Railway MEDEVAC 2024 Workshop

Why a Workshop on Railway Medical Evacuation?
What happens if we have to deal with a large number of patients and the risk of local overload of the national health systems in Europe at the same time? The catastrophic events that occurred recently in Europe, the Covid-19 pandemic and the war of aggression in Ukraine, have been accompanied by the return of pictures of medical treatment facilities in Europe overwhelmed by large numbers of patients and requiring bulk transfer of patients towards less affected medical facilities and, in the case of Ukraine, safer areas. Unfortunately, prospective analyses warn us that our European societies should prepare for more frequent events challenging our health systems in the future, linked to increasing security threats, risks of catastrophes (in particular due to more frequent extreme weather events) or outbreaks of pandemic-prone diseases. As a result, there is an increased necessity to move large numbers of injured or ill patients over long distances while maintaining a high level of medical care during the transport, which has led to a resurgence of medical evacuation trains. Due to events like the Covid-19 pandemic or the war in Ukraine, nations in a state of emergency had to reinvent, solely within a national frame, railway medical evacuation (MEDEVAC) assets that could be deployed on short notice to address specific emergency situations. Those situations highlighted the need for the European nations to increase their preparedness for the coordinated movement of large numbers of patients as well as the need to develop assets for the use of railway for the transport of patients in addition to the limited and mostly airborne existing capabilities.
The MMCC-E has been working on patient flow management in Europe in situations of peer-to-peer large-scale conflicts, especially in case of an activation of the article 5 of the North Atlantic Treaty (Art. 5 situation). During its last major exercise, Casualty Move 2023 (CAMO 23), which was conducted in Tartu, Estonia, in April 2023, the MMCC-E already considered the large-scale use of trains to move wounded and sick soldiers across Europe, crossing borders with groups of multinational patients that needed to be retrieved from the medical treatment facilities in the battle zones of the frontier states in order to provide them with appropriate medical care in safer areas. This would also prevent an overload of the medical support system and allows for the proper medical management of a constant flow of patients at the tactical level. Along with other considerations, the use of trains for that purpose was underpinned by the enemy anti-access/area denial capabilities in the area of operation and, as a result, the restriction of the use of air assets. A total of 22 “virtual” trains had been used during the 4 days of this table-top exercise, allowing for the movement of several hundred of patients each day. Yet, those railway MEDEVAC capabilities remain to be developed in a way that enables their use in the multinational frame of a conflict resembling the CAMO 23 scenario, but also in case of large-scale disasters.
The MMCC-E was asked to organise and host a workshop about the medical and operational requirements for the use of trains for the medical evacuation of large numbers of patients across Europe, in particular in an Art. 5 situation. The intent of the workshop was to contribute to the development of the capabilities which are required to address the challenge of moving higher numbers of patients with the best possible onboard medical care and treatment results, using the lowest possible amount of medical resources and particularly medical personnel, which is already notoriously scarce in Europe. The ambition of this event is to initiate the development of a common approach between medical and railway experts (both civil and military) and, furthermore, support the standardisation and interoperability regarding railway MEDEVAC assets in the prospect of capability development.

“Train of Hope” HMET real MEDEVAC to UKR border and then to POL (source: HMET)

Scope and Organisation of the Workshop
The MMCC-E was tasked to address railway MEDEVAC from a medical, logistical and operational perspective. How should trains be used for MEDEVAC purposes? What are the minimum medical requirements (personnel, material)? What kind of trains should be preferably used for the transport of patients, and how could their movement be coordinated across Europe?
In order to address those questions, a 2-in-1 workshop was organised in Koblenz, Germany, from March 5 to 7 2024, focusing on medical issues during the first two days and on logistical and operational issues during the third day.
High-level civil and military experts from national, international or non-governmental organisations and academic institutions were invited to share their knowledge and experience about patient transport by train, management of railway systems, planning and execution of logistical support for military operations or the development of technical specifications for interoperability in railway transport. They used the opportunity of this workshop to exchange ideas in order to establish a common understanding of the requirements and challenges of railway MEDEVAC and set the stage for recommendations that could support the capability development of our nations as well as international or non-governmental organisations. A major assumption of the preparatory work was the necessity to consider civil-military dual use of railway assets that would most probably be operated by civilian organisations from both railway and medical fields. The use of train ambulances was explored under the perspective of the management of a large flow of civil and/or military patients in an Art. 5 situation, without excluding the implementation of railway MEDEVAC in a civil disaster response setting.
The workshop, organised as a hybrid event, gathered 50 civilian and military participants from 19 countries in Koblenz, while 35 persons took part remotely by video conferencing. 13 speakers presented their experience with regard to the recent use of ambulance trains, while some of them shared their expertise in railway transport regulation and management in Europe or in movement control and patient flow management under military authority, in particular in an Art. 5 situation. The participants exchanged their ideas in smaller groups – including virtual chatrooms –and during syndicate working sessions aiming at establishing points of consensus and points of disagreement on medical, technical and operational requirements for railway MEDEVAC. The syndicates were asked to discuss about criteria of eligibility for patients, on-board medical capabilities, ratio between medical personnel and patients, specifications of the carriages for the transport of patients, desirable type of rolling stock (locomotives and cars), required coordination and communication systems to allow for seamless handovers, cross-border transport and the takeover of patients using railway. Their findings were reviewed together in plenary assembly and will be processed and summarised in an upcoming report.

