UKRAINE MEDICAL LESSONS

LEARNED REPORT

By MEDCoE Lessons Learned

Article published on: June 1, 2025 in the The Pulse of Army Medicine June issue

Read Time: < 13 mins

Banner source: U.S. Army National Guard by Sgt. Samantha Hill

DISCLAIMER: This document presents current information as of March 2025. Many of the practices, methods, and challenges described herein are specific to the units, regions, and operational conditions reported in the papers, articles, and briefings drawn during data collection over the past three years. This analysis used Artificial Intelligence to assist in summarizing portions of the documents. This document provides information for comparative purposes. It does not represent the entirety of the Ukrainian medical system nor the official policies and procedures of the AFU.

Since Russia's initial incursion into Ukraine in 2014, the Ukrainians fought counterinsurgency in its eastern Oblasts or Provinces. The conflict escalated significantly with Russia's full-scale invasion in February 2022, leading to widespread devastation across Ukrainian cities, towns, and villages.

In the ensuing years, both Russian and Ukrainian forces have adapted their strategies and tactics, resulting in a dynamic and protracted war. The conflict has resulted in substantial casualties and a humanitarian crisis, with both sides experiencing heavy losses. The U.S. and the. The protracted nature of the war underscores the challenges in achieving a decisive resolution, as both Russian and Ukrainian forces continue to engage in intense ground combat across various fronts.

The extensive use of drones by both sides has introduced a new dimension to the warfare, providing intelligence, targeting data, and engaging in direct attacks, thereby complicating traditional combat operations and creating a technology exclusion zone.

Observations from the Russo-Ukrainian War provide crucial lessons for U.S. Army Medicine preparing for Large Scale Combat Operations (LSCO). The conflict highlights the need to protect medical assets from direct attack, given frequent targeting of medical assets. Prolonged care is essential due to extended evacuation times, requiring improved training and resources for medics. Additionally, reassessing tourniquet use, implementing walking blood bank procedures, and addressing the erosion of amputee care are crucial skills. Allied vaccination gaps and the rise of disease non-battle injuries like hypertension and diabetes among older combatants pose further challenges. Finally, field sanitation requires renewed emphasis. These observations underscore the need for adaptable Tactical Combat Casualty Care (TCCC) guidelines and comprehensive medical preparations for protracted conflict in a LSCO environment.

FROM OBSERVATIONS TO RECOMMENDATIONS

This document highlights 8 observations from the Russo-Ukrainian War that have implications for the U.S. Army Medicine in preparing for future Large Scale Combat Operations.

The 8 observations are:

1. The war in Ukraine highlights the need for the protection of medical assets.
2. The war in Ukraine highlights the need for resiliency training and a rotational deployment strategy.
3. The Ukrainian conflict identified a significant need to proactively reassess and convert tourniquets.
4. Ukrainian Implications for Evacuation.
5. Lack of portable imaging capability at Role 1.
6. Army Medicine needs to enhance medical proficiency at echelon.
7. The Russo-Ukraine War created numerous strategic implications for the U.S. and its European Allies.
8. New Disease Non-Battle Injuries (DNBIs) challenge medical systems.

Observation 1: The war in Ukraine highlights the need for the protection of medical assets.

The World Health Organization reports 1,986 attacks on Ukrainian health care infrastructure and 428 attacks on medical evacuation vehicles between 24 February 2022 and 23 April 2025.¹ When adversaries disregard the Geneva Conventions, medical units need to adopt practical procedures to protect themselves.

The proliferation of drone technology for intelligence, surveillance, reconnaissance, and attack impairs the ability to achieve protection through concealment for small teams operating throughout Ukraine. The constant threat of UAS surveillance and attacks forces medics and patients to remain vigilant, complicating medical operations and increasing stress levels.

Source: Author-generated image using ChatGPT.

Recommendations: As Army Medicine updates its doctrine and tactical guidance, the doctrine must adequately address medical battlefield survivability. The Army medical forces must integrate MEDEVAC and CASEVAC planning efforts with the Protection warfighting function through appropriate Boards, Bureaus, Centers, Cells, and Working Groups (B2C2WG).

