The experiences of the missions in Iraq and Afghanistan have transformed military medicine, and helped develop the skills of medical personnel. Now it is time for another lesson – the war in Ukraine has shown that rescuers must focus their particular attention to prolonged care of the injured patient.

Polish troops spent nearly two decades on missions in Afghanistan, from which they emerged richer in knowledge and practical skills in virtually every military field. This was particularly noticeable in battlefield medicine. Among other things, a mission-proven medical security system was introduced, which stipulated that a wounded soldier transported aboard MEDEVAC helicopters must be taken to the care of qualified personnel, including anesthesiologists and surgeons, as soon as possible. The principle of the so-called "golden hour" was adhered to, as this was the amount of time it usually took to transport a casualty from the battlefield to the hospital. In the case of special operations forces, there was even talk of medical evacuation lasting only 40 minutes. The solutions developed at that time pay off in the army to this day.

Afghanistan is a closed chapter for the Polish army, but not far from our borders there is an ongoing armed conflict of an entirely different nature. The heavy fights in Ukraine show the difficulties their forces have with medical support for the fighting subdivisions. The Ukrainian armed forces lack well-trained medics, there are serious problems with evacuating the wounded from the battlefield. There is no possibility of using MEDEVAC helicopters, and due to artillery shelling, evacuation by land takes a long time.

Polish rescuers follow what's happening across our eastern border, and point out that it is time to revisit the rules for tactical care of casualties in combat conditions. They suggest abandoning solutions proven in Afghanistan, such as evacuating the injured by air, and looking for alternatives. After all, if there was an armed conflict in Poland, our army and our medics would face similar challenges as their Ukrainian counterparts do now.

Milestones

The guidelines on casualty care on the battlefield, valid in the Polish Armed Forces, i.e. the TCCC (Tactical Combat Casualty Care) concept, was implemented by the US Army at the end of the 1990s, and later became a standard throughout NATO. The Committee for Tactical Combat Casualty Care was created to develop recommendations on medical care of casualties in combat conditions. “It doesn’t matter if it’s Afghanistan, Africa, or Ukraine. There are many different injuries, but the most popular reversible causes of death on the battlefield remain the same – massive hemorrhages, pneumothorax and airway obstructions,” says Maj Anita Podlasin, PhD, Head of the Education Department at the Military Medical Training Center, adding: “There is an old saying that medicine thrives during war. Today, due to military missions, medical rescuers concentrate on life-threatening cases.”

Experience gained during missions in Iraq and Afghanistan has contributed to the fact that our soldiers now have modern medical equipment, such as individual medical packs and tourniquets. They also know the importance of self-help or help offered to a wounded fellow soldier on the battlefield. “Now it’s time for the lesson learned in Ukraine. I expect the TCCC Committee will soon update the rules of patient management and issue new recommendations. It has become clear that it’s difficult to adhere to, for instance, the medical evacuation time regimes implemented by NATO,” emphasizes Maj Podlasin.

Damian Duda, the founder of W Międzyczasie – a volunteer group of combat paramedics operating in Ukraine, a university lecturer and one of the leaders of the pro-defense organization Academic Legion, confirms that evacuation of the wounded is a serious challenge for the Ukrainian Armed Forces. “It’s impossible to use rescue helicopters, the injured are evacuated only by vehicles. It’s good when a given unit is equipped with armored vehicles, but most of the time the injured are evacuated from the front line in pick-ups,” he explains. Thus, an injured person usually arrives at the stabilization point after two or three, and often even five or seven hours. This falls outside the NATO standard of the aforementioned 60 minutes, and at the same time severely impedes the stipulated procedure.

In Ukraine, Duda, together with paramedics from W Międzyczasie, deals with the evacuation of injured soldiers from the so-called zone zero, i.e. places of direct clashes between Ukrainian and Russian forces. As recently as several weeks ago, he supported units fighting with the occupiers in Donbas, in places such as Soledar. Earlier, he had operated in the Kherson Oblast, in the south of the country. The volunteers support the Ukrainian medical security system, according to which the soldiers wounded in action are evacuated to stabilization points located several hundred meters or several kilometers away, usually in the basements of abandoned buildings. They are staffed with doctors, surgeons and anesthesiologists, as well as nurses. Stabilization points can be compared to a field hospital organized, for instance, for Polish soldiers at Ghazni base. The next, higher level of medical support for Ukrainians are civilian hospitals. However, it takes time to reach one of them.

