German Version

The Combat Anesthesiologist in Modern Military Medicine: 
A Key Role in the Context of Changing Threats

Martin Kulla^a, Willi Schmidbauer^b, Florent Josse^c

^a Bundeswehr Hospital Ulm, Department of Anaestehesiology, Intensive Medicne, Emergency Car and Pain Therapy

^b Bundeswehr Central Hospital Koblenz, Department of Anesthesiology, Intensive Medicine, Emergency Medicine and Pain Therapy, Speaker of the AINS Consultative Group

^c Bundeswehr Hospital Ulm, Department of Anesthesiology, Intensive Medicine, Emergency Medicine and Pain Therapy, Commissioner for Deployment Medicine AINS

Summary

Today, the modern anesthesiologist is an interdisciplinary actor in pre-hospital, clinical, and post-clinical patient care. Particularly in the military context, the combat anesthesiologist assumes a leading role as they work competently within an interprofessional team during crises. This competence requires thorough and extensive training as a specialist in anesthesia, complemented by additional qualifications. Beyond administering anesthesia, intensive care treatment, and emergency care, their duties include tactical evacuations and performing damage control resuscitation. Maintaining this competence post-training requires regular practical activity in the field and lifelong learning.

Keywords: anesthesiologist; combat anesthesiologist; emergency medicine; damage control resuscitation; interprofessionalism

Introduction and Background

The role of anesthesiology in medicine has significantly evolved over the past decades. Previously limited primarily to perioperative care, the modern anesthesiologist is now an interdisciplinary actor in pre-hospital, clinical, and post-clinical patient care. In the military context, the combat anesthesiologist holds a central role [3][4][5]. Their responsibilities extend from classic anesthesia in the operating room and intensive care, including organ replacement procedures, patient transport, to short- and long-term pain and palliative medicine—both domestically and in multinational deployments, as well as within the framework of national and alliance defense [6].

The Combat Anesthesiologist

Profile and Scope of Duties

A combat anesthesiologist is a specialist in anesthesiology with broad training in emergency medicine, clinical acute and emergency medicine, intensive care, and pain therapy (AINS). In their routine professional life, they cover the entire AINS spectrum but must specialize in one area. Only through acquiring additional qualifications (e.g., emergency medicine, clinical acute and emergency medicine, intensive care, or pain medicine) can they act as an “enabler” for operational partners in the routine operations of a trauma center.

This balance of professional excellence and broad competence across all AINS areas is a prerequisite for meeting the requirements of the entire mission at all levels of care (routine operations, Role 1–4, international crisis management, national and alliance defense). They work closely in an interprofessional team with emergency paramedics, medical assistants, specialist nurses for anesthesia and intensive care or emergency medicine, and anesthesia technical assistants.

Often, they are part of specialized teams, such as the Special Operations Surgical Team (SOST), Casualty Support Units (CSU), or on-board medical officer groups during naval deployments. Besides performing general anesthesia and regional procedures, intensive care treatment, and emergency care, their scope of duties also includes tactical evacuations (MedEvac, StratAirEvac, MilEvacOP) and conducting Damage Control Resuscitation (DCR) as part of Damage Control Surgery (DCS) [4][7][8][9].

Damage Control Resuscitation (DCR)

Damage Control Resuscitation is a strategic treatment approach for severe trauma with potentially life-threatening bleeding. The goal is to prevent or early disrupt the “lethal triad”—hypothermia, acidosis, and coagulopathy. DCR competence must be applied at all treatment levels and during tactical/strategic patient transport until surgical bleeding control is achieved [10].

The three fundamental principles of DCR are:

1. Hemorrhage control
2. Permissive hypotension until surgical hemostasis is possible (CAVE traumatic brain injury)
3. Coagulation management through maintaining warmth and early transfusion of blood and blood products in a 1:1:1 volume ratio of red blood cell concentrate to plasma to platelets (international: use of whole blood) and avoiding dilution.

Core Competencies of the Combat Anesthesiologist

To succeed in military deployment (International Crisis Management (IKM) and LV/BV), every combat anesthesiologist must master the following core competencies. They are thus a specialist (FA) in anesthesia with competencies in

1. pre-hospital emergency medicine, including Tactical (Air) Medical Evacuation,
2. clinical acute and emergency medicine in Role 2–3 for traumatic and non-traumatic patients of all age groups,
3. damage control resuscitation (incl. transfusion management, coagulation management, warm blood donation, diagnostics, heat management) in Role 2–4,
4. vascular access (monitoring/volume and blood therapy up to REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)) in Role 2–4,
5. anesthesia-focused point of care diagnostics such as anesthesia-focused ultrasound (e.g., vascular puncture/regional anesthesia) and orienting transthoracic/transesophageal echocardiography for quantifying shock types,
6. anesthesia for thoracic procedures with one-lung ventilation (ELV) in Role 2–4,
7. anesthesia for (facial) skull trauma and treatment of increased intracranial pressure in Role 2–4,
8. difficult airway management in Role 2–4,
9. regional anesthesia in Role 2–4 with increasing relevance in LV / BV,
10. care for blunt and penetrating injuries in Role 2–4,
11. intensive care for 24 hours in Role 2, as well as 2–3 days in Role 3 (from Role 4 always with competence following No. 12.),
12. intensive care, with additional training (ZWB) in intensive care medicine for organ replacement procedures and long-term patient care until ward capability (Role 4),
13. pain therapy (represented by FA Anesthesia) in Role 3,
14. (StratAir) MedEvac from Role 2 to 4 and beyond/contribution to the administrative needs of patient logistics within LV/BV, as well as
15. transfusion medicine, including warm and fresh blood donation.