Observation 2: The war in Ukraine has highlighted the need for resiliency training and a rotational deployment strategy. The Armed Forces of Ukraine have signaled a need for Combat and Operational Stress Control (COSC) training within their formations. As the war passes its third-year mark, and with the large number of casualties sustained, the members of the AFU may be experiencing battle fatigue.

The omnipresence threat of drones as a weapon system and artillery fire contribute to a heightened sense of vulnerability among combat troops. The continuous sound and frequent sightings of UASs may create a sense of perpetual unease, often inflicting significant psychological strain on personnel. Furthermore, the presence of friendly drones that deliver essential supplies, adds a layer of complexity to an already tense environment. This dichotomy can be challenging for forces to navigate, as it requires soldiers to differentiate between hostile and benign UAS activity, thereby amplifying the psychological and operational burden.²

Recommendation: Army Medicine should integrate the lessons we are observing in Ukraine to prepare and treat Soldiers for the devastating psychological effects of sustained warfare. The AFU have demonstrated the need for commanders to deploy COSC assets far forward and provide essential support to troops, regardless of the operational tempo. Army Medicine should give all Soldiers the aids and the coping skills to endure a protracted LSCO fight.

Observation 3: The Ukrainian conflict identified a significant need to proactively reassess and convert tourniquets. In scenarios with prolonged evacuation times that delay casualties from reaching trained medical personnel, self-aid and buddy-aid are the primary forms of immediate medical intervention. Delayed evacuation and prolonged use of tourniquets are resulting in higher morbidity and mortality cases. Additionally, improper application of tourniquets may account for another risk category.

Recommendation: The U.S. military healthcare system needs to emphasize reassessment and conversion of tourniquets, especially with prolonged care. The Committee on Tactical Combat Casualty Care is actively working on this matter. During the recent wars in Iraq and Afghanistan, the U.S. evacuation times were relatively short. In general, combat medics had to manage casualties for a short duration; therefore, casualty reassessment may not have been a critical task in most situations.

However, in a LSCO prolonged care scenario, medical personnel will need to reassess their casualties to include reassessing tourniquets. The Army should teach tourniquet conversion at the lowest level.

Observation 4: Ukrainian Implications for Evacuation. Twenty years of counterinsurgency (COIN) operations diminished our use of ground evacuation. Air Ambulances flew directly to the Point of Injury (POI) during COIN operations. The timely evacuation was not the only contributing factor to U.S. military's low died of wounds rates during COIN operations; the proximity to world class medical treatment was the other key factor. With Ukraine, the operational environment denies both factors³ and complicates the outcome of the Wounded in Action soldiers AFU experiences per day.⁴ These challenges have challenged the AFU to explore and exploit other capabilities for evacuation.

Recommendation: Army Medicine’s modernization efforts need to bridge the gap from the frontline to as far forward as Air Ambulances can operate. Additionally, the observations from Ukraine suggest a need to experiment with and invest in robotics, unmanned, and autonomous ground and air systems dedicated to evacuation.

Observation 5: Lack of portable imaging capability at Role 1. A portable ultrasound device is an essential diagnostic tool that enhances medical capabilities in combat zones by providing real-time, non-invasive imaging. Its portability, speed, and versatility make it invaluable for triage, diagnosis, and guiding procedures in resource-constrained environments.⁵

Recommendation: Utilize diagnostic equipment, such as X-ray and ultrasound machines, closer to the front lines to detect and identify serious injuries earlier and more effectively, enabling timely and appropriate treatment to improve patient outcomes.

