German Version

Railway Medical Evacuation: Historical Development, 
Current Challenges, and Future Perspectives

Federico Probst^a, Florent Josse^a, David Lacassagne^b, Martin Bricknell^c

^a Bundeswehr Hospital Ulm, Department of Anesthesiology, Intensive Care, Emergency Care, Pain Treatment

^b Multinational Medical Coordination Centre-Europe

^c Centre for Global Health Security and Conflict, and King’s Centre for Military Ethics, London

Summary

Railway medical evacuation has progressed from its origins in 19th-century wartime transport to a scalable, high-capacity MEDEVAC solution, especially important in large-scale conflicts such as those in Ukraine. Modern hospital trains must meet NATO standards, integrate civilian and military systems, and navigate technical and regulatory challenges related to cross-border operations. Key factors for future readiness include modular design, interoperability, and multinational coordination.

Keywords: hospital trains; MEDEVAC; NATO; modular systems; cross-border logistics

Introduction

For over 150 years, hospital trains have been an essential component of medical evacuation (MEDEVAC), particularly in wartime and disaster scenarios. Their development reflects the adaptability of both military and civilian structures, continuously adjusting to each era’s technological and operational demands. This analysis examines their historical significance, current challenges, and necessary advancements to meet future demands. As large-scale divisional conflicts and cross-border operations become increasingly probable, hospital trains are again gaining prominence as an indispensable asset [4][7].

Historical Development

Hospital trains were first employed in the mid-19th century when the need for effectively transporting wounded soldiers became apparent in military conflicts.

• 19th Century: The first documented uses occurred during the Crimean War (1853–1856), the American Civil War (1861–1865), and the Franco-Prussian War (1870–1871). These early trains provided rudimentary medical care, setting new standards for treating and evacuating the wounded. Despite their improvised nature, they laid the groundwork for more systematic approaches in later developments [1].
• World War I and World War II: During these global conflicts, the capacity and capabilities of hospital trains expanded significantly. Beyond functioning as mobile hospitals, they enabled efficient transportation of casualties from active combat zones to rear-echelon medical facilities. Their standardized equipment and organization made them a crucial element of military logistics [2].
• Cold War: In this period, hospital trains were further developed to serve both military and civilian needs. Advances in medical technology and standardized designs improved their efficiency and versatility. However, introducing AirMedEvac for overseas operations led to decommissioning hospital trains for NATO operations in Europe [3].

Current Situation

The ongoing war in Ukraine has reaffirmed the relevance of hospital trains. The strategic challenge on NATO’s eastern flank highlights the potential need to evacuate large numbers of casualties from heavily contested areas efficiently. Such operations introduce a previously unconsidered quantitative dimension. In a large-scale combat engagement, a six-digit number of soldiers could be involved, with an estimated 3 % becoming casualties per day (Remondelli, Remick et al. 2023). Among these, approximately one-quarter would succumb to their injuries, while the remainder would be severely or moderately wounded. For an engagement involving five brigades, this would result in an estimated high three-digit number of casualties per day, including those with severe injury patterns.

Fig. 1: Patients lay on stretchers on a station platform, having been taken off the ambulance carriage. (Image courtesy of the Willis family, https://www.railwaymuseum.org.uk/objects-and-stories/ambulance-trains-bringing-first-world-war-home)

Civilian Patients and Injury Patterns

Experience from Médecins Sans Frontières (Doctors Without Borders) operations in Ukraine in 2022 revealed that civilian evacuations involve a high proportion of patients who do not fit the typical military profile. Of the 2,481 patients evacuated, 2,292 did not require intensive care and were transported using civilian-standard stretchers. A particularly notable aspect was the significant proportion of children and infants requiring specialized medical equipment and trained personnel.

Managing such casualty numbers presents significant logistical challenges. While Air MedEvac systems represent a modern solution, their use is limited by threats from enemy air defenses and the sheer volume of casualties. AirMedEvac remains better suited for specialized and crisis response operations. In contrast, railway MedEvac systems provide a scalable and secure means of transporting large numbers of wounded personnel, even under adverse weather conditions. However, their effectiveness depends on adapting to modern requirements. Many nations demonstrated their utility during the COVID-19 crisis, and the Ukrainian military and civilian health services have recently reaffirmed their relevance.

Key advantages include:

• A high capacity of patient transfer with medical care conditions close to those of medical facilities, which could also be used as a temporary reinforcement of an overwhelmed regional healthcare system (e.g. with intensive care capabilities).
• A more economical and flexible ratio of patients to medical personnel compared to other MedEvac solutions, allowing seamless up- and down-scaling within the evacuation chain.
• A robust, modular, and scalable transport solution that can rapidly adapt to changing needs regardless of the weather conditions.

Constraint: In Europe, strong multinational coordination is necessary to achieve seamless cross-border rail movements and bridge the technical and organizational differences between the concerned states [7][9].