To achieve these core competencies [1], the specialist in anesthesiology must undergo additional training according to the further training regulations of the federal/state medical associations [1]. These competencies can only be achieved through extraordinary training, corresponding qualifications, and regular competency maintenance.

Hybrid and Asymmetric Warfare and Their Impact

Hybrid warfare describes the combination of classical military operations, economic pressure, and cyberattacks up to propaganda in media and social networks [3]. This can primarily affect the combat anesthesiologist through restricted logistics, faulty or vulnerable medical and documentation technology, and inaccurate situational reports.

Additionally, the threat of asymmetric attacks, particularly targeting medical forces, poses an increasing danger [11]. The combat anesthesiologist is not only physically present in conflict zones but also becomes a target themselves due to targeted attacks on medical facilities and logistical supply chains [3][13]. The conflict in Ukraine provides examples of improvised operating rooms in basements, unmarked evacuation vehicles, and shortages of medications and technical equipment.

Technical-Organizational Requirements

Operational reality demands robust and resilient medical technology: battery-operated anesthesia machines, oxygen concentrators, portable monitoring and ventilation systems, diagnostics using point-of-care ultrasound and blood gas analysis, and redundant communication systems. Cybersecurity in AINS is gaining increasing importance. Regular exercises with the troops to be cared for, civilian police, and other authorities are essential. Exercises must not be misunderstood as “being there” or “participating.” They only provide medical insights if they include realistic medical content.

Challenge: Lifelong Competency Maintenance

Qualitatively, a balance of broad training in all four AINS pillars for military deployment and a high specialization in routine operations is required. Quantitatively, there are bottlenecks due to a limited pool of deployable anesthesiologists. Continuous readiness requires structured concepts for “keeping in practice,” or competency maintenance. The idea of introducing a military qualification, “Combat Anesthesia” is one of the most essential building blocks here.

The idea “ military qualification Combat Anesthesiologist” describes

1. a multi-stage professional competency concept with different requirements for deployment in the routine operations of a Bundeswehr hospital during Medical Evacuation, in Role 3/Role 2e facilities, CSU, Role 2, within the framework of MilEvacOP/MEO and SOST,
2. military basic skills, physical and mental stability, to safely apply the professional core competencies at any time in any deployment scenario, as well as
3. a lifelong competency maintenance in the AINS field for all medical officer specialists in anesthesiology of the Bundeswehr.

    

Only if all medical officer specialists trained to become anesthesiology specialists maintain their core competencies (as mentioned above) through lifelong competency maintenance in the five Bundeswehr hospitals, will there be enough personnel available within the framework of LV/BV. From the perspective of the AINS consultative group, requirements comparable to those for the field of pre-hospital emergency medicine with competency maintenance, a military qualification in “Emergency Medicine” for medical and non-medical personnel should be pursued. This is particularly true as anesthesiology specialists currently leave clinical care in significant numbers after 11–13 years of study and training without any competency maintenance.

Future Perspectives in Deployments and Within the Framework of National and Allied Defence

In the context of security policy shifts, combat anesthesiologists are increasingly integrated into strategic structures. They contribute to the establishment of mobile surgical capacities (e.g., Role 2E, SOST), participate in civil-military cooperation, and are integrated into research networks (e.g., NATO Center of Excellence) [2].

This will succeed if the previously proven structures are not adapted to the current situation, but to the future. Rigid and inflexible structures are inherently doomed to fail. This applies to all areas: fixed personnel numbers, inflexible qualification requirements, and lengthy procurement processes should be avoided, as should the desire to “always do everything perfectly.” The enormous changes in the civilian healthcare system are fundamentally transforming the routine operations of the BwKrhs. Professional concepts (e.g., transfusion medicine, regional anesthesia, interprofessional cooperation) are changing. Military needs are rapidly evolving (e.g., patient transport/drones). It will be good if we move forward quickly, crossing today’s still-existing red lines, trying new things, and anticipating and allowing (planning) mistakes. National, international, civilian, and military cooperation and research alliances should be pursued to push this rapid development in the right direction.

Conclusion

Combat anesthesiologists are highly qualified specialists whose importance in modern deployment medicine is steadily growing. They combine clinical excellence in routine operations with tactical understanding and operational flexibility in various deployment scenarios. Their foundation is their core competencies, for which lifelong competency maintenance is required. In a world of increasing uncertainties, new threats, and technological upheavals, they form a cornerstone of the medical service’s responsiveness and resilience [12].

References

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10. LaGrone LN, Stein D, Cribari C, et al.: American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96(3): 510-520. read more
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13. Schmidt KF: Erkenntnisse aus dem Krieg in der Ukraine für den Sanitätsdienst der Bundeswehr. WMM 2024; 68(1-2): 1-6. read more

Manuscript Data

Citation

Kulla M, Schmidbauer W, Josse F: The Combat Anesthesiologist in Modern Deployment Medicine: A Key Role in the Context of Changing Threats. WMM 2025; 69(6E): 6.

DOI: https://doi.org/10.48701/opus4-509

For the Authors

Colonel (MC) Prof. Dr. Martin Kulla

Bundeswehr Hospital Ulm

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

Oberer Esselsberg 40, 89081 Ulm

E-Mail. martin.kulla@uni-ulm.de