Wartime medicine NATO-wide has long been associated with the military medical personnel. Yet the war in Ukraine has shown that delivery of medical care during a full-scale armed conflict necessitates a totally different approach. It requires an orchestrated effort among the civilian and military medical communities, going as far as requiring that our knowledge and understanding expand far beyond the medical domain itself. To guarantee our own survival and to improve outcomes of our patients we must understand the operational environment (= place of action), which is quite complex and definitely not limited to the frontline surroundings. When facing the enemy who could not care less about Geneva Conventions and other rules of engagement, red cross seems equivalent to a target sign, and safety is relative at most. As medical personnel we are a hot commodity, with both military and civilian being subject to substantial risk. Between February of 2022 and July 2025, WHO has documented over 2400 attacks on healthcare settings in Ukraine, including maternity and children’s hospitals.
You think it would be any different for us?
With the rapid advances in weaponization of technology comes the dramatic increase in threat and risk for both civilians and military, including medical personnel. Asides from more expensive conventional weaponry, in this war of drones precision has become quite cheap. Thanks to inexpensive drones, both sophisticated charges and improvised explosives can reach their targets with unprecedented precision. For a few hundreds to a few thousands dollars, millions worth of equipment or infrastructure can be destroyed, and many people can be injured or killed. Hereby let’s not forget about the use of drones to propel chemicals. On one hand it’s about the direct toxic effect of the substance being spread, and on the other about the potential to cause widespread panic. This obviously complicates any healthcare operations, regardless of the location. Under such circumstances it’s not the case of persecutory paranoia to think that some “evil big brother” is watching you 24/7. It’s more or less a life-saving mindset.
Do we know how to treat combat casualties?
Sadly enough, even military doctors these days signal deficiencies in wartime readiness. Few practice in settings with high incidence of penetrating trauma, and most, if not all of NATO medical personnel, have not had any exposure to acute combat injuries of modern warfare. One could argue that blast waves and shrapnel injuries are not a novelty in the military environment. Yet as clinicians we also know, that damage is done by the application of force, and acceleration matters in this equation. Injuries caused by a static roadside IED, would logically differ from those elicited by an explosive flown precisely towards a casualty at 150 km/h. Angle and direction of force application also contribute to the end effect. It all matters, and our protective gear was not quite developed for the drone scenarios.
On the civilian side there is surely a handful of tactical medicine enthusiasts. Otherwise too few would know how to place a tourniquet or to pack a wound – even on themselves. Let alone conduct damage control resuscitation and surgery, or provide post-op critical care to a combat casualty. No, it’s not rocket science, but now is the opportunity to start learning, while we have the luxury of time and peace. Beginning with basic Stop-The-Bleed skills, and cultivating fundamental awareness are already a step in the right direction. These days medical training institutions of any level should include such life-saving knowledge in their curricula. Few already do! Healthcare facilities should acknowledge it’s no different than requiring some skills in basic life support (BLS). Believe it or not, knowing how to control life-threatening bleeding may come in handy on your next vacation.
“Golden hour” makes sense, but the enemy won’t let you achieve it!
Speaking of comprehensive combat casualty care we have to admit that our current clinical practice guidelines (CPG’s) may already be not-so-current. They rely primarily on what was learned in prior conflicts – most CPG’s of modern military medicine are still based on the analytics from Iraq or Afghanistan. And things are quite different on the battlefields of Ukraine. Hailed principle of “golden hour” has unfortunately gained an utopian status. Considering anatomy and physiology it still makes perfect sense, but it is usually NOT achievable in today’s combat environment. Hell of tactics has replaced the tyranny of distance as the leading cause of care prolongation in the field. With medical personnel being deliberately targeted by the enemy, pushing more qualified people closer to the frontline is not justifiable. It is also not rational to throw some “turbo-medic” knowledge and equipment at people with 3-6 days of prior tactical medical training. It simply won’t stick.
So what can we do?
I surely keep repeating myself since 2022, but nothing creates a more lasting effect than some spaced repetition. We need to partner with our Ukrainian colleagues and we must learn from one another. We can actually support them more effectively and efficiently if learning leads to enhanced understanding. For that we need the following:
- CONTEXT
- RELIABLE INFORMATION & DATA
- MUTUAL BENEFIT (NOT WAR-PROFITEERING)
More to follow 🫡
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