Large Scale Combat Operations and far forward Damage Control Resuscitation: observations of Ukraine

Background
Over the past three decades and following the Global War on Terror (GWOT), the nature of warfare has undergone significant transformation, demanding an equivalent evolution in military medical care to reduce preventable morbidity and mortality. In Large-Scale Combat Operations (LSCO), especially against the backdrop of the GWOT and the ongoing conflict in Ukraine, there is a critical need to rapidly adjust Clinical Practice Guidelines (CPGs); indeed LSCO has challenged much for war and medicine alike.
The GWOT, which employs Counterinsurgency Operations (COIN) tactics, typically involves a large group of medics attending to a single patient. In contrast, LSCO scenarios often feature a single healthcare provider managing care for a large group of patients. By revisiting historical conflicts and analyzing current military engagements, a rapid yet comprehensive understanding of the advancements and challenges in military medicine, particularly through applications from the Ukraine experience, yields clear best practices and paths forward to reduce preventable morbidity and mortality.
The focus on blood transfusion protocols most notably the colossal need for universal donor O negative blood and the need for a new Low Titer O Whole Blood (LTOWB), closer adherence to established CPGs, and Tactical Combat Casualty Care (TCCC) guidelines illustrate the vital role of medical care in improving soldier survivability and consequently, with core focus of Damage Control Resuscitation (DCR) starting at Point of Injury.
Force lethality and operational effectiveness are directly proportional to access to prehospital best practices. The insights gleaned from frontline medical experiences in Ukraine offer invaluable lessons for enhancing NATO’s medical strategies and provide a clear path for Ukraine to benefit from and help reduce preventable morbidity and mortality. This review aims to bridge the gap in medical care, describe the complexities of modern battlefield environments, advocate for a unified approach to medical read- iness and combat effectiveness through access to blood and blood products, and encourage interoperability.

Introduction to GWOT/COIN and LSCO
The GWOT, a response to the September 11, 2001, terrorist attacks, brought about expeditionary forces counterinsurgency operations with significant air medical and medical evacuation chains to higher echelons of care, ultimately reducing morbidity and mortality for clinically severe battle and nonbattle related injuries and illness. The strategic approach of the U.S. under the Bush Administration focused on military engagements in Afghanistan and Iraq. The human cost of these conflicts is highlighted, notably the displacement of approximately 38 million people and the estimated loss of over 4.5 million lives, spanning numerous countries, including Afghanistan, Iraq, Libya, the Philippines, Pakistan, Somalia, Syria, and Yemen; with geopolitical knock-on and third order effects reverberating to present-day medical readiness. During Operation Enduring Freedom (OEF) in Afghanistan, the U.S. suffered 2.219 total deaths and over 20.000 wounded. The Iraq War (Operation Iraqi Freedom; OIF) saw coalition forces numbers between 309.000 and 584.799, with 4.821 killed and over 32.776 wounded, not including contractors and other third-country nationals. These figures underscore the human toll of these conflicts and provide context for understanding the scale and severity of modern warfare.

Weapons and Trauma in Modern Warfare:
This section compares the weaponry and trauma types in the GWOT and current conflicts, such as the Russian-Ukrainian war. The evolution in the nature of injuries, with a shift from gunshot wounds to more complex injuries caused by artillery, anti-aircraft missiles, chemical weapons and antipersonnel blast trauma prevail. This evolution necessitates more complicated medical responses and evacuation procedures.

Comparison of OEF/OIF and the Russian-Ukrainian War:
Casualty rates and injuries across different military operations ebb and flow based on the threat and weapons systems deployed. Casualty rates and the nature of injuries have evolved, impacting medical treatment and evacuation strategies. TCCC has developed to overcome several of these changing trends. Advancements in TCCC, now an essential aspect of military medicine, has significantly improved survival rates on the battlefield. TCCC continues to be adapted to meet the changing needs of the battlefield, especially in the context of LSCO.
Medical personnel and team challenges in Ukraine are faced daily with both the capacity and capability to confront the clinical challenges of LSCO, emphasizing the dangers and difficulties of providing care and evacuation under enemy fire. Russian force doctrine specifically targets medical care points and personnel, making the Red Cross a significant target. When Geneva Convention protocols are not adhered to or otherwise insufficient in ensuring the safety of medical teams and patients, survival rates plummet.
The Russian-Ukrainian war that escalated significantly in 2022 posed numerous logistical and medical challenges, particularly in the field of blood transfusion services. This narrative aims to elucidate the difficulties faced, the innovative solutions imple- mented, and the lessons learned during this tumultuous period, using data and experiences from two critical phases from the echelons of care: the Forward Surgical Team (FST) operations and the Stabilization Point activities.

