Prehospital Lessons From the War in Ukraine: Damage Control Resuscitation and Surgery Experiences From Point of Injury to Role 2

ABSTRACT

The ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict.

Graphical Abstract

INTRODUCTION

In February 2022, Russia invaded Ukraine. Warfare intensified with the entire country being attacked, the level of violence increased rapidly from the deployment of hypersonic missiles, attack aircraft, large use of tanks and armor, and broad use of artillery, causing unprecedented preventable morbidity and mortality among vulnerable populations, volunteers, and Armed Forces of Ukraine (AFU) warfighters. NATO and its major partners and aspiring members like Ukraine face major challenges in prehospital medicine during war and disaster. This is especially true against a formidable and superior adversary like Russia, which is using conventional weapon systems to their full capacity across Ukraine.¹ This descriptive commentary aims to explore direct point-of-injury (PoI) and peri-PoI prehospital clinical support along the frontlines, ensuring that the lessons learned (LL) in Ukraine become lessons shared (LS) and not of lessons lost.

Distinct from any NATO or unilateral military operation in the past seven decades, the war in Ukraine features no allied or partner troops as active belligerents on the ground or NATO presence offering direct aid, support, or logistical assistance.² Consequently, non-governmental organizations (NGOs) providing medical evacuation (MEDEVAC), critical care transport, prehospital training, and medical supply distribution to the AFU must closely collaborate with Ukrainian military and civilian authorities in order to fill various supply, training, treatment, transport, and capability gaps. The primary challenges in this endeavor include communication, coordination at the military–civilian level across NGO platforms, and supply chain management. The absence of a central body overseeing and coordinating foreign NGOs’ efforts in Ukraine increases the individual organizational command, coordination, and logistical burden for cooperation with Ukrainian military combatant commands and civilian medical and disaster authorities. Civilian interoperability and liaison requirements are unprecedented in the provision of medical care across Ukraine.

FIGURE 1.

Objectives and Obstacles of implementing the Lessons Learned Process.

CHALLENGES AND MISSING DATA

The Ukraine war presents a distinct set of challenges compared to recent unconventional and coalition-based operational environments found in Iraq, Afghanistan, and elsewhere in irregular conflict (see Fig. 1). Multiple factors have increased the complexity of trauma care delivery to casualties. Changes to the function of medical units include forward Role 1 Medical Treatment Facilities (MTFs) offering aspects of Role 2 capabilities in some settings,³ damage control resuscitation (DCR), and the use of blood far forward.⁴ Prolonged field care (PFC)⁵ implementation in both cold and hot environments and extended evacuation times⁶ has become commonplace. Increased training requirements, the needs for delivery of medical supplies across distances and varied terrain without fit-for-purpose vehicles, and a diverse pool of personnel for MEDEVAC contribute to this complexity.⁷ This situation has proven to be more intricate than the use of Special Operations Forces and Special Operations Surgical Teams seen in the past.⁸ The absence of singular unified military medical command and control (C2), training, and supplies further complicates imposing standardization and interoperability of forces and volunteers.

CLINICAL BACKGROUND

In the context of battlefield trauma, severe blood loss and coagulopathy, accompanied by acidosis, hypothermia, hypokalemia, and hypocalcemia, combine to form an interlinked Lethal Diamond (see Fig. 2) generating a positive feedback loop of patient deterioration, endothelial injury, and adverse clinical effects.^10,11 To counteract these pathologies and effectively treat these casualties, the Depatment of Defense (DoD) Joint Trauma System established the Tactical Combat Casualty Care (TCCC) framework, guidelines, and quality control methodology as the gold standard for PoI care, which includes the use of blood in the prehospital space.^12,13

Building upon the TCCC information and quality improvement process as presented by the Committee on TCCC (CoTCCC), several subsequent clinical practice guidelines (CPGs) have been developed and implemented, including En Route Combat Casualty Care, Surgical Combat Casualty Care, and the core concepts of DCR⁴ and damage control surgery (DCS), which not only include blood in the prehospital space but also prompt access to surgery to stop life threats and save life and limb.^14,15 This framework fosters best practice critical care standards, captures trauma data and LL, and promotes LS, all while facilitating the creation of evidence-based CPGs—ultimately aiming to reduce preventable morbidity and mortality on the battlefield and in the prehospital environment.

FIGURE 2.

The Lethal Diamond, created based upon the concept proposed by Ditzel et al.¹¹

APPROACH AND ANALYSIS

This commentary is drawn from experiences throughout Ukraine, spanning over 13 months and involving numerous patient cases from concentrated areas of conflict. It employs an unsystematic and conditional approach to examine PoI, peri-PoI, self-aid, and buddy aid. For this commentary, standard military medical doctrine definitions for echelons of care and casualty severity are used. Activities of Role 1 to Role 3 and DCR/DCS from February 22, 2022 (Russia’s hybrid attacks on Ukraine began in 2014; the most recent iteration of Russian violence and invasion occurred on February 24, 2022. J.Q. deployed to Ukraine in anticipation of imminent attack before this date; several other co-authors were already in uniform or otherwise working in civilian clinical settings before full-scale Russian invasion), to March 31, 2023, are described here. Role 3 to Role 5 and MEDEVAC out to the country are not covered. Anecdotal case studies and insights from multiple clinical sites were assessed and included. The NATO LL process and methodology,⁹ adhering to best practice standards and guidelines across the NATO alliance, have been implemented and executed in collaboration with partner forces whenever possible.