Promising Experiences of Train Ambulances, Challenges of Cross-border Railway MEDEVAC Implementation
The use of train ambulances is consubstantial with conflicts since more than 150 years and, for that matter, the development and use of railway for medical evacuations of wounded and sick patients preceded the invention of combustion engine and aircrafts. Railway MEDEVAC was largely implemented during the first and second world wars (WW) and fully integrated in the patient flow management of the belligerents. Whether using converted passenger carriages or carriages specifically developed for medical purposes, the ambulance trains and their use had to comply with requirements that are almost unchanged today. Ambulance trains made a notable comeback in Europe since a few years in connection with two crises affecting the health systems: the Covid-19 pandemic and the full-scale war in Ukraine. Although addressing two very different contexts and types of patients (contagious patients in intensive care during the Covid-19 pandemic, mainly trauma patients in Ukraine), trains proved to offer a valuable alternative to already existing MEDEVAC capabilities (road ambulances and aircrafts). Their ability to move 

"Train of Hope“ HMET equipment (source: HMET)

patients directly from one city centre to another quickly and on relatively short notice – close to the main hospitals –, regardless of the weather conditions, and their wide inner space and relatively comfortable conditions for healthcare provision onboard allowed to transport patients without noticeable worsening of their clinical condition. Furthermore, highly effective MEDEVAC assets could be developed and deployed in very short time (a few days) by converting passenger carriages into railway medical units providing a high level of medical care, also for intensive care patients. The feedbacks provided by experienced speakers from France, Italy, Poland and Ukraine all tended to demonstrate that train ambulances are a valuable asset for the management of crisis situations that require a fast transfer of high numbers of patients on long distances and on short notice, particularly during conflicts.
However, the recent examples of patient transport by railway were facilitated by their limited geographical extent; unlike transfers of patients by road or by air assets, cross-border medical evacuation by train has not been undertaken in Europe since the end of WW2. Whereas the use of trains as part of national crisis management within national borders is already achievable, technical and operational obstacles appear when trains have to cross borders. Due to different track gauges, electrification and signalisation systems that coexist in Europe, as well as a high number of players involved (railway operators, railway network managers, railway regulation authorities), planning and execution of cross-border train movements requires a high level of coordination. Harmonisation of railway procedures and systems is continuously increasing in Europe under the auspices of the European Commission, offering tools that could support the development and deployment of long-distance railway MEDEVAC assets across Europe. In an Art. 5 situation, part of the railway movement in Europe would be conducted under NATO responsibility and under the coordinating responsibility of the NATO Joint Support and Enablement Command (JSEC).