Fig. 2: Scheme depicting the foreseen patient flow in a NATO large-scale combat operation in Europe; large numbers of patients are transferred from front line to rear NATO nations by long-distance bulk medical evacuation transport platforms (trains, airplanes, ships)

Requirements of Modern Railway MedEvac

To ensure effective Railway MedEvac operations, several key requirements must be met, in alignment with NATO MEDEVAC doctrine:

Fig. 3: Ukrainian border guards and National Guard receive ambulances from NATO.(Photo: ©State Border Guard Service of Ukraine)

Clear Authorities and Responsibilities

Well-defined roles and responsibilities must be established for medical operations and movement planning. Coordination between military and civilian railway operators, medical personnel, and logistics planners is crucial for seamless execution.

Advanced MEDEVAC Planning

A structured patient transfer process must begin at the Medical Treatment Facility (MTF), ensuring efficient movement to departure stations. This requires pre-­established evacuation corridors, designated transfer hubs, and clear medical triage procedures before loading onto hospital trains. The multinational coordination of MedEvac trains requires (NATO-) standardized protocols and centralized command structures. Continuous updates on patient numbers, conditions, and train occupancy to thePatient Evacuation Coordination Center (PECC) are crucial for coordinating onward transport via AirMedEvac or transfer to specialized hospitals. Integration into multimodal transport networks – including bus feeder systems and air transport – must also be considered.

Robust Communication and Information Systems

Effective communication between medical units, transport coordinators, and command structures is vital. Standardized NATO protocols must be in place to relay real-time patient data, train occupancy, and onward transport requirements to the Patient Evacuation Coordination Center (PECC). Effective communication must be ensured both with railway undertakers and network managers, and with giving (ROLE 1–3 in the forward area) and receiving (intermediate medical hubs¹, ROLE 4) medical facilities; robust, interference-resistant communication systems such as SATCOM are essential.

Adapted Rolling Stock

• Locomotives: Railway MedEvac operations must not rely on the electric power grid. Diesel or hybrid locomotives ensure autonomy and the ability to operate on less frequently used or damaged rail lines.
• Carriages: Train carriages must be ergonomically designed for the loading and handling of lying patients. Medical treatment areas must provide sufficient electric output for life-supporting devices and proper environmental controls (e.g., temperature regulation, lighting, and ventilation) to ensure patient stability during transport.

Availability and Timeliness

Hospital trains must be maintained at a high state of readiness, allowing for rapid deployment with minimal notice-to-move delays. Cross-border movements must be pre-coordinated to mitigate bureaucratic and logistical obstacles, ensuring uninterrupted patient transfer.

Interoperability of Equipment and Standard Procedures

Standardizing medical equipment, stretchers, and procedural protocols across NATO ensures interoperability between national hospital train systems. Common specifications for mounting infusion pumps, oxygen systems, and monitoring devices facilitate the seamless integration of personnel and equipment from multiple allied nations, enhancing operational efficiency.

Challenges to Cross-Border Railway Medical ­Evacuation

Cross-border railway medical evacuation (MedEvac) operations face several challenges rooted in technical and regulatory discrepancies among European Union (EU) member states. Addressing these issues is crucial for enhancing the effectiveness of railway-based MedEvac systems.

Technical Barriers

Significant technical obstacles impede seamless cross-border rail movement:

• Electrification Differences: Variations in electrification systems across EU countries necessitate locomotive changes at borders, leading to delays. For instance, the abrupt end of electrification on bridges between Germany and Poland exemplifies this issue.
• Operational Procedures: Divergent operational protocols, such as mandatory technical checks and brake adaptations at borders, contribute to extended transit times. At the Brenner Pass between Italy and Austria, these procedures can cause delays of up to 50 minutes.

Regulatory Challenges

Regulatory inconsistencies further complicate cross-border railway operations:

• National Regulations: Varying national rules require trains to undergo multiple checks at borders, resulting in delays. For example, trains can be delayed by up to six hours between Romania and Bulgaria due to such regulations.
• Vehicle Authorization: The necessity for separate vehicle authorizations in each country adds complexity and time to cross-border operations. This requirement hampers the establishment of efficient international services.

Impact on Medical Evacuation

These technical and regulatory challenges directly affect the efficiency of railway MedEvac:

• Operational Delays: Extended transit times due to border procedures can delay the timely transfer of patients, potentially impacting medical outcomes.
• Resource Allocation: Inefficient cross-border operations may necessitate additional resources to manage delays, diverting attention from patient care.

  

  Fig. 4: Modern medical evacuation train operated by Ukrainian Railways. (Photo: ©https://war.ukraine.ua/

Recommendations for Improvement

To enhance cross-border railway MedEvac capabilities, the following measures are recommended:

• Harmonization of Technical Standards: Aligning electrification systems and operational procedures can reduce the need for locomotive changes and minimize delays.
• Streamlining Regulatory Processes: Developing unified regulations and mutual recognition of vehicle authorizations can simplify cross-border operations [6].
• Enhanced Coordination: Establishing robust communication and coordination mechanisms among EU member states can facilitate smoother cross-border medical evacuations.