The spectrum of Russian warfare, which includes, cyber warfare, combined arms cyber warfare, which includes combined arms attacks on medical facilities and enhanced use of drones, both defense and humanitarian sector staff, and evacuation routes, occurs daily and is likely to continue and intensify. Estimates of the number of dead or wounded across all sectors vary widely, ranging from 200,000 to 400,000. The targeted nature of Russian hybrid warfare and cyber-attacks on individuals, groups of rescuers and volunteers, and health care professionals at large presents challenges in sharing data and LL from the frontlines among partner forces. All mobile messaging services and devices carry inherent cyber risks that can potentially lead to targeted Russian attacks or exploitation and ultimately increased morbidity and mortality of rescuers and those in their care. To ensure operational security, this analysis employs anonymized locations, omits specific casualty counts, and removes or anonymizes the names and details of humanitarian organizations, volunteers, and specific units.

Lessons Learned (LL)

The following list presents observations and LL by the authors, accompanied by comments and clinical anecdotes. Some potential solutions to these issues are addressed here, including novel and innovative Ukrainian approaches to complex challenges that offer opportunities for information sharing and global clinical advances. Discussion is limited and focused on sharing anecdotal data.

esson Number 1: Scene Safety

Scene safety, which prioritizes rescuer safety, is the foundation of prehospital medicine. Rescuers can only provide care if the rescuer does not become a casualty. Modern Russian warfare, which uses deadly weapon systems targeting medical infrastructure and personnel as high-value targets, threatens rescuers and scene safety. All uniformed services, including NATO and NATO partner forces, faced counterinsurgency, asymmetric, and irregular warfare challenges during the Global War on Terror (GWoT), which posed similar challenges to medical operations.¹⁶ Since the rise of irregular and stateless assets like Islamic State in Iraq and Syria / the Islamic State in Iraq and the Levant and other non-state violent actors, the Law of War and Rules of Engagement have been challenged with many actors abandoning international agreements, treaties, and conventions. Russia is committing war crimes in Ukraine.

In irregular and multi-domain warfare, Geneva Convention articles, protocols, and humanitarian principles are ignored by our enemies. International Humanitarian Law (IHL) and the core humanitarian principles of humanity, neutrality, impartiality, and independence¹⁶ are challenged in an unprecedented fashion, resulting in morbidity and mortality for combatants, rescuers, and vulnerable communities alike. Clinical governance at the military–civilian disaster–response interface is complicated by Martial Law in Ukraine and in other conflicts.

The NATO and NATO partner experience from wars in Afghanistan, Iraq, and elsewhere focuses on counterinsurgency operations and low-intensity conflicts where improvised weapon systems are used by elusive and unseen enemies, giving rise to other irregular warfare challenges.^17–21 Humanitarian and NATO and NATO partner military medicine ethics have always respected international norms, Geneva Conventions and IHL. However, indiscriminate Russian attacks against medical personnel require personal protective equipment (PPE) adjustments, contingency communications planning, and enhanced operational security for rescuers. Long- and short-range artillery, multiple launch rocket systems (MLRS), high-caliber highly effective sniper fire, and drone-assisted target acquisition require advanced PPE. Multiple wounding patterns and resulting morbidity and mortality from these weapons impact anatomical areas and structures not protected by conventional PPE with devastating effect. This new risk illustrates that modern Kevlar helmets and level 4 plates and carrier vests alone may be insufficient and more or different PPE systems may be required for warfighters and rescuers to protect themselves on the battlefield.

The Russian military and their proxies have both attacked several frontline medical teams. Pete Reed, a former U.S. Marine and medic, was helping war patients with an NGO when he was hit by an anti-tank-guided missile while rendering care at the roadside in early February 2023. Reed died instantly, his team was wounded, and several patients died from lack of care.²² Several other medical volunteers have been targeted for providing care for no other reason than being a medical volunteer.²³

Lesson Number 2: Mass Casualty, Triage, and Casualty Collection Points

Multi-domain battle, conventional and hybrid warfare with a peer adversary, present challenges that are not present in current irregular and unconventional warfare approaches to war or mass casualty incidents. A lack of proper resources, training, NATO military medical doctrine, and Role 1 and Role 2 echelons of care pushed far forward and near the battle space challenge the triage process, often overwhelming the medical capabilities available at the MTFs in the area.

Triage attempts to bring order to chaos, making overwhelming situations manageable by sorting and prioritizing patient treatment to maximize medical outcomes. Triage and assigning patients with triage categories are performed at various echelones of care, ranging from the battlefield to the battalion aid station to the field hospital. Traditional categories of triage include immediate, delayed, minimal, and expectant.^23,24 This classification scheme is useful for mass casualties involving both surgical and medical patients.²⁵ However, most casualties in the Ukrainian battle space sustain multiple wounds owing to the explosive fragmentation mechanism of injury, resulting in primary, secondary, and tertiary blast injuries. This can lead to several mass casualty events at one single MTF in a 24-hour period, draining medical resources and impacting staff with morale injury, exhaustion and preventable morbidity and mortality. Currently, little trauma data are available on these injuries or clear understanding of numbers and timelines of clinical interventions as a patient moves through the evacuation chain and continuum of care.²⁶ Collection of data in the current Russian invasion of Ukraine war may create a better understanding of casualties and their treatment and inform decision makers and better enable best practices to sustain through clinical paradigms and practices that must adjust.

