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personnel killed. Of the civilians murdered, approximately 200 mainstream NATO doctrine. At the most basic level, every
men, women, and children were murdered inside their homes, servicemember, not just mid and lower-level medics, need to
while the remaining casualties were murdered in an open field master TCCC, echoing one of the SOF Truths that humans
at a music festival, in their cars, or in the streets of local cities. and their skills outweigh any piece of hardware. Additionally,
a core SOF truth that “competent special-operations forces
Methods: Currently, official data have not yet been pub-
lished regarding the types of injuries suffered by Israeli civil- cannot be created after the war begins” frames the urgency
ians during the terror attack. However, the massive damage of institutionalizing SOF-derived medical practices across
found in buildings infiltrated by the terrorists, weapons found NATO before the next crisis erupts. Universal TCCC mastery
on neutralized terrorists, and the findings of the pathologists for every servicemember, forward whole-blood capability in
tasked with examining and identifying the casualties, as well as the form of DCR, and modular damage-control surgery teams
preliminary clinical evidence, suggested that many died from must therefore be built into doctrine now, not improvised once
hand-held explosive devices or rocket-propelled grenades con- evacuation routes are cut and airspace contested.
taining a “thermobaric”-type warhead. Effective POI care therefore hinges on universal competence
in tourniquet application, junctional hemorrhage control, with
Results: The use of thermobaric weapons has also been re- consideration of REBOA, rapid airway adjunct deployment, hy-
ported from the Russia–Ukraine war, suggesting that these pothermia prevention, and, when feasible, forward whole blood
weapons are becoming more common. Thermobaric injuries transfusion sustained far forward. When evacuation is delayed,
differ from typical battlefield injuries due to their specific blast as it often is under contested airspace, DCR and PCC/PFC be-
characteristics. Considering that thermobaric weapons are rel- come indispensable. Small, modular surgical teams positioned
atively cheap to manufacture and highly efficient, it can be close to the forward line have demonstrate the life-saving value
assumed that their unique injury patterns will become more of selective, damage-control procedures; to staff these teams, ad-
common in future battlefields.
vanced surgical courses such as ASSET+, HEST, and dedicated
Conclusions: This paper reports on a possible change in the DCR/DCS curricula must be opened to junior surgeons, physi-
nature of terror and battlefield injuries and alerts emergency cian assistants, and experienced SOF and other advanced med-
organizations and military forces worldwide to prepare for the ics, with strict adherence to clinical practice guidelines (CPGs).
need of treating more blast injuries, burns, smoke inhalation,
and asphyxiation. Sustaining these clinical advances requires resilient logistics
and governance. Ground-based evacuation assets need armored
protection and en-route care packages, while blood and pharm-
Large-Scale Combat Operations:
Implications for NATO and NATO Partner Forces aceutical cold chains must extend to the platoon level. Interop-
John Quinn et al. erability gaps, ranging from credentialing and scope-of-practice
discrepancies to incompatible documentation standards, de-
Background: Large-scale combat operations (LSCOs) against mand a coalition-wide clinical-governance framework led by
peer or near-peer adversaries present unique medical challenges the NATO Centre of Excellence for Military Medicine and sup-
requiring innovative and out-of-the-box solutions. As evi- ported by the NATO Special Operations University (NSOU).
denced by high-intensity conflict in Ukraine, a steep and rapid Rapid, secure sharing of battlefield biogram data will in turn
evolution of warfare requires information sharing and adap- support evidence-based antimicrobial therapy and curb resis-
tation in order to reduce preventable morbidity and mortality. tance, as well as early warning for potential CBRNe events. Fi-
NATO and NATO partner militaries face the task of manag- nally, an encrypted, coalition-wide casualty-tracking system is
ing mass casualties in contested environments after decades essential for real-time visibility of patient status and resource
of smaller-scale operations experienced in Counterinsurgency allocation, across the continuum of care. Together, these inte-
Operations and the Global War on Terror (“COIN/GWoT”). grated, evidence-based adaptations promise to reduce prevent-
This abstract unpacks how Special Operations Forces (SOF) able deaths and enhance coalition readiness for future LSCOs.
medicine principles can be translated into scalable practices
for conventional forces in future LSCOs in preparation for Conclusions and Implications
multi-domain battle. Key focus areas include point-of-injury NATO and NATO partner forces can leverage these lessons
care, damage control resuscitation (DCR), prolonged casualty/ from Ukraine to enhance preparedness for future LSCOs. In-
field care (PCC/PFC), medical logistics, casualty evacuation, tegrating SOF medicine innovations into conventional force
and interoperability.
doctrine, such as widespread TCCC and PFC/PCC training,
Methods: A field-informed qualitative analysis was conducted, far-forward resuscitation teams, and prehospital whole blood
drawing on direct experience from the Ukrainian war (2014– capabilities, will significantly improve combat casualty care.
2025) and scholarly research. The authors’ fieldwork ranged Likewise, investing in medical logistics resilience and coali-
from a 2014 audit of Ukrainian military medical evacuation tion interoperability (unified CPGs and joint operations) is a
systems to leading frontline medical support and training ef- strategic imperative. Adopting these evidence-based improve-
forts during the 2022 invasion. These firsthand observations ments and fostering a robust lessons learned process that is
were supplemented by peer-reviewed military medicine studies open to partners can reduce preventable mortality and bolster
on the Ukraine conflict. Through comparative analysis of SOF the overall medical readiness of NATO and partner forces in
medical tactics and conventional military medical planning, the large-scale conflicts.
study identified practical lessons and emerging best practices.
References
Key Findings: Battlefield lessons from Ukraine highlight that 1. Quinn J, Panasenko SI, Leshchenko Y, et al. Prehospital Lessons
several SOF-derived medical practices are critical for wider From the War in Ukraine: Damage Control Resuscitation and Sur-
adoption. Battlefield experience in Ukraine makes clear that gery Experiences From Point of Injury to Role 2. Mil Med. 2024;
Special-Operations–derived practices must migrate into 189(1–2):17–29. doi:10.1093/milmed/usad253

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