Qualitative assessment of point of injury to Role 2+ combat casualty care in Ukraine

Abstract

Background

The ongoing Russian-Ukrainian war created an extended battlefield with the prolific use of missiles and drones. Such tactics require placement of care facilities far from the frontline, thereby delaying definitive trauma care and necessitating prolonged casualty care (PCC).

Methods

Between June 2023 and February 2024, we conducted qualitative key informant interviews with Ukrainian healthcare personnel using an expanded version of the Global Trauma System Evaluation Tool. Analysis focused on identifying and understanding casualty care from point of injury through Roles 1, 2, and 2+. We included 36 civilian and military healthcare or healthcare-affiliated participants. Sampling continued until thematic saturation was achieved.

Results

Respondents indicated medics lacked a standardized formal training system for prehospital care across emergency services and regions. Reliance on “walking blood banks to collect fresh whole blood for blood banking and direct transfusion was noted frequently. Of respondents at Roles 1, 2, and 2+, 73% stated damage control resuscitation was done at their level, and 71% of respondents in these same Roles stated they were doing some level of damage control surgery. Security and the tactical situation were common limitations to prehospital care leading to PCC.

Conclusion

The experience in Ukraine shows that, in the face of large-scale combat, the effectiveness of Role 2+ and lower facilities degrades very quickly. Future attention should be focused on improvements to prehospital care training, safe and timely patient movement in the absence of air superiority, PCC, blood supply, and medevac coordination. Efficient combat casualty care may require enhancing the capabilities of current Role 2+ units, or moving Role 3 facilities closer to the battlefront.

Level of evidence

Level III

WHAT IS ALREADY KNOWN ON THIS TOPIC

• The ongoing Russian-Ukrainian war is the first instance of large-scale combat operations in the 21st century. The combination of large, comparably armed military units engaged over a relatively constrained battlefront with high-lethality weaponry leads to a high volume of severely injured casualties that outpace the capacity for effective and efficient combat casualty care.

WHAT THIS STUDY ADDS

• We conducted qualitative key informant interviews using an expanded version of the Global Trauma System Evaluation Tool. Respondents identified opportunities to strengthen care far forward, including coordinated and standardized training for medics, improved access to blood products far forward, training for prolonged casualty care (PCC), improved patient movement, and medevac coordination. Early access to damage control surgery and higher level surgical care is vital to survival of casualties.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study highlights areas of improvement in Ukraine, includin improvements to prehospital care training, safe and timely patient movement in the absence of air superiority, PCC, blood supply, and medevac coordination. Enhancing the capabilities of current Role 2+ units or moving Role 3 facilities closer to the battlefront may be necessary for improved combat casualty care.

Background

The ongoing Russian-Ukrainian war represents the first example of large-scale combat operations (LSCO) in the 21st century, combining the armed forces of state actors with the lethality of modern weapons technology.^{1 2} At present, it is estimated that there have been 450–500 000 casualties among the armed forces of Ukraine, with about twice that number sustained by the Russian military.³ In contrast to prior wars fought by the USA and other North Atlantic Treaty Organization (NATO) members extending back to the Vietnam era, the Russian-Ukrainian war has been protracted, included mobile and static phases, involved combat in urban and rural environments, and witnessed the proliferation of drones, loitering munitions, and directed rocket attacks in addition to conventional military tactics. These realities have combined to result in a high incidence of severely injured combat casualties, which has put a strain on the military and civilian healthcare systems within Ukraine.