Although there has been a significant evolution of Ukrainian medical care, there is a notable lack of organized TCCC and PFC training or implementation for both military and civilian personnel in Ukraine or preparing to deploy.²⁷ There is a growing cohort of fully certified National Association of Emergency Medical Technician (NAEMT), TCCC, Emergency Medical Techncian (EMT), and paramedic trainers at select centers; this must continue to grow and be supported by a coalition of the Ukrainian Ministry of Health (MoH), Ministry of Defense, and partner organizations.

Examples of skills that should be improved through training include:

• tourniquet assessment and attempting conversion to pressure dressings

• widespread use of blood product transfusion in the prehospital space

• use of inotropes for the patient in shock

• indications for hypertonic saline

• pain and antibiotic management (in keeping with best practices and antimicrobial resistence trends)

• understanding management of blast-induced traumatic brain injury

• understanding ventilation strategies and prehospital anestesia

• clear guidance on terminating resuscitative efforts.

Lesson Number 3: Patient Assessment

Core concepts within TCCC¹³ and other widely used military and civilian clinical algorithms, such as International Trauma Life Support, Prehospital Trauma Life Support,²⁸ and Advanced Trauma Life Support,²⁹ begin with scene safety and emphasize the importance of primary and secondary trauma assessments in guiding patient management. These internationally recognized courses offer a systematic approach to the undifferentiated trauma patient and help reduce morbidity and mortality. Indeed, advanced life support care can only commence after sound basic life support is initiated. Prolonged field care cannot commence until TCCC is completed to standard.²⁷ Basic life support and attention to detail during primary trauma assessments are essential to identify not only life-threatening catastrophic injuries but also secondary traumatic injuries that require immediate intervention.

Wounding patterns from anti-personnel weapon systems such as cluster munitions and artillery fragmentation have caused catastrophic bleeding; chest, abdominal, and pelvic bleeding; and long bone injuries necessitating standardized high-quality primary and secondary assessments to reduce morbidity and mortality.²⁶ The wounding patterns caused by these munitions create a high potential for missed injuries. For example, a small entrance wound that is not actively bleeding or involving other injuries in the axilla, neck, or groin can lead to preventable death.³⁰

Ukraine needs additional volunteer rescuers, clinical providers, and advanced care providers because of the high patient volume. To meet this need, ad hoc prehospital training organizations and volunteers have been utilized building an enhanced degree of military and civilian interoperability and exchange. These include police, school staff, municipal workers, firefighters, and rescue workers. However, clinical standards, methods, and levels of acuity are highly variable. Basic operational security and light and sound discipline can pose challenges during primary and secondary assessments, preplanning and preparation can help mitigate risks and gaps to trauma assessments in austere settings.

Lesson Number 4: Tourniquets

It is well established in the literature that peripheral hemorrhage is the number one preventable cause of death on the battlefield.^23,31–34 Immediate self-aid and buddy aid using a CoTCCC-approved tourniquet device for peripheral trauma can save lives and reduce preventable morbidity and mortality.³⁵ Since 2014 and the invasion of the Crimean region of Ukraine and fighting against the separatists in Eastern Ukraine, Ukraine has made great strides in disseminating TCCC and other CPGs in Ukrainian and emphasizing the combat application tourniquet and equivalents. Consequently, access to tourniquets in 2023 for warfighters and volunteers alike is unprecedented.

Unfortunately, there are remaining gaps related to tourniquets and their use that must be addressed. Because of the extreme cost of the approved and verified combat application tourniquet and other CoTCCC-approved equivalent tourniquet devices, several Ukrainian manufacturers and other vendors have provided Ukraine with tens of thousands of alternative tourniquets. However, in some cases, these are substandard and, in some instances, even unsafe. Until the early 2000s, the medical system offered a 1-meter, 2.5-cm-wide rubberized band as an alternative to the CAT or other tourniquets. The aging and brittleness of organic rubber can make this tourniquet ineffective if not used appropriately. Several clinics and ambulances in Ukraine still stock and use these rubber tourniquets, though fewer than in 2014.

Ukraine has started to produce its own tourniquets that are more affordable and easily produced and used inside Ukraine; the Dnipro II tourniquet, the Sich tourniquet and others are some examples with preliminary good outcomes. The research and development is ongoing, and CoTCCC review would be beneficial for the new Ukrainian tourniquets coming on the market in 2024. The Dnipro II and the Sich locally developed tourniquet potentially offers a good low-cost alternative to the current CoTCCC-approved tourniquets. Additional Ukrainian innovation may offer novel low-tech, cost-efficient locally procured modalities in dealing with many of these challenges in the prehospital space. Several Ukrainian-sourced tourniquets may also offer NATO with new and novel approaches, and these must be researched further to confirm combat effectiveness; Ukraine can improve battlefield medical response by addressing these issues and assuring interoperability with NATO partners.

