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increasingly challenge access to conventional medical resources, 1. All-Ukrainian Resuscitation Council and Emergency Medicine,
the prepared medic must be both practitioner and innovator. Kostiantynivska Street 75, Kyiv, 04080, Ukraine.
2. Tactical Medicine School, 184th Training Center of the Hetman
Improvised medicine represents a critical and underutilized Petro Sahaidachnyi National Ground Forces Academy, Armed
capability in the broader continuum of combat casualty care. Forces of Ukraine, Starychi, 81052, Ukraine.
As recent conflicts have demonstrated, medics frequently op- Casualty treatment and evacuation processes in the ongoing
erate in environments where commercial equipment is inac- Russo-Ukrainian War differ significantly from those envisioned
cessible or exhausted, requiring adaptive, evidence-informed in current NATO doctrine and as seen in recent conflicts in-
solutions to sustain life and limb. This presentation and work- volving NATO partner forces. In Ukraine, a high casualty rate,
shop discussed both the conceptual framework and practical strikes on evacuation teams and insufficient medical planning
application of improvised medical techniques, grounded in the often lead to reactive deployment of medical teams and extended
current scientific literature and operational experience. evacuation times. These times can range from 6 to 8 hours for
alpha category patients and up to 18–24 hours for bravo cat-
References egory. Shortage of Combat Paramedic Providers (CPP) means
Haque U, Bukhari MH, Fiedler N, et al. A Comparison of Ukrainian Hos-
pital Services and Functions Before and During the Russia-Ukraine that effective prolonged field care (PFC) cannot be provided and
War. JAMA Health Forum. 2024;5(5):e240901. doi:10.1001/jama this extended care typically exceeds combat medic/corpsman
healthforum.2024.0901 (CM/C) capabilities. Furthermore, tactical planning guidance is
Loftus A, Morris R, Friedmann Y, Pallister I, Parker PJ. Combat trousers needed for medical teams to deal with these challenges.
as effective improvised pelvic binders a comparative cadaveric study.
J Spec Oper Med. 2017;17(3):35–39. doi:10.55460/1P7E-2OL4 Since February 2022, the Tactical Medicine School (TMS)
has trained over 60,000 soldiers in TCCC. To address the
Therapeutic Processing of Shame above-mentioned challenges, the TMS developed a fast-track
and Moral Injury in Military Personnel training program where students are selected based on their
Caroline Diekmann, Department of Psychiatry, proficiency to learn and perform advanced interventions. The
Psychotherapy and Psychotraumatology, Military Hospital course teaches CM/C advanced airway management and ven-
Berlin, Berlin, Germany tilation, thoracotomy, IV/IO access and whole blood transfu-
sion as well as ultrasound diagnostics, basic monitoring and
During military deployments, German Armed Forces person- teleconsultation. A Medical Planning Module was developed,
nel are frequently confronted with events that challenge their providing planning and decision-making guidance for medical
personal moral values and beliefs. Exposure to civilian suf- unit leaders. Troop Leading Procedures (TLP) was used as the
fering, violence, and poverty, as well as the injury or death guiding process and the CMPEC acronym (Casualties, Mate-
of comrades or civilians, can lead to profound moral conflict. rials, Personnel, Environment, and Command & Signal) was
Such experiences may result in uncertainty about the legiti- developed for analysis of mission variables. It aids in the sys-
macy and meaning of one’s actions and in a destabilization of tematic planning and execution of medical missions, ensuring
personal values, described as moral injury. that relevant variables are considered and addressed including
The discrepancy between perceived moral transgressions and possible limitations and capability gaps. This information is
individual values often evokes shame, guilt, anger, and alien- then collated into an evacuation scheme depicting placement
ation, which may evolve into maladaptive coping behaviors of medical treatment facilities (MTFs) on a map overlay with
such as aggression, withdrawal, substance use, depression, or both time and distance between these points. The guiding prin-
suicidality. Evidence suggests that moral injury differs from ciples are the pathophysiology of the trauma patient and rele-
posttraumatic stress disorder (PTSD), despite shared symp- vant clinical timelines.
toms, such as avoidance, emotional numbing, and intrusive The module stimulates formation of multiple plans based on
thoughts. Whereas PTSD avoidance is driven by fear and likely scenarios as well as ensuring redundancy and backup
threat, avoidance in moral injury stems primarily from shame for critical parts of the operation. Continuous updating of the
and impaired self-worth. medical plan, guided by the TLP framework, is encouraged,
This study evaluated a 3-week, inpatient, values-based cog- after which a five-paragraph order is written and presented.
nitive-behavioral group intervention for soldiers with moral Feedback from approximately 100 students over five courses
injury. The program combined cognitive behavioral therapy, showed positive responses in terms of feeling more confident
acceptance and commitment therapy, spiritual counseling, and in planning, assuming responsibility of the medical team and
adaptive disclosure within an interdisciplinary setting. providing a structured approach to balance between the seem-
Using the Compass of Shame Scale, outcomes from an interven- ingly conflicting priorities for evacuation, treatment outcomes,
tion group (n=45) and control group (n=40) were compared. and safety.
Significant improvements were observed for Withdrawal, At- In conclusion, the persistent constraints of time, safety, re-
tack Other, and Attack Self subscales (P<.05). sources and personnel in the Russo-Ukrainian conflict demand
Findings highlight the central role of shame processing in moral a smart adaptation of TCCC training programs, to include
injury and support values-oriented interventions promoting for- competency-based selection and a tactical-level planning mod-
giveness, compassion, and reconciliation. Integration of such ap- ule. These “lessons learned” offer significant value to NATO
proaches into trauma care and leadership training may strengthen Allies in preparation for future conflict, especially when fur-
resilience and operational readiness in military personnel. ther development is done in collaboration. 1,2

Ukraine Lessons Learned: Advancing Combat Medic References
Proficiency and Planning Capabilities 1. Bongartz LG, Quinn V JM, Fransen CM, et al. A call for com-
Dr. Denys Surkov ; Igor Zbyshko ; Dr. Lennart Bongartz 1 prehensive reform of military medical planning of NATO and its
1,2
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