Next Level of Involvement

The prolonged time of casualty evacuation opens a discussion on training soldiers in the subject of Prolonged Field Care (PFC). We can talk about PFC when the wait for medical evacuation lasts from several up to over a dozen hours. Such skills have so far been reserved mainly for special operations forces, based on the guidelines formulated several years ago by Col Sean Keenan, Command Surgeon for US Special Operations Command Europe. Referring to the tasks performed by Americans in remote locations around the world, he concluded that PFC courses should be the main direction for the development of US special forces medics.

Polish special operations forces, benefiting from the American experience, also understand the need for PFC training. However, medics from other branches of the armed forces should also be trained on prolonged patient care, even more so that acting according to PFC rules is not easy. Grzegorz, a medic of the Army Commandos Unit (Jednostka Wojskowa Komandosów – JWK), says that it requires knowledge and skills in many different medical specializations. “These include mainly intensive care, surgery, pain management, but also nursing care, patient nutrition, and even psychological support.” He adds that in PFC, the medic has to be a paramedic, a nurse and a doctor in one, but also have good team management skills, and be able to plan and divide tasks between his team members. “During the war in Ukraine, the PFC procedure has become a rule, as getting a patient under the care of medical personnel within an hour of an incident happens very rarely,” explains Damian Duda.

Training medics from all types of armed forces in PFC would require a systemic approach. First and foremost, they would have to be skilled in providing TCCC, and only then the best of them can be trained on an advanced level, in prolonged field care. “We should implement the rule that there can be no PFC without TCCC. Providing proper care immediately after the incident is critical to the subsequent management of the patient. If, for instance, a unit medic or a team member puts on a tourniquet in a wrong way and thus fails to stop the bleeding, the wounded soldier will die before getting a chance to receive PFC. Therefore, TCCC is always the foundation for medics,” says Maj Podlasin.

Damian Duda, sharing his experience from Donbas, admits that the level of training among military medics in Ukraine varies from person to person. “Many experienced soldiers are familiar with NATO guidelines on TCCC and are very skilled in providing combat care. However, many people are volunteer medics, and some have joined the army very recently and are still learning,” says Duda. According to the implemented rules, the combat medic (not paramedic) training lasts three months and ends with an exam. Unfortunately, due to staff shortages, soldiers train their TCCC skills also in combat conditions, which does not make it easier to provide care to the injured. Even more so that, as the Polish volunteer medics report, there are many various types of combat injuries and a multitude of patients that require immediate care.

New Programs

According to military medics, the experience gained by the Ukrainians must be applied as soon as possible to modify Polish training programs. Priority must be given to preparing as many soldiers as possible in medical self-help and peer assistance, as well as PFC training. “We would like to train all soldiers in saving life on the battlefield. CLS [Combat Life Saver] courses have been organized at the center in Łódź for many years. Such skills are also acquired by officer cadets, around 1,000 students a year. In order to further increase the potential of combat medics in our army, we decided two years ago to train soldiers outside the center, at their mother units,” explains Maj Podlasin.

The Military Medical Training Center has already prepared over 200 paramedics with instructor qualifications to run CLS courses all around Poland. With a view to raising the qualifications of the medical personnel, this year the center will also launch new courses on PFC, which will be organized regularly. “In the middle of the year, we’re going to train the first group of medics on PFC. We are aware that PFC is an absolute must,” emphasizes the Head of the Education Department at the Military Medical Training Center.

We can also expect changes in the special operations forces. JWK is currently implementing a new training program. “We want our operators who are combat medics and have completed a course on advanced first aid to develop. We need fully qualified medical rescuers,” says Grzesiek of JWK. “We have to make sure that during special operations, the soldiers who are separated from own forces are well protected,” he adds.

JWK has prepared a multi-level plan of educating their operators. Already during basic training, all soldiers are obliged to attend advanced first aid (KPP) courses, followed by CLS. Later, the people who are to work as medics in combat teams, attend specialist, medical classes for several weeks. They observe and assist at hospital emergency and intensive care wards or in the prosectorium. The next phase of learning is emergency medical service studies (with additional funding from the Ministry of National Defense) and a six-month specialist training organized by JWK.