Tourniquets remain a prehospital medicine challenge despite several training and train-the-trainer programs. Anecdotal reports from recipient hospital facilities across several clinical sites describe the use of Soviet rubber tourniquets at less stable two-bone locations, such as the wrist and forearm and lower limb at the shin, with potentially poor outcomes if not managed by trained professionals. “Stop the Bleed”-style mass public health tourniquet training to medical personnel and the public could prove beneficial to the proper utilization of tourniquets.³⁶

Furthermore, several anecdotal reports showed tourniquets being used on wounds that did not need them to stop traumatic bleeding, leading to limb ischemia and threatened limb loss. Indeed, the decision to use a tourniquet versus a pressure dressing requires clinical training and experience, as well as adequate supply of pressure dressing material to convert. Tourniquets that are prematurely applied may be delayed in conversion to a pressure dressing. Delays of several hours are common before the patient is received at a DCR point, potentially significantly impacting medical outcomes.⁴

Finally, consider the preventive or “provisional” tourniquet. Preventive tourniquets should be used in non-catastrophic bleeding limb injuries due to the country’s MEDEVAC and multiple suboptimal methods of getting from PoI to definitive care. A preventive tourniquet applies the Velcro strap snugly to the affected limb without tightening the windlass, allowing arterial and venous blood flow (in the absence of catastrophic bleeding). The preventive tourniquet should be applied to a limb injury that does not need a tourniquet to stop bleeding or is well controlled with a pressure dressing but requires transport or movement through echelons of care. Preventive tourniquets do not stop bleeding or blood flow to the affected limb but allow the rescuer to quickly ratchet the tourniquet and stop any bleeding which may occur while in transit with minimal space and resources to hand. A preventive tourniquet is placed so that if massive, catastrophic bleeding, or re-bleeding occurs during transit through patient-centered care, the tourniquet can be tightened, and bleeding stopped quickly. This helps when providing care in small MEDEVAC vehicles and tight spaces.³⁷ All peripheral injuries that have received DCS at a remote facility and need critical care transport should be treated with preventive tourniquets to affected limbs.³⁸

Despite the ample supply of combatants with effective tourniquets, tourniquet application and control require more detailed training and access. Instructors must emphasize clinical indication for tourniquet application, clearly defining catastrophic and life-threatening bleeding, and tourniquet control in the future to include constant assessment and reassessment. These training details must include serial considerations for tourniquet conversion to a pressure dressing, replacing the tourniquet closer to the injury to minimize tissue involvement, moving lower down the affected limb and closer to the injury or to leave in place if required. Inappropriate clinical application of a tourniquet and prolonged use of tourniquets without clinical assessment can greatly worsen injuries and lead to preventable morbidity.³⁹ When tourniquet control measures are taken, a provisional (or preventive, see “Lesson Number 3: Patient Assessment” section) tourniquet can be loosened. If possible, tourniquet control allows loosening the tourniquet (transfer to “provisional mode” before transporting the injured to role 1/role 2).

Tourniquet control is a set of measures carried out within 120 minutes (2 hours) from the moment of its application and includes:

• Rapid application of a tourniquet as close to the point of injury as possible.

• Only applying tourniquets if the limb injury is life threatening.

• A critical assessment of the presence of defects (technical, technological, etc.) in the tourniquet application measures and their elimination.

• Assessment of the opportunity for tourniquet conversion, by applying a pressure dressing and leaving the tourniquet in place with additional potential use of a hemostatic agent; and by attempting to replace the tourniquet lower down the limb and closer to the injury and above the wound, or to leave in place.⁴⁰

Adding that resuscitation measures take precedence over diagnostic measures is crucial. During resuscitation or severe shock, one should not manipulate an effectively placed tourniquet.

Quality control, procurement, training, and best practices are needed to address tourniquet usage gaps in Ukraine. Improved prehospital care for Ukrainian warfighters and volunteers requires adequate supply of CoTCCC-approved tourniquets, phasing out substandard and outdated alternatives, and quality assurance measures for battlefield tourniquet use. To reduce preventable morbidity and mortality, comprehensive and standardized tourniquet application, control, and preventive tourniquet training is essential.

Lesson Number 5: Pain Management

Pain management in the prehospital environment is a challenge and is often inadequately addressed.⁴¹ The TCCC CPGs, 2021 update, attempts to tackle this issue by recommending the empirical use of adjuvant forms of fentanyl and ketamine for basic providers, although advanced providers have access to morphine, fentanyl, and other advanced pain therapeutics.⁴² However, the availability and culture of pain management in the prehospital space in Ukraine, both in civilian and military settings, are inconsistent. A comprehensive restructuring of prehospital care and Role 1/Role 2 echelons of care should be addressed in order to ensure safe, effective, and adequate pain management for all patients.

