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IAPs of just 15–20mmHg have been shown to equate to a To mitigate these challenges, NATO must explore the potential
highly significant reduction in arterial blood flow to splenic for medical offsets to restore overmatch against preventable
(>44%), hepatic (>39%), and left gastric (40%–54%) mes- combat deaths. The three proposed offsets include: 1) far-for-
enteric arteries. IAPs up to 40mmHg through fluid adminis- ward medical intervention, 2) technology and innovation, and
tration have been demonstrated to have a titratable effect on 3) allies and partnerships. One potential approach to allevi-
superior mesenteric artery flow, especially in the presence of ating some of the collective medical burden is through task
hemorrhage. Titratable temporizing of hemorrhage has also transfer of medics. However, the role of ‘medic’ is not currently
been demonstrated for high-grade hepatoportal injury porcine a defined or standardized capability across NATO, leading to
models when intraabdominal foams are applied. significant interoperability challenges. This lack of standard-
izing hampers the ability to integrate medics effectively across
In conclusion, an AAJT-S at 250mmHg inflation generates a multinational forces. Achieving the necessary level of inter-
proximal epigastric compartment pressure sufficient to tempo- operability—already established in NATO’s ammunition and
rize hemorrhage from branches of the celiac trunk. A volume fuel supply chains—remains a significant challenge for the
of 500mL of blood in the abdomen does not compromise this NATO medical support community. Addressing this gap is es-
effect. The AAJT-S is a titratable point-of-injury intervention sential to enhancing collective medical capabilities and ensur-
that contributes to clot stabilization and non- surgical hemor- ing mission success in future conflict scenarios.
rhage control for zone 1 non-compressible torso hemorrhage
injuries and, by definition, zone 3, and should now be in the The Role of Open-Source Medical
hands of all military caregivers. Information in Modern Warfare:
Lessons from the Russo-Ukrainian Conflict
The Future of SOF Medicine: Dr. Audrey Jarrassier (FRA)
A SOFCOM Point of View The shift from low- to high-intensity conflict, as seen in the
COL Benjamin Ingram
Russo-Ukrainian war, requires adaptive medical practices.
trategic-level NATO documents highlight emerging global Open-source medical resources are essential in such contexts,
Sand interconnected future threats that demand a collective facilitating real-time collaboration and knowledge sharing
approach to NATO medical support, one that surpasses the ca- among health professionals, even in austere environments.
pabilities of purely national efforts. The medical strategies em- These tools offer accessibility and transparency, enabling the
ployed by NATO medical forces during the era of anti-terrorism, development of medical solutions that respond to new chal-
particularly in Afghanistan, are insufficient for the demands of lenges. However, they also pose risks, particularly in terms
future large-scale combat operations (LSCOs). To address these of data security, which is critical in conflict zones. The sus-
evolving challenges, NATO SOF require an interoperable, sur- tainability of these projects, which often rely on volunteers, is
vivable, and readily available medical force capable of meeting also an issue, and the lack of clinical validation for some tools
operational requirements across all conflict scenarios. raises concerns about their effectiveness.
A review of U.S. medical operations in World War II under- A systematic scoping review was conducted using Embase,
scores the massive scale of deployed U.S. Forces, necessitating Medline, and OpenGrey databases, focusing on data from
the training of more than 300 hospitals within 2 years. Similarly, 11,622 Ukrainian patients and 2,470 surgical procedures
open-source reports from the war in Ukraine suggests that up to (2014–2024). While the dataset provides insights into trauma
39% of Russian combat deaths could have been prevented with management, it is limited by the lack of Russian casualty data
improved far-forward medical care. These examples, coupled and the sensitivity of war-related information. Without a pre-
with the historical challenges of prolonged evacuation time- hospital registry, there is a survival bias, as severely injured
lines—dating back to French physician Baron Dominique-Jean patients often die before reaching stabilization points due to
Larrey innovations during the Napoleonic Wars—highlight the long delays in evacuation.
persistent need for technological solutions to tactical problems,
such as ambulances volantes or ‘flying ambulances,’ in combat Tourniquet use is a critical area for improvement. In several
medicine. While helicopter technology shortened evacuation cases, tourniquets were applied without clear indications, and
timelines in Afghanistan, future warfare will likely require new only 24.6% followed proper protocols. Prolonged tourniquet
advancements to maintain medical superiority. use, ranging from 2 to 16 hours, was associated with evacua-
tion delays caused by logistical challenges such as blocked roads
In a future LSCO, NATO SOF medical risk will be most acute and closed airspace. These longer durations increase the risks
during the early phases of conflict and crisis, when coordi- of compartment syndrome, rhabdomyolysis, and amputation,
nated shaping operations are underway. This critical period, leading to higher mortality rates. This study highlights the need
referred to as the “multidomain operation (MDO) medical for protocol compliance and training, with an emphasis on
risk box,” will pose unique challenges. Activation of NATO’s timely reassessment and tourniquet removal. The development
medical community into a wartime posture will only occur of revised protocols and comprehensive training programs is
upon a political declaration of war, at which point the Alli- essential to effectively manage bleeding and reduce risk.
ance will confront the effects of the interwar “Walker Dip” in
medical readiness. This transition will be further complicated Multi-resistant bacterial infections are another challenge, par-
by anticipating enemy targeting of medical capabilities and ticularly with high rates of carbapenem resistance, such as
the protracted timelines required to train medical personnel Acinetobacter baumannii. This review identified delays in an-
replacements—spanning years or even decades. As a result, ex- tibiotic therapy due to supply disruptions and loss of informa-
isting civilian and military healthcare shortages will likely be tion, resulting in inappropriate treatment. Cross- transmission
exacerbated during prolonged conflict. during evacuation and within facilities exacerbates the problem.

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