While combat-blast exposure and high-acuity injuries such as lumbopelvic dissociation, multiple extremity amputations and low lumbar spine fractures were appreciated in earlier conflicts, their frequency has increased in Ukraine given the combination of personnel numbers engaged in combat operations and the lethality of modern weaponry.^{4 5} 90% of deaths in combat occur before the wounded patient reaches a health facility, largely due to exsanguination.^{6 7} The current battlefield environment in Ukraine precludes rapid evacuation of wounded.⁸ Aeromedical casualty evacuation is not possible due to contested airspace, and ground movement is constrained by distance, degraded infrastructure, and targeting of medical assets.8,10 Therefore, medical evacuation is conducted by ground transportation over poor roads using ambulances or vehicles of opportunity (eg, military vehicles, unmarked vehicles, civilian ambulances, trains), resulting in delays of hours to days before reaching a definitive trauma care facility.⁸ Previous studies involving NATO forces in Iraq and Afghanistan heralded that these conflicts saw the lowest combat mortality rates in military medical history.¹¹ This fact was potentiated, however, by relatively low combat casualty rates, air superiority that facilitated rapid evacuation, and high ratios of medical personnel to treated casualties. Such characteristics are absent in the current combat environment in Ukraine. As a result, NATO medical facility roles that have traditionally been used for damage control resuscitation (DCR) and damage control surgery (DCS) from the point of injury (POI; eg, NATO Role 1, 2, and 2+ units) are having a different experience in Ukraine when compared with similar units in the wars in Iraq and Afghanistan.

The experience of military medical units in Ukraine remains poorly understood, but is vital to senior leaders and military medical planners who may need to revisit NATO doctrine regarding echelons of care and how best to optimize combat casualty care in the setting of LSCO between comparably armed state actors. Such information is vital to the ongoing Ukrainian effort but also potentially influential for future conflicts that may occur in Europe, the Middle East, South America, Southwest Asia, or the Pacific Rim. In this context, we sought to assess the casualty care experience among Ukrainian medical personnel from the POI through NATO Role 1, 2, and 2+ facilities over the course of the current conflict using semistructured key informant interviews (KII).

Methods

Study design and participants

We conducted semistructured, in-depth KII of Ukrainians working in the health and trauma system of Ukraine during the Russian-Ukrainian conflict. Participants were included if they were healthcare or healthcare-affiliated personnel (eg, administrators or logisticians) who were currently working in some capacity supporting health and trauma care in Ukraine in one or more facilities with an applicable NATO-level designation. For the purposes of this investigation, we considered the NATO levels of care as: prehospital care/battalion aid station (Role 1), forward area support medical company/small aid clinic with no surgical capabilities (Role 2), emergent/limited surgical care for stabilization only (Role 2+), district hospital with some specialty care/surgical care with definitive treatment (Role 3), and tertiary hospital, specialty care, rehabilitation (Role 4).¹² Participants could also be identified as an ‘Other’ level of care if in a research or leadership position. There were no other inclusion criteria. Participants were recruited from trauma care-related themed symposia and training events held from June 2023 to February 2024 in Warsaw, Poland, via purposive and snowball sampling methods and attended either an in-person or virtual interview.

Instrument

We adapted the Global Trauma System Evaluation Tool (G-TSET) to create the Ukraine Trauma System Assessment Tool (TSAT) to assess leadership and organization, prevention of injuries, access to injury care, initial injury care, acute injury care, rehabilitation, and education, research, and quality improvement.¹³ The first component of the TSAT collects quantitative demographic information. The remainder of the tool collects qualitative data and limited quantitative data (yes/no responses) from participants on different domains of the trauma system (table 1). The instrument was written in English and translated to Ukrainian to account for culturally sensitive wording while holding true to the intent of the instrument. The TSAT has been previously used to evaluate aspects of healthcare delivery in the Russian-Ukrainian conflict.¹⁴

Table 1. Domains of the Ukraine Trauma System Assessment Tool (TSAT).

Leadership/command and control	Critical care in definitive care facilities
Planning and coordination	Telemedicine in definitive care facilities
Resource assessment	Injury patterns in definitive care facilities
Logistics and supply	Blood product use in definitive care facilities
Communications	Disease and non-battle injuries (DNBI) in definitive care facilities
Mass casualty plan	Mental health
System triage and patient transfer	Rehabilitation
Prehospital care/emergency medical services	Injury registry, epidemiology, and process improvement
Prehospital chemical, biological, radiological, nuclear, and explosives	Technology/products/devices
Prehospital training	Injury prevention
Prehospital training definitive care facilities	Environmental factors and dental trauma
Summation questions

Procedures

Interviews were conducted in Warsaw, Poland, from September 28, 2023 to February 28, 2024. One researcher asked questions in English, and the discussion was translated to Ukrainian if necessary. Another researcher took digital notes using the KoboToolbox platform. A subset of interviews occurred virtually over Zoom. The sample size (n=36) was determined using thematic saturation, when no new themes or patterns emerged from the data.