In some prehospital settings in Ukraine, the opiate agonist–antagonist nalbuphine is used intramuscularly (IM) or intravenously (IV) for pain relief. Although it is widely available and affordable, its efficacy is significantly lower than that of morphine, and its use can lead to vomiting, potentially compromising the airway. Antiemetics such as ondansetron are also widely available, but shortages of IV/IM preparations have been reported. The supply of opiates like morphine and synthetic opiates such as fentanyl, as well as dissociative pain management agents like ketamine, is inadequate across all eastern and southern regions of Ukraine. Furthermore, nalbuphine is less than ideal because it can diminish the effects of morphine and fentanyl for hours or days after nalbuphine administration, because of its action on mu-receptors.⁴³ If the Ukrainian military medicine system cannot provide ketamine, morphine, or fentanyl to combat medics and can only offer nalbuphine, it may be preferable to continue pain management with nalbuphine throughout the echelons of care, despite its suboptimal efficacy and risk of poor medical outcomes. Alternatively, sublingual lozenges or nasal spray fentanyl have been reported to be effective when used by combat medics, although not readily available in the prehospital environment in Ukraine.⁴⁴

Clinical governance is still lacking in areas with adequate supplies, making it difficult for rescuers and providers to provide adequate pain relief safely, effectively, and according to CPG best practice guidance. Prehospital medics and unlicensed physician extenders struggle to manage polytrauma patients’ pain owing to these clinical governance challenges and controlled substances for pain management.

Board-certified equivalent anesthesiologists in Role 1 and Role 2 facilities across Ukraine generally have sufficient pain, induction, and paralytic agents for DCR and DCS; some of course do not. However, gamma hydroxybutyrate for post-surgical narcosis, long-term propofol for post-DCS critical care transport, and pure paralytic medication without pain or induction agents have been used when supplies run low and patient volume increases. These desperate measures reflect the pharmaceutical agent shortage and rescuer and clinical provider challenges with clinical governance, empiric treatment guidelines, and ready access to adequate pain management agents.

The ingenuity and creativity of Ukrainian anesthesiologists, emergency medicine doctors, and surgeons are commendable. Nevertheless, the consistent application of best practices and CPGs is hampered by resource and procurement deficiencies in pain management and adjuvant care. To address these issues, rescuers across all echelons of care need clear prehospital clinical governance and access to adequate pain management resources, such as fentanyl, ketamine, and morphine, administered through IV/IM and intranasal routes, as well as other novel therapeutic methods. This should be supported by comprehensive training, treatment guidelines, and clinical review throughout patients’ MEDEVAC journeys and the various echelons of care.

Lesson Number 6: Transport Immobilization

Transport immobilization has emerged as a significant area of concern in the Ukrainian conflict. This is an area that is ripe for improvement through increased training. The experience from 1 year of war demonstrates the widespread neglect of transport immobilization, which has a negative impact on the quality of care during MEDEVAC.⁴⁵ There is a lack of understanding that immobilization of fractures, using both orthodox and adapted methods, plays an important role in stabilizing the patient’s hemodynamics by providing an “internal tamponade” effect on bleeding sources.

Transport immobilization encompasses temporary measures for immobilizing damaged anatomical parts of the body during the evacuation of victims to the hospital stage. It is a vital aspect of treating bone fractures in limbs and skeletal structures, not only providing an anti-shock effect but also reducing nociceptive impulses, preventing secondary tissue and vascular damage, and reducing the risk of fat embolism.^24,46

Key principles of transport immobilization include:

• Assessing and reassessing peripheral vascular and neurological status of the limb before and after mobilization

• Immobilizing two adjacent joints, both proximal and distal to the fracture

• Positioning limbs in functionally beneficial (physiological) positions during immobilization

• Reducing fractures when possible and clinically appropriate with surgical, anesthesia, and pain management support

• Securing the pelvis with low threshold and index of suspicion for pelvic trauma.^23,24

It is essential to remember that immobilization can be positional (e.g., leg positioning in pelvic fractures) and should be performed even in the absence of bone and joint injuries when vascular and nervous structures are damaged. Furthermore, mechanical immobilization should be complemented with “pharmacological immobilization” with airway support or the use of advanced anesthesia and surgical input when open fractures are reduced; the requirement of surgical input when possible should be considered; and aggressive pain management considered when immobilizing, transporting, and reducing traumatic fractures (see “Lesson Number 3: Pain Management” section).

Lesson Number 7a: Warming the Patient

In cases of severe injuries and the development of critical conditions, relying solely on thermal/Mylar blankets is insufficient. Whereas thermal blankets are an indispensable tool for passively maintaining a patient’s body heat at the PoI, active warming methods should be employed during transport and evacuation. These methods may include electric sheets, thermal fans, and infrared heaters. It is also crucial for medical personnel to utilize fluid warmers and vehicle heaters to ensure patient comfort and stability.