Forward Surgical Teams (June-July 2022)
Operations and Logistics
The FST was equipped with a substantial stockpile of blood products, including Fresh Frozen Plasma (FFP) of various blood types and Erythrocytes Concentrates. Approximately 80 units of blood products were stored, with facilities that included a large refrigerator with a freeze chamber for FFP and a stable electricity supply which was crucial for maintaining the cold chain required for blood storage.

Challenges and Disadvantages
Despite the relative logistical efficiency, the FST faced significant unpredictability in blood usage, which was compounded by the volatile situation at the contact line. Some deploying anesthesiologists were able to start central venous lines far forward but may have lacked the ability to offer blood or life-saving medications due to scattered supply lines. Blood products often arrived with only 5 to 7 days of shelf life remaining and had to be disposed of if not used promptly, leading to wastage. This wastage is completely understood of the system has an overwhelming abundance of blood supply from partner states, able to fill up at all Points of Injury and Stabilization Point areas, but it currently does not.

Adaptation and Innovation
As the Russian invasion continued, resources became even more strained. At the Stabilization Point, few had access to blood products stored on-site, although some could provide them; however, this led to the implementation of a “Walking Blood Bank” (WBB) out of necessity. This emergency response involved using blood from soldiers and medical staff who were mildly injured but could donate. Transfusion criteria were tightened, and blood was only used when absolutely necessary to stabilize patients with life-threatening conditions. Patient outcomes for this phase in the response cycle are not neatly captured.

Environmental and Operational Challenges
Stabilization Points/Casualty Collection Points lack any type of standard and can offer extremely high levels of clinical care, well beyond any NATO doctrine or a lack of standard. The Stabilization Point was closer to the line of contact, resulting in more challenging logistics and an unstable electricity, water and medical consumables and staffing supply. This severely impacted the ability to store and transport blood products safely; temperatures in Ukraine are very cold and very hot, making cold chain a challenge, not only for blood but also advanced pharmaceuticals, antibiotics and pain management.

Advantages and Strategic Implications
The use of the WBB, although a measure of last resort, highlighted the need for adaptability in combat medical practices; the evolution and dynamic aspects of LSCO require new and more adaptive models to better support force lethality on the battlefield. The absence of advanced diagnostic tools was compensated for by the innovative use of portable ultrasound devices, which facilitated immediate medical interventions such as the reinfusion of blood collected from thoracic injuries.

Large-Scale Combat Operations
This section addresses the nature of LSCOs, using the conflict in Ukraine as a primary example. LSCOs have not been experienced in Europe for over seven decades. These operations involve extensive violence extending over large geographic areas, stretching resources thin and directly impacting civilians. LSCO is not COIN and requires different approaches from a premedical and DCR perspective. LSCO impacts the entirety of society and all aspects of the economy, requiring every sector to support or face poten- tial obliteration.
Humanitarian organizations have jumped in to fill a void and offer a disproportionate level of care in the healthcare space while preliminary reports describe the environmental impacts across the region as abysmal; this was the case in Ukraine since 2014. Anecdotally, there is an overreliance on non-governmental organizations (NGOs) and the humanitarian sector for prehospital medical care in Ukraine leading to preventable morbidity and mortality.