Data analysis

Deductive thematic content analysis was used to identify patterns or themes in the data guided by the assessment objectives and research questions using NVivo and open coding techniques.¹⁵ The research team manually summarized, categorized, and compared interview data and NVivo results to identify common themes from transcribed documents, including expected themes from the G-TSET tool and new themes. Emphasis was placed on discussions involving the needs and gaps for casualty care, including prehospital care, system triage and patient transfer, prehospital care, training, evacuation, and prolonged care, which crossed many of the domains in the trauma system and were included in the thematic analysis. Research team members selected and agreed on illustrative quotes for each prevailing theme identified to limit any biases, subjectivity, assumptions, and experiences that may shape the research process.

Results

Demographics

Between June 2023 and February 2024, thirty-six civilian and military healthcare or healthcare-affiliated participants across all NATO roles were interviewed. Demographic characteristics of the cohort are presented in table 2.

Table 2. Demographics of study participants.

Age, years; mean (range)	34.9 (28–55)
Region, n (%)
Southern	4 (11.1)
Eastern	13 (36.1)
Western	4 (11.1)
Northern	13 (36.1)
Missing	2 (5.6)
Sex, n (%)
Male	22 (61.1)
Female	13 (36.1)
Missing	1 (2.8)
Occupation, n (%)
Trauma surgeon	5 (13.9)
Physician	5 (13.9)
Chief of medicine	3 (8.3)
Nurse	3 (8.3)
Anesthesiologist	3 (8.3)
Director, emergency services	2 (5.6)
Researcher	2 (5.6)
Medic	1 (2.8)
Chief, rehabilitation	1 (2.8)
Commander, Role II	1 (2.8)
Mental health services associate	1 (2.8)
Head, Moral Psychological Service Branch Combat Stress Control Group	1 (2.8)
Deputy director, healthcare innovations	1 (2.8)
Deputy director, health development department	1 (2.8)
Other*	4 (11.1)
Missing	2 (5.6)
NATO role equivalent, n (%)
Prehospital/Role 1	4 (11.1)
Role 2	3 (8.3)
Role 2+	7 (19.4)
Role 3	7 (19.4)
Role 4	4 (11.1)
Other	6 (16.7)
Missing	5 (13.9)
Civilian/military provider, n (%)
Military	20 (55.6)
Civilian	16 (44.4)
Military rank, n (%)(n=20)
Major	1 (2.8)
Captain	1 (2.8)
Lieutenant	4 (11.1)
Sergeant	4 (11.1)
Missing	10 (27.8)
Organization affiliation, n (%)
Ministry of Defense	17 (47.2)
Ministry of Health	12 (33.3)
Ministry of Interior	1 (2.8)
National Guard	2 (5.6)
Commercial company	1 (2.8)
Charity	1 (2.8)
Missing	2 (5.6)
Years in current position; mean (range)	4.6 (0.33–19)

^*Grant manager, deputy director general, project lead—commercial company, sergeant.

NATO, North Atlantic Treaty Organization.

Prehospital care administration

Prehospital care is administered by both military and civilian personnel. Combat medics, trained through short courses (on average, 2 weeks), provide care in the military setting. There also appears to be participation on the part of nurses or feldshers (paramedics). Prehospital care included DCR and DCS across a wide range of injuries.

Prehospital care supervision

Combat care experience is key to effective guidance and leadership of military medical support units.

It is not always [a] doctor. In the unit it may be [a] person who is more experienced. But it is not always [a] doctor. In Ukraine we just say the name. But the position would be the kind of senior medical officer. Or senior combat medic who is responsible for the smaller units. (Role 2+, Physician, East)

Prehospital care training

Prehospital care training ranged in length from 4 to 30 days, of which Tactical Combat Casualty Care (TCCC) was the most common. Some respondents did not receive any formal training and noted there was no standard training system for medics. “The combat medics would have two weeks of training if they are lucky” (Role 2, Commander, East). Many expressed a desire for standardized training across emergency services and greater familiarity with common types of injuries across body regions. Specific topics included, but were not limited to, prolonged mass casualty care, Stop the Bleed, first aid, combat stress, search and rescue, tourniquet conversion, caring for traumatic brain injuries, and sexual assault training.