Observation 6: Army Medicine needs to enhance medical proficiency at echelon. The ability of a critically wounded personnel to reach damage control surgery within an hour (also referred to as the “golden hour”) during COIN operations is no longer a feasible expectation in a LSCO environment. As stated earlier, the operational environment prevents the rapid evacuation of the wounded. By providing comprehensive, enhanced, and extended care across echelons, the AFU preserves valuable resources by reducing the demand for immediate evacuation and evacuation-related risks while enhancing the chance of survival and recovery for their personnel.⁶

Recommendation: Provide enhanced medical care across each echelon/role of care from combat medics at the POI through and to rehabilitative Role 4 centers to facilitate rapid recovery, rehabilitation, and return to duty of injured Soldiers.⁷ Increase Training Equipment and Supplies for Medics and Combat Lifesavers. Facilitate the parallel increase in training equipment and supplies to match increased operational requirements to enable effective, enhanced training.⁸

The Army should train medical personnel on the prolonged care-approach and emphasize the importance of comprehensive, extended field care in enhancing patient outcomes and preserving resources.⁹ The Army should develop and implement protocols for continuous monitoring, treatment, and assessment of wounded personnel to ensure their condition does not deteriorate before evacuation.¹⁰

The Army should equip those providing prolonged care with advanced medical technologies, such as point-of-care ultrasound and telemedicine capabilities. These medical technologies can enable real-time consultation with more specialized medical providers.¹¹

Observation 7: The Russo-Ukraine War created numerous strategic implications for the U.S. and its European Allies. Since the full-scale invasion of Ukraine in 2022, the U.S. and its European Allies have provided a significant amount of support to Ukrainians. According to Direct Relief, more than 2,480 tons of medical aid have been deployed.¹² Fifteen NATO countries are providing or supporting medical training for All Service Members, Combat Lifesavers (CLS), and Combat Medics. In 2024, these NATO countries trained personnel in CLS, CLS Instructor, Combat Medic, and Combat Medic Instructor courses.

Recommendation: The Russo-Ukraine War necessitates a sustained, multinational medical support structure for Ukraine, encompassing refugee care, hospitalization, and medical training. This long-term strategy must address both the ongoing conflict and the post-war recovery, including psychological trauma support and rehabilitation services for Ukrainian soldiers and civilians.

Observation 8: New Disease Non-Battle Injuries (DNBIs) challenge medical systems. Historically, the Ukrainian conflict involved DNBI issues such as diarrheal diseases, respiratory infections, trench foot, lice infestations, and nicotine withdrawal symptoms. Recent additions to the DNBI are due to frontline personnel of a more advanced age. Significant numbers of older combatants live with chronic disease, and the inadequate access to treatment and medication exacerbates their conditions. These DNBIs include hypertension and diabetes.¹³

Recommendation: Optimize medical logistics and supply chains to ensure a steady supply of essential medications and medical equipment. Implement health education and awareness to promote self-management among personnel. U.S. dental officers may need to be proficient in oral surgery and prosthodontic care.

Conclusion: The Russo-Ukrainian War has provided a stark and invaluable glimpse into the realities of modern LSCO and their profound implications for military medicine. This analysis, drawing upon a range of sources documented in JLLIS, reveals critical vulnerabilities and underscores the urgent need for adaptation within U.S. Army Medicine. The widespread use of drones to target and engage, coupled with the blatant disregard for the Geneva Conventions protecting medical personnel and facilities, indicates a need for a paradigm shift in our approach to battlefield protection. We must prioritize the protection of medical assets.

Beyond the immediate challenges of battlefield treatment, this conflict has revealed the need for a more holistic approach to Soldier health and well-being. The psychological toll of sustained combat, exacerbated by the constant presence of attack drones and artillery fire, necessitates increased investment in resiliency training and robust mental health support. Furthermore, the challenges faced by the AFU in managing tourniquet application underscore the need for continuous reassessment and refinement of TCCC protocols, ensuring they remain relevant and effective in the face of prolonged care.

Finally, this analysis highlights the importance of interoperability and collaboration with allied forces. The lessons learned from the Russo-Ukrainian War are not merely observations; they are imperative calls to action. By proactively incorporating these insights into our Doctrine, Organization, Training, Materiel, Leadership & Education, Personnel, Facilities, and Policy (DOTMLPF-P) domains, we can enhance survivability and optimize the care of our Soldiers in future LSCO environments, ensuring that Army Medicine remains ready and resilient in the face of any challenge.

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