Wars have always given back to civilian medicine more than they have taken. Baron Larrey's flying ambulances in 1792, systematic triage in World War I, medical evacuation by helicopter in Vietnam, the tourniquet making its comeback in Iraq and Afghanistan: every conflict has forced a rethinking of protocols, often within months. The Russo-Ukrainian war is no exception — but this time it is different. It is the first large-scale, high-intensity conventional conflict in Europe since World War II, and the challenges it is generating directly concern those working in civilian prehospital emergency care.
Four themes are emerging from the literature: the tourniquet called into question, advanced haemostatic resuscitation, drug-resistant infections as a silent complication, and training in wartime. None of these is exclusively military.
1. The Tourniquet Called Into Question
In Iraq and Afghanistan, the tourniquet was almost always safe: evacuation times rarely exceeded one hour, and prolonged tourniquet application syndrome was an exceptional event. In Ukraine, everything has changed.
Medical evacuation times in the Russo-Ukrainian conflict regularly reach 12–24 hours, and in some cases extend beyond that. The primary cause is the saturation of airspace by FPV drones, which have made traditional medical evacuation extremely dangerous. The result is that tourniquets remain in place well beyond the window considered safe, triggering a cascade of complications — prolonged application syndrome, rhabdomyolysis, compartment syndrome, acute kidney injury — that dialysis units in Ukrainian hospitals are now overwhelmed by [1, 2].
The problem is compounded by a second factor: non-indicated use. In a study by a Ukrainian vascular surgeon cited by Butler et al. (2024), appropriate indications for tourniquet placement were present in only 24.6% of cases [1]. The combination of inappropriate application and prolonged evacuation is producing avoidable amputations.
The Ukrainian response has been pragmatic. On 18 July 2023, the Armed Forces of Ukraine officially adopted a tourniquet conversion protocol, establishing that — as soon as the tactical situation allows — any tourniquet in place for more than 2 hours must be reassessed by anyone who has received the necessary training. Telemedicine is included as a support option when the rescuer is not qualified [2]. This is a significant doctrinal shift, with implications for civilian prehospital care in remote settings or with prolonged transport times — scenarios not so distant from alpine rescue reality.
2. Haemostatic Resuscitation: Whole Blood and Prehospital TXA
Ukraine has accelerated the adoption of two practices that were already emerging from American and French military literature, but had struggled to find systematic application.
The first is low-titer group O whole blood (LTOWB). Compared to the traditional 1:1:1 strategy with separate blood components, whole blood dramatically simplifies logistics — one product instead of three — while maintaining haemostatic efficacy in prehospital and tactical settings. The US and French militaries now use it routinely [3]. In Ukraine, necessity outpaced debate: "walking blood banks" — living donors within military units — have been documented as widespread practice since the early phases of the conflict [4].
The second is prehospital tranexamic acid (TXA). When administered within three hours of injury, TXA halves mortality in massively transfused casualties [3]. In Ukraine, a dedicated programme was implemented to extend this competency to frontline EMS operators, including intraosseous access for its administration [5]. The result is that a molecule known for years in ATLS guidelines has finally found systematic application at the earliest point in the chain of care.
3. When the Wound Won't Heal: Bacterial Resistance in the Ukrainian Conflict
The Ukrainian conflict has brought to the fore a problem that traditional tactical medicine underestimated: drug-resistant organism infections in combat wounds.
A study of 73 wounded soldiers treated in civilian hospitals in northeastern Ukraine (January–April 2024) found that 84.6% of isolated bacteria were multidrug-resistant. The most frequent organism was Acinetobacter baumannii (36%), followed by Enterococcus faecalis (12%) [6]. This is not an isolated finding: Ukrainian casualties evacuated to Germany have imported extensively resistant strains into NATO facilities, and clinicians in the UK and across Europe are reporting the emergence of resistant bacteria originating from Ukraine [7].
The causes are systemic: prolonged evacuations with contaminated wounds exposed for hours, empirical antibiotic therapy without culture guidance, overwhelmed healthcare facilities. The practical implications concern those who receive these patients — but also raise open questions about prehospital wound management in resource-limited settings, where early decontamination (irrigation with clean water, antisepsis at the point of injury) could reduce bacterial load before the patient reaches a facility.