Prehospital care coordination

Some respondents indicated variable coordination in the prehospital setting: “uncoordinated…no regulations and no rules” (Role 4, Chief Anesthesia, West). Others noted that there was limited coordination that depended on the specific combat environment. Prehospital coordination occurred through messaging apps. Military control over these processes increased with proximity to the frontline. Care and evacuation coordination was conducted through secure radio, WhatsApp, Telegram, and mobile phones. Respondents expressed a desire for a system for prehospital care with standard guidance: “…provide special protocol, provide dispatcher system—unifying system—with electronic form and provide quality control” (Director of Emergency Services, North).

Triage

Prehospital triage is a fluid process influenced by the local tactical situation and the resources available for patient care. Triage was described as a “dynamic process at all levels of care” (Role 2+, Trauma Surgeon, East), while also consisting of “formal triage criteria” (Role 4, Mental Health Services, West). Triage is generally coordinated by a military coordinator for battlefield triage and an intensive care unit doctor for hospital triage. Destination after battlefield triage depended on facility proximity, the type of injury, military versus civilian, and hospital capacity. The patient’s clinical needs and available medical resources shaped triage decisions. “It depends on …specialty inside each hospital. In this hospital [there is a] very good [vascular] surgeon and if the problem is arteries we go there” (Role 1, Medic, South).

Blood

Banked blood is positioned both at blood centers to supply blood to frontlines and at Roles 2 and 2+ (stabilization points). “Large reserves of blood supply, components are stored in blood centers if speaking about stabilization points, they [have] refrigerators and battery ones which can work without electricity” (Captain, Medical Forces of Ukraine, East). Both universal and type-specific blood is being used to support the combat effort. Blood product transfusion consists of type-specific blood (O negative mostly), red blood cells, and fresh, frozen, and freeze-dried plasma. Fresh donor whole blood, obtained from a “walking blood bank”, was mentioned frequently by respondents as a means for blood supply and direct transfusion at prehospital levels. “There is a group of people at the stabilization center, 30–50 people, everybody knows the blood type they have. If there is a need there is a direct blood transfusion” (Role 2, Commander, East). There was some reliance on Eldon cards, blood typing, and massive blood transfusion protocols. Coagulopathy monitoring is not done at stabilization points. Testing of the blood supply for infectious diseases was reported but was not consistent across all prehospital levels.

DCR and DCS

More than 70% of respondents up to Role 2+ facilities stated DCR and DCS are performed at their levels (table 3). DCS, however, is limited to thoracotomies, vascular surgeries, and fasciotomies. The lack of formal surgical teams precluded DCS in many settings: “We didn’t have enough docs in our unit …” (Role 2+, Physician, East). Many of the respondents stated that abdominal, pelvic, and neurosurgical injuries were evacuated to Role 3 for care because of the care limitations at Roles 1 through 2+.

Table 3. Characteristics of POI and Role 1 to 2+ casualty care in Ukraine.

Characteristicn=36	Yesn (%)	Non (%)	Don’t known (%)
Do you transfer patients needing a higher level of care than what is available at your facility?	31 (86)	4 (11)	–
Do you have written clinical practice guidelines for prehospital care?	32 (89)	2 (6)	2 (6)
Is there a prehospital medical director?	25 (69)	4 (11)	7 (19)
POI to Role 2+	11 (79)	2 (14)	1 (7)
Roles 3 and 4	7 (70)	2 (20)	1 (10)
Do you give tranexamic acid (TXA) for massive bleeding in the prehospital phase of care?	26 (72)	2 (6)	7 (19)
Do you collect data from prehospital care?	23 (64)	11 (31)	1 (3)
Is the prehospital care recorded in the electronic health record?	8 (22)	22 (61)	6 (17)
Do you analyze your data based on age and sex?	17 (47)	11 (31)	8 (22)
Are you performing damage control resuscitation?	24 (67)	10 (28)	2 (6)
POI to Role 2+	11 (79)	3 (21)
Roles 3 and 4	7 (70)	3 (30)
Are you performing damage control surgery?
POI to Role 2+	10 (71)	4 (29)
Roles 3 and 4	6 (60)	3 (30)	1 (10)
Are you caring for traumatic brain injuries?
POI to Role 2+	12 (86)	2 (14)
Roles 3 and 4	7 (70)	3 (30)
Are you caring for vascular injuries?
POI to Role 2+	13 (93)	1 (7)
Roles 3 and 4	9 (90)	1 (10)
Are you caring for extremity fractures?
POI to Role 2+	12 (86)	2 (14)
Roles 3 and 4	10 (100)
Are you caring for penetrating injuries from bullets and fragments?
POI to Role 2+	13 (93)	1 (7)
Roles 3 and 4	9 (90)	1 (10)
Are you caring for crush and soft tissue injuries?
POI to Role 2+	11 (79)	3 (21)
Roles 3 and 4	8 (80)	2 (20)
Are you caring for burn patients?
POI to Role 2+	13 (93)	1 (7)
Roles 3 and 4	8 (80)	2 (20)