NGOs in the Prehospital Space: Historical Background
Since the onset of conflict in 2014, Ukraine’s prehospital military medical system has increasingly relied on NGOs and volunteers to provide essential services. This dependence has become more pronounced with the escalation of war in 2022, highlighting significant deficiencies within the Ministry of Defense’s (MoD) capabilities in healthcare provision. The dynamics of this reliance, its implications, and the urgent need for enhanced clinical governance are best observed through patient outcomes and the great need for standardization across the Armed Forces of Ukraine (AFU).
The crisis in Ukraine beginning in 2014 exposed substantial gaps in military medical support, prompting an influx of volunteer efforts and NGOs to bridge these gaps. Organizations such as Medsanbat, Pirogov First Volunteer Mobile Hospital, Patriot Defense, the Hospitallers, and others have been pivotal in providing training, direct patient care, logistics, and procurement of medical supplies; the AFU did not learn from this experience and did not make adequate adjustments to its system to prepare for the next Russian onslaught. As the conflict expanded in 2022 across the entire country, these initial makeshift arrangements underlined persistent shortcomings and amplified the need at a logarithmic scale.
The escalation of war across Ukraine brought the healthcare challenges into sharper focus. New NGOs such as Migrant Offshore Aid Station (MOAS), GoDocs, Médecins Sans Frontières (MSF), Dark Horse, Road to Relief, The Weathermen, and several unnamed groups have played crucial roles in filling the immediate need. Sadly, with no oversight, no clinical governance, and no command or control structures, patient outcomes and sustainability were mixed. These entities stepped in to deliver medical services where the Ministry of Health (MoH) and AFU were overwhelmed.
The reliance on these groups raises critical concerns regarding clinical governance. The absence of structured oversight and integration with national health policies from the MoH and AFU risks the consistency and quality of care, and these groups do not share a command and control (C2) structure with the AFU, the MoH or any agency or body other than the specific units that tolerate their medical support in specific ‘salients’ and bridgeheads. Effective governance is essential for ensuring accountability, transparency, and the application of best practice standards in medical treatment for both military personnel and civilians. Moreover, the reliance on volunteer and NGO-led initiatives has led to a disproportionate level of care within the healthcare system, with preliminary reports indicating severe environmental impacts since 2014. This scenario suggests a fragmented healthcare response that has likely contributed to preventable morbidity and mortality.
Ukraine’s heavy reliance on NGOs and volunteer groups for prehospital medical care reveals a critical vulnerability within its military healthcare system. While these organizations have commendably filled a significant void, their role underscores the MoD’s and MoH’s inability to provide sustainable and uniform healthcare services during prolonged conflict; LSCO challenges the whole of society. It is imperative for Ukraine to develop robust clinical governance frameworks to integrate these efforts effectively, ensuring that all individuals receive the highest standards of medical care.

Medical NGOs and LSCO: space for both?
Some practical measures may be to simply establish a centralized clinical governance framework involving MoH and AFU to oversee all aspects of military medical care. Additionally, medical partnerships can be strengthened with NGOs through formal agreements that align with national health standards and strategies, some still in draft form. Lastly, through enhanced training and provision of resources for the AFU’s medical units, with clear C2 structures and engagement with NATO partners, this may help reduce AFUs dependency on external groups and offer a sustainable model. No matter the solution chosen by the AFU, the implementation of continuous monitoring and evaluation mechanisms to ensure adherence to medical standards and improve patient outcomes must be deployed and reviewed constantly; a challenging feat during active LSCO. The situation in Ukraine underscores the complexity of these scenarios, involving multiple states with varied roles and interests, and highlights the global repercussions.
Historical parallels exist, notably with the Tunisian battles of Sidi Bou Zid and Kasserine Pass during World War II, where the U.S. Army experienced heavy losses and significantly challenged casualty care. This historical comparison illustrates the evolution of warfare, emphasizing the intensity, chaos, and brutality of large-scale combat and its significant toll on military forces, and the requirement for more robust Point of Injury care and DCR, with access to blood and basic medical training apparent.

Russian-Ukrainian War and LSCO
A detailed analysis of the Russian-Ukrainian war rooted in quantitative data is not possible, and operational security concerns notably block the ability to share data. However, providing stark anecdotal evidence from the field on troop casualties and severity and case-study-level evidence of DCR/Damage Control Surgery (DCS) access and outcomes may offer a glimpse of the need for CPG alignment and access to blood further forward. Highlighting the immense scale of the conflict and the severity of injuries, distinguishing the nature of warfare in the GWOT era and the current LSCO in Ukraine.