Lesson Number 7b: Blood Products at the PoI and During Transport

Additionally, warming fluids and using fresh whole blood and blood products must be prioritized. Using basic fluid warmers when using crystalloids and offering blood that is red cell mass and O negative through a warmer system must be considered.^{15,23,31,47,48} The use of low-titer O whole blood is not widely available in Ukraine at the time of this writing, and cross-matched blood is often used at a Role 2 facility. Prehospital blood administration and transfusion is now legal in Ukraine, training and monitoring and evaluation must be priorititized. The use of O-negative blood and consideration of low-titer O whole blood as far forward as possible to the PoI, to include the prehospital peri-PoI environment, must be considered across the entire line of contact to help reduce preventable morbidity and mortality.^33,48–50

Lesson Number 8: Antibiotics, Antimicrobial Resistance, and Infection Control Measures

The authors have observed patients dying from sepsis within 24 hours of sustaining battlefield wounds in Ukraine. Biogram data, which support appropriate antimicrobial guidance and empiric antibiotic therapy for trauma patients, are extremely limited in Eastern and Southern Ukraine.^51,52 Antimicrobial Resistance (AMR) is a growing concern requiring rapid attention by health security agencies and institutions to limit morbidity and mortality related to infections. Some improvised first aid kits do not include empiric antibiotic treatments for PoI use (oral or IM/IV). Additionally, several rescuers and medical professionals lack access to adequate clinical governance or resources to administer IV/IM or oral antibiotics at the PoI or during the peri-PoI period.

Developing basic biogram data to describe antimicrobial epidemiology and resistance in areas along the frontlines would significantly improve outcomes and provide targeted antimicrobial guidance, ultimately reducing morbidity and mortality. Furthermore, fighting forces and vulnerable civilian communities caught in the middle do not have a clear understanding of common antibiotic allergies or resistant organism profiles. Additionally, it is important that basic infection control procedures are employed at all stages of patient evacuation with adherence to principles of infection control, including hand hygiene, adequate PPE, safe sharps management, aseptic techniques for procedures, sterile instruments, and clean and disinfected environmental surfaces. This includes the need to consider various hypochlorite solutions in addition to high-volume, low-pressure irrigation of wounds with saline, potable water, and other solutions to prevent infections and induce tissue regeneration and efforts to reduce infections and promote limited scar formation. Additionaly, lifesaving clinical procedures such as central venous catheterization must adhere to “Safe Insertion of Centrally Inserted Central Catheters” guidelines and protocols which may help further reduce iatrogenic infection in high-risk environments. These guidlines and procedures must be trained on for a broader range of providers and followed in the prehospital environment.⁵³

Because of potential delays in MEDEVAC and access to higher echelons of care, PFC and the empiric use of oral, IV/IM, and other enteral routes for antibiotic therapy should be considered, trained, and embedded to CPGs for broad use. The U.S. DoD CPGs incorporate several antibiotics for use at the PoI, as well as during and after DCR/DCS; however, regional biogram data must influence the best antimicrobial vigilance against the microbial threat.⁵⁴ Ceftriaxone has been widely used throughout DCR and DCS with positive results in the prehospital space in Ukraine. Metronidazole, which is readily available and affordable throughout Ukraine, has also been used effectively. It is unclear if other penicillins, fluoroquinolones, and other broad-spectrum agents can offer benefit in the Ukraine prehospital and DCR/DCS space.

Furthermore, the ease of access to broad-spectrum antibiotics at pharmacies for use by non-medical personnel for undiagnosed ailments may become a significant issue. The potential for resistant organisms to develop because of widespread and large-scale use of broad-spectrum antibiotics is considerable and must be addressed.⁵⁵ It is unknown and unclear what Russian clinicians are using for antimicrobial agents; this practice will affect resistance and the biogram across the region. It is clear that in order to provide antimicrobial stewardship and reduce resistant organisms, a comprehensive approach through biogram and antimicrobial resistance strategies are needed. The CDC has initiated a program to attempt to address these issues in the early 2023; this needs to be rapidly supported and expanded to include all regions and cooperate across borders in order to mitigate morbidity and mortality associated with antimicrobial resistance.

Lesson Number 9: Be Prepared for All Patient Demographics

The traditional paradigm of military medicine focuses on providing care to fighting males aged 18 to 35 years. However, the reality of conflict in Ukraine has turned this notion on its head. Military medical professionals must now be prepared to provide care to a diverse range of patients, from newborns to geriatrics, and special needs patients.⁵⁶ This necessitates understanding and managing high volumes of military trauma outside the typical “fit, healthy, 18- to 40”-year-old age range, as well as addressing non-communicable diseases (NCDs), abnormal physiology, comorbidities, and a wide catchment of mental health disorders.

Clinical practice guidelines must be adapted to be more inclusive of varying patient demographics, such as pediatric and geriatric populations. Special pathways should be developed to ensure that appropriate care is provided for these individuals, who may present with unique challenges and require different treatment approaches. In the Ukrainian conflict, it is not uncommon to see patients in their 50s or 60s actively participating as combatants and warfighters and sustaining significant trauma with associated comorbidities; per-existing medical conditions and a myriad of prescription medication's may influence empiric treatment paradigms. Medical professionals must be adaptable, knowledgeable, and skilled in addressing the needs of a wide range of patients and presentations and not trauma alone.

Lesson Number 10: Clinical Governance

Clinical governance is a significant administrative and operational challenge in Ukraine, affecting volunteers, NGOs, humanitarian actors, and even public sectors such as the AFU, MoH, and Ministry of Internal Affairs (MoIA). This challenge encompasses the scope of practice, accountability, and professional roles of nurses, medical doctors, and medics. Issues such as proper identification, documentation, associations, in-date licensure and certification, and security at checkpoints and maintaining freedom of movement all contribute to the complexity of the situation.

