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.

Fig. 1: Injured body regions presented at the 59th COMEDS Meeting 2023: At the time of the meeting, the proportion of extremity injuries was even higher at approximately 70 %.

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.

Tab. 1: Estimated current stay duration of the wounded in the Ukraine war

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.

Fig. 2: Drones, now capable of operating at night, are used to detect medical waste and identify nearby medical facilities. (Source: Vyacheslav Ratynskyj on https://war.ukraine.ua/en/photos)

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].

Fig. 3: Medics of the volunteer medical battalion Hospitaller treat wounded Ukrainian soldiers in the evacuation bus on the way to the hospital in October 2024. (Source: Roman Piliej on https://war.ukraine.ua/en/photos)

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