LSCO and DCR
The critical roles of blood transfusion and CPGs are blatant in the evolving battlefield, and blood transfusion needs as the nature of warfare evolves, so too must the medical responses that are critical for saving lives on the battlefield. LSCOs present unique challenges that demand quick and efficient medical interventions, especially regarding access to blood transfusion protocols, blood products and CPGs, for both advanced and basic clinical practitioner/medical providers. In such high-stakes scenarios, DCR becomes a cornerstone of trauma management (after effective TCCC/Basic Life Support are rendered through self-aid and buddy aid), with the absolute best practice requirement of blood far forward as close to the Point of Injury as possible. The need for Low Titer O whole blood (LTOWB), universal donor and fresh whole blood becomes evident as compatibility of recipients allows, thus saving valuable time in life-threaten- ing situations and allowing the non-clinical provider to be able to fill the void and transfuse when needed. The DoD’s Walking Donor Program, a valiant effort with limitations, has been a staple in military medicine, allowing for the rapid collection and administration of fresh whole blood directly on the front lines. Soldiers, often comrades of the wounded or medical providers themselves, serve as immediate donors – the requirement for pre-deployment screening and other point-of-care retesting is required. While effective in small-scale engagements and for small teams with clear preventative strategies, this method faces logistical and practical challenges in LSCO and should be avoided when possible through a robust blood transfusion protocol. After donation, there is one patient with a unit of blood and one non-patient short a unit of blood that may need to fight or become wounded themselves. The scale of these operations often overwhelms the capacity of walking donor programs, as the demand for blood products exceeds the supply that can be provided by immediate donors; so plainly, walking donor programs are excellent, but completely inefficient for LSCO. Increasing European blood donation and funneling universal donor blood and LTOWB to Ukraine from NATO and NATO patterns can mitigate these massive needs for blood due to hemorrhage and life threatening trauma in the presence of LSCO.
This shortfall is highlighted in studies by Kakaiya et al. and Gaddy et al., which point to the need for more robust systems capable of supporting large-volume transfusions. Pushing blood and blood products far forward, and as close to the Point of Injury as possible, is absolutely required in order to reduce preventable morbidity and mortality.5 Cold chain and logistical management is a challenge, although examples in Ukraine have found real time and low tech solutions that must be shared across the NATO alliance that address this challenge.
The innovative spirit of Ukrainian warfighters is robust and exemplifies resilience, traits NATO needs and must learn from or face significant impacts to force lethality. The DoD Joint Trauma System (JTS) CPGs in response to the complex clinical requirements, mostly from COIN, and other small scale, hybrid experiences, crafted comprehensive CPGs that serve as a blueprint for implementing DCR (and several other aspects of military medicine) with blood far forward. Although these CPGs may not be directly updated due to LSCO in Ukraine yet, the set point offers clinicians and non-clinical providers a place to work from.These guidelines are meticulously detailed, covering everything from the use of tourniquets and hemostatic dressings at the Point of Injury to the administration of blood products. The “DeployedMedicine” application is the main repository for these great resources and through hard work and support by volunteers worldwide, they are now available in Ukrainian at tccc.org.ua. These CPGs, and the associated CPGs relating to other aspects of resuscitation and prehospital care, promote clinical best practices rooted in clinical evidence and led by subject matter experts. The DCR CPG represents a shift away from crystalloids towards a preference for blood products, a practice supported by research to reduce the risk of complications described in the lethal diamond as coagulopathy, acidosis, hypothermia, and hypocalcemia. These CPGs also address the importance of early intervention, particularly the administration of Tranexamic Acid (TXA) for patients at risk of significant hemorrhage prior to the first unit of blood transfused. This recommendation is based on evidence showing that TXA significantly reduces mortality when administered within 3 hours of injury. Of course, a renewed focus on calcium replacement therapy, hypothermia management, and prevention, among several others, are also documented in this comprehensive CPG, along with several other clinical aspects not presented here. New data from LSCO must be analyzed in more rigorous detail to see of this CPG, any all other trauma-related CPGs require adjustments or revisions based on any new threat/ risk and rooted in clinical evidence.
Additionally, the guidelines are adaptable, accounting for the variability in medical resources and conditions across the continuum of care from Point of Injury to definitive care facilities. There are several other CPGs within the series that focus on prolonged field care and advanced management of casualties in austere and remote environments, especially those patients requiring advanced Resuscitation and advanced surgical interventions far forward. How these CPGs will be updated based on the Ukraine experience and based on data are still under review.