What are the Next Steps toward Railway MEDEVAC Capabilities?
In case of an Art. 5 situation, train ambulances should be integrated in an overall Reinforcement and Sustainment Network with a clear movement priority and a strong coordination with the military and civilian healthcare systems in order to achieve a smart dispatch of patients, taking into consideration their individual clinical needs and the healthcare capacities in Europe. The discussions during the workshop highlighted the need for a stronger international cooperation between the actors of both medical and railway fields. Multiple layers of coordination are required between – mostly private – railway actors, national and supranational military and civilian authorities and stakeholders. In order to prepare for an efficient use of railway for MEDEVAC, whether in conflicts or in response to civil crises, nations need to develop appropriate capabilities for the long-distance transport of large numbers of patients, including in need of intensive care or contagious patients. Carriages need to allow an easy and quick loading and handling of litter patients; appropriate electrical power supply and communication means (inner and external). The provision of water, sanitation and hygiene facilities, catering, accommodation and waste disposal is also mandatory for the sustainment of long-lasting patient transport, being cared for by medical personnel working rotating shifts. Locomotives ensuring the most flexible use of ambulance trains are to be prioritised. For that matter, diesel or, preferably, diesel-electric propulsion should always be given priority, allowing medical evacuation through non-electrified lines and ensuring secure electric generation of the medical devices in case of breakdown of the electric grid. Innovation in the medical and railway fields could support the development of more efficient railway MEDEVAC capabilities; however, the participants broadly gave their preference to low-tech, more cost-effective and robust solutions that could be developed easily at a broader scale. To some extent, ambulance trains could also be made fit for the transport of medical supplies to a battle zone or a disaster area in order to increase their flexibility of use.
Beside the use of trains in an overall trans-European bulk MEDEVAC system, the attendees also highlighted the need to getting a better common understanding of the setting and functioning of the medical hubs that would welcome and redistribute large numbers of patients. Several questions like legal issues or technical solutions for the exchange of patient data were noted during the discussions and should also be addressed in the appropriate arenas in time.
The development of such capabilities has better chances to succeed if European nations combine their efforts and agree on basic principles and requirements. Moreover, they should implement a modular approach to develop and deploy multinational medical railway units, collectively contributing to both the enablement of a bulk MEDEVAC system for an Art. 5 situation and the development of a European civil crisis response system including train ambulances. The European Union could support the devel- opment of such dual-use capabilities with the Directorate General for European Civil Protection and Humanitarian Aid Operations. Interoperable and standardised solutions and cooperative capability development would allow economies of scale and a more flexible use of ambulance trains. For an efficient deployment of ambulance trains across Europe, standard procedures should be developed and trained. Regarding the required rolling stock for which the participants foresee a possible competition in case of an Art. 5 situation, the attendees of the workshop agreed on the necessity to ensure a nation-independent granted availability of locomotives and coaches – belonging to private companies – for MEDEVAC purposes.

Conclusion
This workshop represents the first brainstorming about railway medical evacuation in Europe since 35 years and aims at feeding the current reflection about bulk MEDEVAC in the frame of a large-scale operation in Europe. On request of its participating nations, the MMCC-E gathered experts from the fields of medical evacuation and railway transport in order to initiate a comprehensive thinking on the topic and support the development of related concepts and capabilities. The strong commitment of the nations and international or non-governmental organisations in this event reflect the increasing interest of the medical community for the ambulance trains. These trains proved to be useful tools of medical crisis management during the Covid-19 pandemic and are currently used for the transport of wounded soldiers in Ukraine almost on a regular basis.
During the Railway MEDEVAC workshop, a lot of valuable experiences and expertise were shared between specialists from diverse horizons and background, allowing fruitful exchanges and a thorough exploration of the topic. The attendants came to consen- sual conclusions on many points regarding the way railway patient transport should be achieved as an element of response to a major crisis with a high number of patients to be evacuated. The workshop provided very interesting results that will be processed and summarised in a report that can further feed the reflection on railway MEDEVAC and support the development of capabilities. Beside appropriate medical material, personnel and rolling stock, the implementation of cross-border railway MEDEVAC also requires a higher level of international coordination in order to achieve cross-border movement in a multinational environment. The workshop helped developing a comprehensive awareness of the subject, however, some questions remained unanswered, e.g. particularly questions concerning the civil-military interaction of railway movement control in Europe.
The topic of railway MEDEVAC will need further meetings, discussions and cooperative efforts in the near future to pave the way towards the required capabilities and operational framework. For that matter, the MMCC-E will remain committed to supporting its participating nations, NATO and the EU, and carry on creating synergies for the improvement of the medical support of our armed forces.

Author:
Colonel (OF-5) Dr. David Lacassagne (FRA)
MMCC-E Deputy Director EU Matters
Andernacher Strasse 10056070 Koblenz
Email: MMCCPAO@bundeswehr.org

Date: 11/04/2024

Source: European Military Medical Services 2024