Navigating the clinical governance landscape requires addressing the following concerns:

1. Scope of practice: Ensuring that health care professionals work within their expertise and qualifications and that their current certification or licensure are in date and in good standing to provide appropriate care

2. Accountability: Determining responsibility and reporting lines for health care personnel, both within their organizations and to external authorities

3. Documentation: Obtaining and maintaining necessary letters, identification, and professional association memberships to operate in the conflict zone and electronic medical records. The current landscape presents a multitude of challenges related to document management, including instances of missing documentation, reliance on outdated Soviet and Union of Soviet Socialist Republics formats, and the patchy adoption of new NATO standard documents, such as the TCCC card and others, that are not implemented systematically. This inconsistency, coupled with the absence of a systematic approach, generates organizational discord, potentially even disrupting the continuity of MEDEVAC chain management and overall medical command and control (C2)

4. Security and checkpoints: Ensuring safe passage for medical personnel and resources through checkpoints, often requiring relationship-building and negotiation with local authorities.

Moreover, NATO interoperability in clinical governance is an essential consideration, as it impacts the ability to coordinate and deliver health care services across different national and organizational entities.

In some areas of Ukraine, even official MoIA/MoH documents were insufficient to guarantee smooth medical operations. Building relationships with local checkpoint authorities proved to be crucial in overcoming these hurdles and ensuring the delivery of quality medical care to those in need. Clear guidance from authorities will support freedom of movement of medical volunteers as the war evolves in Ukraine and will better support and facilitate patient care.

The lack of active and engaged LL programs on both the donor and Ukrainian sides has hindered the identification of preventable mortality and morbidity. A comprehensive LL program on the part of donor institutions would have allowed for early recognition of issues, prompting the provision of training and material support to reduce mortality and morbidity.

Although several donor institutions, including the U.S. EUCOM, have broad LL efforts engaged in collecting observations on the overall effort, none have directed their LL efforts specifically toward medical observations and working them through the LL process. Similarly, an active and engaged LL program within Ukrainian military and civilian institutions would have facilitated early recognition of preventable mortality and morbidity, enabling requests for necessary training and resources to decrease these negative outcomes.

RAPID DISCUSSION

The changing nature of warfare and new threats demands a reevaluation of existing CPGs and treatment algorithms, such as TCCC/Tactical Emergency Casualty Care, Emergency Resuscitative Care and Civilian Combat Casualty Care, Sustained Combat Casualty Care, and Remote Damage Control Resuscitation and DCR/DCS. As the battlefield evolves, new weapon systems are deployed by the enemy; it may be necessary to push Role 2 capabilities to Role 1, focusing on en route casualty care and critical care aspects of post-DCR/DCS patients requiring transport in a multi-domain battle. The rate limiting step of offering DCS remains access to purpose built critical care transport to scale.

To address clinical gaps in the PoI and MEDEVAC chain, relevant data on casualty, wounding patterns, mechanisms of injury, and specific time to treatment need to be gathered in keeping with Joint Trauma Registry/Joint Trauma System principles and core clinical metrics. This documentation should be organized and collated into the trauma registry so that performance improvement efforts can be established, as well as modifying current CPGs to best fit the battlefield. Although the ideal data would be extracted from TCCC casualty cards (DD 1380)⁵⁷ and the Resuscitation Form (Parts I and II, DD 3019),⁵⁹ obtaining this information from partner forces might prove to be challenging but must be pursued and encouraged. Therefore, it is essential to identify alternative data sources that can provide anecdotal insights to impact CPGs and patient care in general in real time. Definitive analysis of these data may take several years before clear clinical paradigms can be described.

Global Health Engagement (GHE) strategies by NATO member and partner states can best support Ukraine warfighters through training, support of medical material, and potentially direct medical support in the country at PoI. Offering clinical training across the continuum of care from PoI to rehabilitation must be coordinated and unified to reduce duplication of efforts and maximize standardization. GHE activities for Ukraine will better suport Ukraines’ NATO aspirations and membership. Information gathered through engagement can benefit the NATO alliance and CPGs in general. Global health engagement programming supports not only units in the field and through capacity building in training providing medical aid but also units at higher levels through the AFU, MoIA, and MoH. Global health engagement can help support lethality and overall battlefield effectiveness. Lines of effort and portfolio projects that support and focus on capacity and capability enhancing medical C2, the evacuation chain, force health and strategies for deepening coordination of GHE should be prioritized. These efforts at both the bottom–up and top–down approaches may help not only address the LS in this rapid report from the field but also reduce preventable morbidity and mortality on the multi-domain battlefield with new weapon systems and a peer adversary.

CONCLUSION

Improved prehospital care and casualty evacuation in Ukraine through increased use of pain management, focused antibiotic guidance, patient assessment training, blood, and transport immobilization practices should be prioritized. A robust and active LL program to reduce preventable morbidity and mortality in the war zone, with the recommendations presented in this study serving as a starting point for improvements benefits Ukraine and the NATO alliance. Prioritizing the most critical data to reduce preventable morbidity and mortality is crucial. A comprehensive analysis of available data sources and their relevance to the current context of warfare must be conducted to identify the next steps for medical care in this complex environment for Ukraine and across the NATO alliance.