4. Training During War — and Updating Guidelines on the Fly
Perhaps the most underappreciated aspect of the Ukrainian conflict is its capacity to generate real-time learning and rapidly transfer it into international guidelines.
Between August 2022 and April 2023, over 4,300 Ukrainian healthcare workers were trained in 164 courses — ATLS, trauma nursing, paediatric trauma management, prehospital care, Stop the Bleed — across seven regions of the country, during active conflict [8]. 83.3% of participants reported using the skills acquired within 8 weeks of training. Between June 2023 and June 2024, nine international symposia brought together global experts and Ukrainian medical personnel to share lessons from the conflict: the result was an evidence-based revision of US and NATO trauma guidelines [9].
This is a model of knowledge translation worth paying attention to: war as an accelerated learning system, with a feedback-to-protocol-update cycle compressed into months rather than years.
What Prehospital Providers Can Take Home
You do not need to operate in a war zone to find these themes familiar.
A tourniquet applied to a casualty at altitude, waiting for the helicopter that cannot take off due to weather: how many hours can it remain in place before anyone reassesses the indication? The Ukrainian answer — mandatory conversion protocol after 2 hours, telemedicine as support — is already transferable today, without any systemic changes.
TXA has been in ERC guidelines for traumatic cardiac arrest since 2021. But how many EMS crews administer it within the first hour of trauma? Ukraine has shown it is possible to train non-physician EMS providers to do so — intraosseous access included — in a single training day. The problem is not the molecule. It is training.
On drug-resistant bacterial infections, the discussion is less immediate but no less relevant: every contaminated wound that arrives late at a facility has travelled part of the Ukrainian journey. Prehospital wound management — cleaning, covering, antibiotic timing — is not a detail.
Ukraine does not teach military providers things civilians don't need to know. It teaches what happens when the margin for error disappears. And in emergency medicine, that margin is always narrower than we think.
References
[1] Butler F, Holcomb JB, Dorlac W, et al. Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. J Trauma Acute Care Surg. 2024;97(2S Suppl 1):S45-S54. PMID: 38996420
[2] Holcomb JB, Dorlac WC, Drew BG, Butler FK, et al. Rethinking limb tourniquet conversion in the prehospital environment. J Trauma Acute Care Surg. 2023;95(6):e54-e60. PMC: 10662576
[3] Jarrassier A, Boutonnet M, Duranteau J, et al. Initial management of haemorrhagic war casualties: tactical priorities and innovative approaches in modern and future warfare. Crit Care. 2025;29:509. PMC: 12664260
[4] Quinn J, Panasenko SI, Leshchenko Y, et al. Prehospital lessons from the war in Ukraine: damage control resuscitation and surgery experiences from point of injury to Role 2. Mil Med. 2024;189(1-2):17-29. PMID: 37647607
[5] Bury G, Fitzpatrick C, Heron B, et al. Ukraine Trauma Project: the feasibility of introducing advanced trauma-care skills to frontline emergency medical services responders. BMJ Open. 2023. PMID: 37945303
[6] Holubnycha V, Kholodylo N. War impact on antimicrobial resistance and bacteriological profile of wound infections in Ukraine. Commun Med. 2025. DOI: 10.1038/s43856-025-01056-6
[7] Pallett SJC, Trompeter A, Basarab M, et al. Multidrug-resistant infections in war victims in Ukraine. Lancet Infect Dis. 2023;23(8):e270-e271. PMID: 37451296
[8] Kivlehan SM, Niescierenko M, Murray K, et al. Designing, implementing and evaluating multidisciplinary healthcare training programmes in the wartime humanitarian context of Ukraine. Emerg Med J. 2025;42(3):165-170. PMID: 39746801
[9] Holcomb JB, Rauch TM, Dittlinger S, et al. Assessment and training of Ukrainian trauma and combat casualty care via international symposia. J Trauma Acute Care Surg. 2025;99(3S):S150-S156. PMID: 40457994