Capacity Management

In large-scale combat operations, different patient transport logistics systems must be considered, including for civilian casualties and displaced patients. Standardizing patient transfer onto hospital trains using common equipment – such as NATO-standard stretchers – ensures a scalable and redundant evacuation chain. Additionally, interior train configurations should incorporate flexible and interoperable systems (e.g., standardized mounts for infusion pumps, oxygen tanks, or monitors). This allows for seamless exchange of train personnel across different NATO-operated trains and facilitates the repurposing of equipment from decommissioned trains or carriages.

Readiness

Using dual-use trains and carriages from the civilian sector enables rapid mobilization when required. Such systems would be maintained to current technological standards and would not require extensive refurbishment before deployment. Civilian seating and compartment dividers must be quickly removable, with modular MedEvac interiors pre-positioned for installation within hours.

Adaptations and Solutions

To address these challenges, several key strategies must be implemented:

• Standardization and Civil-Military Cooperation: Introduction of modular and interoperable designs (e.g., convertible seating/sleeper configurations) and decentralized energy sources to enhance resilience and scalability.
• Coordination: Harmonization of technical standards in railway signaling and control systems within the EU and NATO.
• Training: Expansion of multinational exercises to enhance personnel readiness.
• Resilience: Use of redundant systems and civilian railway infrastructure.

Example of a Modern Solution

General Specifications

• Total capacity: 15 carriages
• A third of the carriages are dedicated to logistics and infrastructure
• Maximum number of patients per carriage: 24
  - 1 carriage with 4 IMC patients and 20 lying patients
  - 3 carriages with 24 lying patients each
  - 5 carriages with mixed use (based on the previous model):
       – Each carriage accommodates 24 lying patients or alternatively
       – 60 seated patients per carriage

• Endurance: 48 hours in a two-shift system (6 hours per shift)

Carriage Distribution

• 2 locomotives – Provide propulsion and power supply
• 1 kitchen carriage – Equipped with a modern field kitchen to supply personnel and patients
• 1 baggage and supply carriage – Storage for consumables, medication, and technical equipment
• 1 personnel accommodation carriage – Sleeping and resting facilities for core medical staff
• 1 command carriage – Mobile operations center for coordination and medical supervision
• 1 IMC patient carriage – 4 IMC patients and 20 lying patients
• 3 patient carriages – Each carriage accommodates 24 lying patients
• 5 special carriages for lying or seated patients – Flexible use depending on the scenario:
  - each carriage accommodates 40 lying patients or alternatively
  - 60 seated patients per carriage
• 1 treatment carriage – Emergency care, wound management,

Conclusion and Outlook

Hospital trains have played a crucial role in large-scale conflict medical evacuation for over a century. Their future viability depends on modularity, scalability, international cooperation, and strategic planning. The war in Ukraine has once again underscored their importance while exposing challenges that must be addressed. By integrating dual-use train systems and modular, interoperable medical equipment, NATO’s medical resilience can be significantly enhanced.

References

1. Bricknell MC: The evolution of casualty evacuation in the British Army 20th century (Part 1)--Boer War to 1918. J R Army Med Corps 2002; 148(2): 200-207. read more
2. Bricknell MC: The evolution of casualty evacuation in the British Army in the 20th century (Part 2) - 1918 to 1945. J R Army Med Corps 2002; 148(3): 314-22. read more
3. Bricknell MC: The evolution of casualty evacuation in the British Army in the 20th century (Part 3) - 1945 to present. J R Army Med Corps 2003; 149(1): 85-95. read more
4. Bricknell MC: Railway MEDEVAC: back to the future. Invited talk on DiMiMed Conference 12.Nov. 2024.
5. European Space Agency: European Space Agency to fund ICU hospital train. , last accessed April 22, 2025. read more
6. European Union Agency for Railways: Report Cross Border Rail Transport. , last accessed April 22, 2025.. read more
7. Lacassagne D: Railway medical evacuation workshop. , last accessed April 22, 2025. read more
8. Remondelli MH, Remick KN, Shackelford SA, et al.: Casualty care implications of large-scale combat operations. J Trauma Acute Care Surg. 2023; 95(2S Suppl 1): S180-S184. read more
9. Walravens S, Zharkova A, De Weggheleire A, et al.: Characteristics of Medical Evacuation by Train in Ukraine, 2022. JAMA Netw Open 2023; 6(6): e2319726. read more

Manuscript Data

Citation

Probst F, Josse F, Lacassagne D, Bricknell M: Railway Medical Evacuation: Historical Development, Current Challenges, and Future Perspectives. WMM 2025; 69(6E): 9.

Also published in WMM 2025; 69(6): 303-307.

DOI: https://doi.org/10.48701/opus4-501

For the Authors

Major (MC) Dr. Federico Probst, MD

Bundeswehr Hospital Ulm

Department of Anesthesiology, Intensive Care, Emergency Care, Pain Treatment

Oberer Eselsberg 40, D-89081 Ulm

E-Mail: federicoprobst@bundeswehr.org

Lieutenant General (rtd) Martin CM Bricknell CB DM PhD

Professor of Conflict, Health and Military Medicine

Centre for Global Health Security and Conflict, and King’s Centre for Military Ethics

School of Security Studies

King’s College London

K7.23 Kings Building, London WC2R 2LS

E-Mail: martin.bricknell@kcl.ac.uk