The Imperative for LTOWB Far Forward
There is no question that the requirement of a massive transfusion protocol requires a significant amount of blood and blood products in order to reduce preventable morbidity and mortality. This requires addressing significant logistical, and medical resource challenges that make this difficult in LSCO. Strandenes et al.’s work underlines the critical role of LTOWB in emergency situations,6 especially in austere and semi-permissive environments typical of LSCO.
The forward deployment of LTOWB ensures that life-saving blood is available where and when it is needed most. This strategy is particularly important in circumstances where traditional supply lines are compromised, enabling medical personnel to provide immediate care without the delay that often comes with type-matching blood. Additional innovation in DCR in Ukraine can be seen with the deployment of second-generation Retrograde Balloon Occlusion of the Aorta (REBOA) for non-compressible junctional hemorrhage, deployed in Ukraine at far forward locations with mixed results requiring analysis and data sharing.
The use of drones for blood delivery have already been deployed in Ukraine; the scalability is a challenge given the operational environment and the prioritization of fighting. The “Trauma Hemostasis and Oxygenation Research” (THOR) Network has conducted several significant studies in support of blood and blood products with their use in resource-deprived and cold chain management in reduced clinical scenarios. The research is ongoing, but core principles of providing blood and blood products over crystalloid solutions in order to reduce preventable morbidity and mortality are manifest.
The exchange and health engagement activities in support of both Ukraine undergoing LSCO and that across the entire THOR Network must be shared, supported and further researched in both academic and practical terms across the entire AFU, and the NATO Alliance, to include the NATO bloodwork and Blood Panel and all affiliations. Some of this has started, it must be expanded upon and more direct levels of care and support need to be optimized directly from NATO and NATO medical structures. The time is now.

Lessons from Ukraine: Pioneering Prehospital Care and the NATO Alliance
The decade-long conflict in Ukraine has shed light on the practicalities of DCR under the duress of modern combat. The Ukrainian medical services’ innovative approaches to prehospital care, often under fire, have provided valuable anecdotal lessons in the delivery of emergency medical care in LSCO. At several locations across the forward line of troops, several Ukrainian surgeons, anesthesiologists, and other clinical staff have pushed DCR and even DCS as far forward as the Role 1 environment and even pre-Role 1, further forward, sometimes within only a few hundred meters from the “zero line” or “line-of-contact” and Point of Injury (collectively, referred to as Stabilization Points or Casualty Collection Points).
These lessons are now informing NATO’s strategies, as collaborative efforts are underway to integrate these experiences into a standardized DCR protocol across the alliance, as noted by Remondelli et al. This was also highlighted at the NATO Centre of Excellence for Military Medicine ‘marquis event’, Vigorous Warrior 2024, where NATO and NATO partner nations exchange ideas, promote live exercises about medical evacuation, and share lessons across the alliance. More needs to be done, more focus on Global Health Engagement (GHE) activities across the NATO alliance with our key ally and partner of Ukraine in support of state sovereignty, collective defense, and deterrence.

The Nexus of Medical Readiness and Combat Effectiveness: Force Lethality
The interdependence of medical readiness and combat effectiveness cannot be overstated. In the realm of LSCO, the capability to carry out effective DCR protocols, including the use of LTOWB, directly translates to maintaining a fighting force’s operational capacity and, consequently, its success on the battlefield. As medical capabilities increase and offer higher standards far forward, force lethality is directly proportional.
It is understood that weapon systems have been prioritized across the NATO alliance in support of the key ally found in Ukraine, although medicine and medical support must not be overlooked as we clearly understand the directly proportional relationship of Medical Readiness and force lethality. Medical preparedness is a strategic asset, as it ensures the sustainability of military operations and the survival of combatants.