Collaborative efforts among military and civilian institutions, partner forces, and medical professionals will be essential in achieving these goals and ultimately enhancing the overall effectiveness of medical care in the evolving landscape of multi-domain warfare. By continually updating and refining approaches to medical care in military contexts, preventable morbidity and mortality can be reduced and ensure that our armed forces and civilian populations receive best practices across the continuum of care in war and disaster.

ACKNOWLEDGMENTS

The authors would like to thank all the fallen who have given the ultimate sacrifice, all of the warfighters and volunteers sacrificing hourly in support of Ukraine’s right to exist, of state sovereignty, democracy, freedom and independence, NATO core principles, and liberty on Europe’s eastern flank.

FUNDING

The authors have received no funding for the production, drafting, editing, or publishing of this report.

CONFLICT OF INTEREST STATEMENT

J.Q. served as a medical director for the Humanitarian NGO Migrant Offshore Aid Station from February 15 until July 1, 2022, based at operational sites throughout Ukraine. He served as consultant for the Canada Ukraine Foundation on health assessments and activities in February to May 2023. He serves as a medical volunteer for the NGO HEAL Corporation outside Kyiv providing DCR training support to the National Academy of Internal Affairs for Ukraine. He served as a medical officer for the Organization for Security Co-operation in Europe Special Monitoring Mission to Ukraine from June 2020 until June 2021. He is a lead researcher at the Prague Center for Global Health and has served as a medical director and trainer for the medical humanitarian organizations of Medsanbat. Views expressed here are that of his own conclusions and findings and do not represent any official or unofficial policy or platform of any organization he has worked for in the past, present, or future.

T.A.P. has served as a clinical provider, medical director/instructor, and advisor to a number of NGOs providing medical care in Ukraine from May 2022 to the drafting of this manuscript, as well as consulting to some governmental agencies. She served as a reserve medical officer in the Canadian Armed Forces and was the Canadian representative to the Interallied Confederation of Medical Reserve Officers, NATO Reserve Medical Officers, for 5 years. The views expressed here are from her personal experience and do not represent any official or unofficial platform or policy of any organization she has, is, or will be associated with.

Dr J.B.H. is on the board of directors of Decisio Health, CCJ Medical Devices, QinFlow, Hemostatics, Zibrio, and Oxyband. He receives research grant support from the DoD, Defense Advances Research Projects Agency, NIH, and Commonwealth Serum Laboratories focused on hemorrhage control and resuscitation. He consults with Wake Forest Institute for Regenerative Medicine, Aspen Medical, is a co-inventor of the Junctional Emergency Tourniquet Tool, and receives royalties from UT Health.

DATA AVAILABILITY

The data underlying this article are anecdotal. The photographs, locations, and case studies that comprise this article and its contents cannot be shared publicly because of ongoing Russian war in Ukraine and operational security concerns. Clinical case data and casualty data are currently held at high levels of security in Ukraine.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

No institutional review board or ethics committee groups have been approached before the drafting of this commentary piece for approval in keeping with commentary standards and requirements to promote information sharing.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (OR OTHER APPLICABLE COMMITTEE) APPROVAL

Not applicable.

INSTITUTIONAL CLEARANCE

It does not apply.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

J.Q. has provided the original draft and LL to expand upon and helped organize the overall drafting and editing process.

S.I.P. offered comprehensive input across the entire DCR/DCS sections throughout the entire paper.

Y.L. offered specific insight into anesthesiology and forward surgical concepts.

K.G. offered both high-level strategic considerations and surgical input throughout the article.

A.O. compiled the final draft, created visuals, and completed extensive editorial work.

D.S. contributed to the LL and was involved in proofreading.

A.J.G. contributed to the LL.

M.B. contributed to the LL.

M.M. contributed to the LL.

T.A.P. offered insight into autotransfusion and PoI stabilization.

L.B. contributed to the LL.

L.S. provided prehospital input and damage control surgical details.

J.B.H. provided overall support and guidance throughout the paper drafting and input across LL sections.

Author notes

The contents of this paper are original and not yet published or presented elsewhere. Briefings by co-authors to partners with elements and preliminary findings of the themes and selected lessons presented here have been alluded to or cursorily described at:

Global Security Themes: Health Security in Future Conflict; M4-86-A-22. NATO SENIOR MEDICAL STAFF OFFICER COURSE (SMSOC), November 3, 2022, NATO School, Oberammergau, Germany.

Using Up One’s 9-Liners - Discussion on lessons identified and learned in Medical Support in current Conflict; NATO TIDE SPRINT 41, Lillehammer, Norway, April 18, 2023.

OPENING KEYNOTE: INTERNATIONAL LECTURE, “Trauma Care in the Ukraine War,” Trauma Association of Canada/Association Canadienne de Traumatolog, April 20, 2023, Edmonton, Alberta, Canada.

Special Operations Medical Association Scientific Assembly 2023 “Lessons Learned, Lessons Shared from the War in Ukraine,” Special Operations Medical Association, Raleigh, NC, USA, May 18, 2023.

The views expressed here in this manuscript are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the DoD, the U.S. Government, the National Health Service of the UK, Charles University, or any corresponding nations relating to the co-authors, any additional author-associated institutes, affiliates, or systems.