POI, point of injury.

Evacuation

Medical evacuation is a multistage process significantly constrained by degraded infrastructure and the tactical situation. From the POI, “It’s direct from the trench…[When] there are combat actions in the forest [we are] on the edge of the forest waiting for everyone that is going to be evacuated. Combat medics evacuate to [the waiting] team” (Combat Stress Control Group member, East). Evacuation from the battlefield included carrying wounded from the field to handoff points using mechanized litters. At these handoff locations, the medical evacuation team would employ armored vehicles, ambulances, buses, minivans, and trains. “We start from the battlefield. Usually, the first stages are by walking…[in] some positions, medics would carry the patient 5–7 km” (Role 1, Chief Anesthesia, East). These battlefield constraints have also resulted in improvised evacuation methods including boats, quadricycles, and drones for evacuation from the POI. Evacuation times are often extended due to the tactical situation, degraded or destroyed roads, mass casualties, cold weather, and a dearth of evacuation resources. Some of the respondents mentioned timing evacuation movements to take advantage of the concealment of darkness. One noted using an opportunity to send a patient in an armored vehicle even if assessment and triage had not been completed.

We don’t have the luxury of triage…, if we have an armored vehicle to transport prioritized patients, the severe patients…Then all the patients who can fit in the armored vehicle [have to go]. We cannot have some patients wait because we don't know if we will get another armored vehicle and when. (Role 2+, Chief Medicine, East)

Prolonged casualty care

Most clinical respondents stated the tactical situation forced them to provide prolonged casualty care (PCC) for 24 hours to multiple days.

We do have that [prolonged casualty care] experience, at times we couldn’t get patients to [a] stabilization point [and] injured [patients] remained for 24 hours. Some remained on [the] battlefield for 48 hours [while] roads were being shelled and we [had to] wait until night to transport patients in armored vehicles. (Role 2+, Chief Medicine, East)

Respondents stated they were caring for casualties with numerous types of injuries. Respondents noted that a lack of training and inadequate equipment impeded PCC. Suggested improvements for PCC include armored vehicles for secure evacuation, training, and uniform guidance on PCC. “I think we need more detailed instructions for combat medics for what they [must] do if they cannot evacuate patients…” (Role 3, Trauma Surgeon, South).

En route care

Respondents reported an absence of defined standards for en route care. Patient needs and type of transport dictated who provided en route care. “We try to not do the evacuation without any medics. If the patient is intubated there might be [an] anesthesiologist…with higher skills or [an] emergency physician” (Role 2+, Physician, East). En route care barriers included the tactical situation and security due to enemy shelling, lack of air superiority, poor roads, weather conditions, and equipment shortages. Education and training were also cited as barriers. “We don’t have experienced staff for long evacuation[s] because our emergency medicine doctor work[s] [at the] prehospital stage and most of them don’t have critical care [specialization]… It’s a gap. That’s why we want to provide special training for them” (Director of Emergency Services, North).

Prehospital care data and process improvement

Recorded prehospital data are not part of a robust data registry, database, or process improvement analysis. For the most part, data are stored on paper forms. “Form 100 has two parts: one travels with the patient, the other stays with the stabilization point. There are also medical journals, and all the information is transferred to the journals at the facility” (Role 2, Commander Military Treatment Facility, East). “We fill the Form 100, take pictures and save it. We have simple Excel sheets where we transfer that data and keep the information to look back [at]” (Role 1, Chief Anesthesia, East). Several respondents discussed internal databases developed by individuals at brigade level used for process improvement but noted concern for operational security with data collection.