Strategic Considerations
Although weapon systems have been prioritized by Ukraine’s senior leadership, GHE can run parallel and not drain resources or partner national support commitments or add any fatigue to communities or voting citizenry. GHE activities support and benefit force lethality. This is not only through DCR support and access to donor blood and blood products but also through additional GHE activities such as data exchange, training and mentorship support and several military medicine training courses and even direct medical care from frontline positions to tertiary rehabilitation care, and everything in between. Ukraine’s de facto military medical doctrine and capabilities have in several ways eclipsed that of NATO and NATO forces; these observations and lessons learned by Ukraine will be lost if they are not shared through GHE activities.
A series of critical questions are presented in this review, focusing on the adequacy of current medical training and strategies in LSCO, with a call to arms to support more engagement that encourages training, advising, assisting and enabling. These questions encourage a re-evaluation of current practices, pondering the need for enhanced training, equipment, and strategies to better address the realities of modern combat. More help must be sent and must be requested to best fill the gaps and address the needs. Owing to the delicate and highly politicized atmosphere in both European capitals and Washington DC, and most notably Kyiv, the requirement of open medical communication is needed, engendering a more open GHE debate, addressing urgent needs and removing red tape when needed.
This was seen most recently with the U.S. European Command (EUCOM) opening the “Security Assistance Group for Ukraine” (SAG-U), to better serve as a lightning rod for support to Ukraine and to help expedite and funnel support to areas of greatest need. This is a closed forum, highly classified and not for public or public-private partnership access, hindering its core objectives and greatly reducing access.

Discussion
The experiences from both Russia’s 2014 to 2022 war and the full-scale invasion of all of Ukraine from February 2022 to present day underscore the need for better planning and resources in combat zones and in the preparation cycle for LSCO, particularly concerning far-forward medical support in the form of DCR with blood administration and management. Recommendations for future operations include ensuring more reliable sources of blood products and enhancing the training of combat medics and non-clinician providers to effectively manage blood resources on the front lines, as well as non-clinical providers as to the basics of TCCC, blood and blood products.
The potential for establishing more robust protocols for emergency blood collection and transfusion, such as the institutionalization of LTOWB programs, may significantly mitigate the risks associated with blood shortages in conflict zones, as well the simple requests from partner states for support with universal donor and other blood products.

Conclusion
The insights gained from the examination of walking donor programs and the evolving nature of military operations culminate in a clear message: there is an urgent need for a unified approach to blood transfusion protocols, administration and evaluation of efforts to scale, in order to meet the demands of LSCO and reduce preventable morbidity and mortality.
The knowledge and experiences shared by frontline medical personnel, such as those from Ukraine, are invaluable in shaping a resilient and responsive medical framework; increased engagement and support is needed now through GHE activities. Ultimately, the goal is to develop transfusion protocols that are as dynamic and adaptable as the combat environments they are intended to serve in order to increase Warfighter lethality and reduce preventable morbidity and mortality.

Literature with the corresponding author.

Authors:
Sevan Gerard, MA, EMT-P, NCEE, General Secretary, Europe Chapter World Association for Disaster and Emergency Medicine (WADEM-EU)
Anna Onderková, MD, MSc, Charing Cross Hospital, Imperial College
London Healthcare Trust, London, United Kingdom
Michael Meoli, EMT-P, NAEMT TCCC Affiliate Faculty for Ukraine
Yaroslav Leshchenko, MD, Anaesthesiologist (Ret.) Armed Forces of Ukraine
Madelyn Banks, Navy Medicine Training Support Center,
Texas and CMO Atlas Global Aid C. Beato
Denys Surkov, MD, PhD, All-Ukrainian Resuscitation Council and Anesthesiology
and Intensive Care Department, St Nicholas Children’s Hospital, Lviv, Ukraine
John Quinn, MD, MPH, PhD, EMT-P, Emergency Medicine, East Surrey Hospital, Redhill, London, United Kingdom and Charles University, First Faculty of Medicine, Prague Center for Global Health, Prague, Czech Republic

Corresponding author:
John Quinn, MD, MPH, PhD, EMT-P
john.quinn5@nhs.net or john.quinn@lf1.cuni.cz

Disclaimers
The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army Medical Center of Excellence, the U.S. Army Training and Doctrine Command, or the Departments of Army, Department of Defense, or U.S. Govern- ment, the National Health Service (NHS) of the United Kingdom, Charles University, First Faculty of Medicine, the National Academy of the Ministry of Internal Affairs for Ukraine, the Ministry of Internal Affairs for Ukraine, the Ministry of Health for Ukraine, the Armed Forces of Ukraine (AFU) or any of affiliate bodies, agencies or supporting institutions, policy or viewpoints, past, present or future.

Date: 09/04/2024

Source: European Military Medical Services 2024