“We have just launched a pilot advanced course for the first group of our medical rescuers. Operators will practice in emergency medical service teams, in intensive care units, hospital emergency wards, they will work with patients, learn telemedicine. They will specialize in the assessment of the patient’s condition and they will know what to do in the event of prolonged medical care. We require our medics to possess a universal set of skills. They must know how to handle a patient during quick evacuation, as well as a several-day-long, or even a two-month-long isolation,” explains Grzesiek of JWK. The unit also provides its soldiers with trainings that allow them to maintain their skills. The commandos have at their disposal a medical simulation room equipped with state of the art phantoms on which they can practice their skills.

Step Outside the Box

The experience of the Ukrainians prove that the army should also train soldiers in using improvised means of medical evacuation. “If war came to Poland, we might not have MEDEVAC helicopters. That’s why I think every unit should implement CASEVAC [casualty evacuation] scenarios in their trainings,” emphasizes Damian Duda. This type of evacuation assumes taking the injured away from the battlefield without using medical vehicles prepared for this purpose or access to special medical care. It can be trained using, for instance, various off-road vehicles or vans which the Polish Armed Forces are equipped with.

Medical rescuers unanimously agree that the knowledge gained in Afghanistan should be treated as a sort of foundation, and the TCCC skills must be maintained on a continuous basis. However, a year of a very brutal war in Ukraine proved it is time to step outside the box, because the procedures that worked at the foot of Hindu Kush might not necessarily work during a conflict with a well-armed and trained adversary in East-Central Europe. 

The aid that Poland has been providing to Ukraine is not only military and humanitarian, but also includes training. We teach Ukrainian soldiers operating military equipment and battlefield medicine.

Sharing Knowledge

The National Security Bureau coordinates the training of medics of the Ukrainian Helicopter Emergency Medical Service (HEMS). At the end of 2022, Ukrainians spent 10 days in Poland, training together with a Medical Air Rescue team. The medics practiced team management within HEMS, in-crew communication and medical conduct in the event of, for instance, cardiac arrest in a patient on board of a helicopter, or intubation. Helicopter medical rescuers also trained procedures implemented in the event of an emergency during flight, and evacuating a patient from a warfare zone.

This was not the first initiative of such kind. In 2022, specialists from the Medical Air Rescue and the Medical University of Warsaw, organized in Ivano-Frankivsk a series of intensive trainings on combat casualty care and life-saving procedures in adults and children. Within the project, 550 doctors and medical assistants underwent training. 50 specialists from that group completed an instructor course. Minister Jacek Siewiera, the Head of the National Security Bureau, announced that in the future, Ukrainian medics will take part in a series of specialist trainings in Poland on treating heavy burns, battlefield injuries and traumatology.

Ukrainian medics are also supported by the University Hospital in Cracow. The medical rescue team members from the Lviv oblast took part in classes taught by doctors and rescuers of the hospital Therapeutic Early Intervention System and the Rescue Medicine and Disaster Casualty Center. One of the teachers was Tomasz Sanak, PhD, a medical rescuer and an educator, once a participant of military missions in Afghanistan. “We focused on the so-called reversible causes of cardiac arrest. We talked about rescue management of an armed conflict casualty. We taught pre-hospital conduct in the event of hemorrhage, respiratory tract obstruction and pneumothorax,” he explains.

Former commandos from Lubliniec, Łukasz Sikora and Krzysztof Pluta, also share their knowledge with our eastern neighbors. “Volunteers and professional soldiers from the Lviv volunteer medical battalion asked us to organize a training,” says WO (Res.) Sikora, a paramedic. The specialists, who have been dealing with battlefield medicine trainings for many years, organized for the Ukrainians an advanced TCCC MP/CTM (Medical Provider/Combat Trauma Management) course, directed to medical personnel. Łukasz Sikora emphasizes that professional medical personnel should also learn about improvised solutions. “They should know how and from what material they can make tourniquets, what to use to successfully stop hemorrhages, how to secure the pelvis of a victim after an injury. This knowledge is crucial in situations where you don’t have access to professional medical supplies, which happens very often. We also practiced removing airway obstructions using all available methods, including cricothyrotomy and chest drainage. We talked about administering blood to patients in hypovolemic shock, pharmacology used on the battlefield, protecting burns and medical evacuation,” enumerates the paramedic. The Military Medical Training Center in Łódź also organizes trainings for Ukrainian medics as part of the EU’s EUMAM mission.