Discussion

The tactical situation in Ukraine is informative for future conflicts, where LSCO may be anticipated between comparably armed state actors, relying on NATO doctrine for combat casualty care and medical evacuation. Comparable realities could be envisioned for US armed forces engaged with any belligerent nation state, Venezuelan/Colombian conflict, European Union forces combatting Russian military, an Indian/Pakistani ground war, Greco-Turkish combat in the Eastern Mediterranean, and a Chinese invasion of Taiwan or Vietnam. The current NATO doctrine regarding POI to Role 2+ care was refined during a period of air superiority by NATO forces that enabled rapid deployment, relatively low incidence of combat casualties, and high ratios of military medical personnel to injured servicemembers.¹⁶ Prehospital and Role 2+ care in the NATO system is intended to rapidly evacuate, triage, and provide DCR with limited surgery as indicated, facilitating the transition of wounded personnel to a Role 3 facility where more definitive treatment is possible. In particular, the ability to effectively perform blood transfusions and medically manage wounded personnel over extended periods of time (ie, longer than 6–8 hours) is absent in NATO facilities of Role 2+ and lower.

The rigors of LSCO in the modern military environment, however, are showing that NATO doctrine regarding echelons of care is ineffective in the face of large-scale combat casualties and breaks down very quickly in the absence of air superiority that enables rapid transportation times. The current investigation highlights several critical areas for improvement within the Ukrainian armed forces, which we believe would also be informative for planners in NATO states and other comparably armed militaries. These include issues around combat casualty care at the POI, medical evacuation, the provision of DCS and DCR, medic training, PCC, and accurate recording of prehospital care data.

Combat casualty care

Initial casualty care at the POI and in transit to treatment facilities determines survivability from preventable deaths, largely due to hemorrhage.67 17,20 Casualty care guidelines are needed to inform care when the tactical situation precludes rapid evacuation.²¹ Extended use of tourniquets without early conversion in the setting of prolonged evacuation caused preventable injury, prompting requests for improved training and new laws to address these challenges.²² Protocol-driven DCR appears to be effective if blood components, experienced medical personnel, and tranexamic acid are available at POI and Roles 1 and 2.^{23 24} Standardization of blood products and availability is lacking due to the tactical situation in Ukraine, including unreliable transportation, deficient products, and reliance on inconsistent foreign supply chains. POI care training for combat medics must focus on TCCC skills for applying tourniquets and hemostatic dressings, as well as the transfusion of blood products.^{17 19 22}

Casualty evacuation and triage

Given the volume of casualties and the frequency with which combat injured are brought to medical facilities, it is challenging for healthcare personnel to perform both DCR/DCS and triage large numbers of casualties while also arranging for evacuation to higher levels of care.^{9 25} When considering that area medical companies and Role 2+ elements only have a limited number of actual medical clinicians, this may require the ‘democratization’ of these combat medical responsibilities, including increased reliance on nurses, paramedics, and combat medics to perform these tasks. The contested airspace and extended battlefield due to drones and missiles increase the distances from POI to definitive care.^{8 9 26} Recognizing this fact, military organizations will either have to provide for more robust or nimble Role 2+ units in the future, or move Role 3 facilities close to the battlefront, with the inherent increased risk to medical assets as a result.

DCS and DCR

DCR attempts to address the “lethal triad” of hypothermia, coagulopathy, and acidosis early after injury.^{27 28} DCS is a staged surgical approach to control hemorrhage, restore perfusion, and control contamination and allow resuscitation to restore physiologic homeostasis before definitive injury repair. In prior engagements, these approaches have been reported to have success rates as high as 60%.^{27 28} Although most respondents at Roles 1, 2, and 2+ stated they were able to perform some aspects of DCR and DCS, the limitations to the type of DCS at these lower echelons of care may actually increase mortality and morbidity.²⁸ A focus on broader DCR and DCS training among area medical companies and non-officer/non-surgeon personnel in Role 2+ units may allow for greater provision of care.2026 28,30 These challenges may also be addressed by the aforementioned increase in capabilities for Role 2+ units, or shortening the ground transportation distance between the POI and the Role 3 facility. As the Role 3 facility moves closer to the battlefront, it could amalgamate the capabilities of Role 2+ units increasing personnel power and the capacity to provide combat casualty care efficiently.

