale Behandlungsleitlinien, Langversion (S2k, AWMF Register Nr. 001-043) 2023. , letzter Aufruf 23. April 2025. read more
3. Eastridge BJ, Hardin M, et al.:Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011; 71(1) :S4-S8. read more
4. Eastridge BJ, Mabry RL, Seguin P, et al.: Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 ;73(6 Suppl 5): S431-S437. read more
5. Gesundheitsministerium der Ukraine: Schäden an Gesundheitseinrichtungen durch russische Angriffe. Kiew, 1. Dezember 2024.
6. KdoSanDstBw: Erkenntnislinien des Sanitätsdienstes der Bundeswehr aus den Russland-Ukraine-Krieg 03-2024, Medizinische Ableitungen.
7. KdoSanDstBw:Taschenkarte Azithromycin und Handlungsempfehlung Combat Related Trauma.
8. KodoSanDstBw: Erkenntnislinien des SanDstBw aus dem RUS-UKR Krieg 09/2023
9. NATO MILMEDCOE: Vortrag zum Ukraine-Krieg auf internationaler Konferenz in Modena (Italien) am 26. März 2025

Manuscript Data

Citation

Ritter D, Czwielung C, Schmidbauer W: Medical Lessons Learned from the War in Ukraine. WMM 2025; 69(6E): 5.

DOI: https://doi.org/10.48701/opus4-511

For the Authors

Lieutenant Colonel (MC) Dr. Dennis Ritter, MD

Bundeswehr Healthcare Command

Branch II – Chief Emergency Physician of the Bundeswehr

Von-Kuhl-Straße 50, D-56070 Koblenz

E-Mail: dennismatthiasRitter@bundeswehr.org