Medic training

Standardized and formal training for medics would provide consistency in medical care within the prehospital area of operations. Currently, Ukrainian combat medics do not have clearly defined directives and obligations to perform medical care. Instead, they execute their duties based on ad hoc orders of commanders.³¹ Legal definitions, protections, and responsibilities of a medic in Ukraine would help standardize care and allow for defined scope of practice to assist in the provision of PCC. While this may be less of an issue for NATO-affiliated organizations, the need for combat medics to provide PCC in the LSCO environment would represent a new paradigm in the traditional scope of practice for these individuals.

Prolonged casualty care

PCC expertise is required by all providers at the frontlines because of the tactical limitations to rapid evacuation, incidence of mass casualty events, and scarcity of trained forward surgical teams.^{8 9 32} Telemedicine is being used to sporadically improve clinical care due to PCC in certain settings.⁸ Doctrinally, NATO Role 2+ and lower are not designed to hold combat casualties for extended periods of time and have fixed amounts of blood products in their inventory. While the use of “walking blood banks” has been implemented with some success in certain situations over the last two decades and in Ukraine as well, the long-term reliance on such a strategy in any one setting could have negative implications for warfighting and the provision of medical care. This is of particular concern when the ratio of medical personnel to combat casualties is unfavorable, as is likely to be the case during LSCO.

Prehospital care data

A trauma registry is fundamental for improving care by using data for systematic analysis and trends to guide ongoing quality improvement, resource allocation, and policy change.^{33 34} A registry collects information related to the injury event, injuries, care, and outcomes across the entire continuum of trauma care. The Ukrainian Form 100 has the right data fields that represent the foundational basis of a registry. Without a registry, casualty care and clinical care improvements will continue to be based on anecdotal information and suffer from the absence of a centralized digital trauma registry that can be used to analyze casualty care data.^{33 34} US forces implemented the Department of Defense Trauma Registry (DoDTR) over the course of the conflicts in Iraq and Afghanistan. It is unclear that similar registries are available within all NATO member organizations. Further, it is unclear how effective entry in a DoDTR, or similar registry, will be in the setting of LSCO and an environment where the casualty numbers rapidly outpace available combat medical assets.

Limitations

As a qualitative study, these data represent the experiences of those individuals who were interviewed and cannot be generalized to all medical providers across all of Ukraine. The study volunteers interviewed represent their experiences in conflict-related trauma. This study does not represent views of non-conflict trauma systems. Interviewers were careful to explain there would be no material gain by participation in the study; however, respondents may have underestimated or exaggerated responses if they thought it would be in their interest to do so. Participants might present a more favorable view of themselves and their experiences given the ability to leave Ukraine and participate in conferences. Furthermore, because these respondents’ travel was paid for the conference attendance, respondents might unconsciously adjust their responses to align with what they perceive as the interviewer’s expectations or socially acceptable answers. Those who have the most combat medical experience (especially those on the frontlines) would not have the opportunity to leave and thus were not included in this study.

Conclusion

The results of this work highlight several areas of immediate improvement in Ukraine and facets that should be considered by senior leaders and military medical planners in nations with military forces that rely on the NATO echelons of care model. The experience in Ukraine shows that, in the face of LSCO, the effectiveness of Role 2+ and lower facilities degrades very quickly. Future attention should be focused on improvements to prehospital care training, safe and timely patient movement in the absence of air superiority, PCC, blood supply, and medevac coordination.³⁰ Early access to DCS and definitive surgical stabilization is vital to survival of casualties, especially in an environment where evacuation is constrained. This issue of efficient combat casualty care is likely best addressed by either enhancing the capabilities of current Role 2+ units or moving Role 3 facilities closer to the battlefront, with all the risks and benefits inherent to such strategies.

The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M Jackson Foundation for the Advancement of Military Medicine Inc (HJF), the DOD, or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US government. The funding agency played no role in the design, analysis, or interpretation of findings.

Data availability statement

No data are available.