Military medical system: how lives are saved in war

The military medical system is a vital mechanism designed to save the lives of service members and restore their combat capability through consistent, timely provision of medical care at all stages.

The Ministry of Defence explains the key elements of the system's functioning, including the types of medical care, the division into stages (tactical pre-hospital, pre-hospital, and hospital care), the classification of roles (R1–R4), and the full casualty pathway from injury to rehabilitation.

Types of medical care

Medical care in the military medical system is classified according to point and time of care, and by the volume and complexity of care delivered. 

As in the civilian healthcare system, medical care is divided into the following types:

Emergency (urgent) care is medical care provided by medical personnel. It comprises urgent organizational, diagnostic, and therapeutic measures, implemented in accordance with applicable legislation, to save life, preserve vital functions in emergency conditions, and minimize adverse health consequences.

Primary medical care includes consultation, diagnosis, and treatment of the most common diseases, injuries, poisonings, pathological conditions, and physiological conditions (including those related to pregnancy), as well as the implementation of preventive measures. It also includes the referral of patients, in accordance with medical indications, who do not require emergency medical care, to receive specialized medical care; providing emergency medical care in cases of a physical or mental disorder when such patients do not require emergency or specialized medical care.

Specialized medical care is medical care provided in outpatient or inpatient settings by medical practitioners of the relevant specialization (excluding general practitioners/family physicians), delivered on a planned basis or in emergency cases, and includes the provision of consultation, the conduct of diagnostic procedures, treatment, and prevention of diseases, injuries, poisonings, pathological conditions, and physiological conditions, (including those occurring during pregnancy and childbirth), including through the use of high-technology medical equipment and/or highly specialized medical procedures of high complexity. It also includes the referral of the patient, in accordance with medical indications, for specialized medical care in another medical specialty.

Palliative care is a comprehensive set of measures aimed at improving the quality of life of patients of all age groups and their family members who are facing problems associated with life-threatening diseases. Such a set of measures includes actions to prevent and alleviate the patient's suffering through the early identification and assessment of symptoms, pain relief, and the management of other physical, psychosocial, and spiritual problems.

Rehabilitation in the Healthcare Sector is a comprehensive set of measures carried out by rehabilitation specialists who work in rehabilitation facilities, departments, units, as well as within territorial communities, either as part of a multidisciplinary rehabilitation team or independently, and who provide rehabilitation care to a person with limitations of everyday functioning (or to a person who may develop limitations in daily functioning) to achieve and maintain an optimal level of functioning and quality of life within their environment. 

“The Casualty Pathway”

An understanding of the types of medical care makes it possible to clearly trace how they are provided sequentially to a service member as evacuation progresses.

The casualty pathway begins directly at the point where the injury is sustained (POI – Point of Injury). At this stage, tactical pre-hospital care is provided through self-aid and buddy aid, as well as by combat medics. This care is based on the principles of TCCC (Tactical Combat Casualty Care) and the MARCH-PAWS algorithm. TCCC is a standardized system for providing medical care under combat conditions, dividing care into phases according to the level of threat. In turn, MARCH-PAWS is the key TCCC algorithm that determines the priority of a medic’s actions. It focuses on the rapid elimination of the primary causes of death on the battlefield, beginning with M (control of massive hemorrhage) and concluding with S (splinting of fractures and immobilization).

A key concept of care at the tactical level is the so-called “golden hour.” This is a critical time period (as a rule, the first hour following a severe injury), during which the provision of pre-hospital medical care has a decisive impact on life-saving outcomes. For this reason, the rapid application of tourniquets, hemorrhage control, and evacuation constitute priority number one on the battlefield. However, due to the complex battlefield situation, it is often not possible to evacuate the casualty within this timeframe. Consequently, as the intensity of hostilities increases, Prolonged Field Care (PFC) assumes growing importance. 

Following the evacuation of the casualty to a medical unit in which care is provided by medical personnel, the pre-hospital medical care phase begins. Initially, the casualty is received at a stabilization point (Role 1 medical formation), where care is provided at the level of resuscitation with (remote/delayed) damage control ((Remote) Damage Control Resuscitation – (R)DCR). Subsequently, the patient is referred to a forward surgical unit or Role 2 group (forward surgical unit / forward surgical group), where surgical care is provided at the level of Damage Control Surgery (DCS). The primary objective of DCS is to prevent death from internal hemorrhage and/or limb loss, or to reduce the extent of a limb that may ultimately require amputation. For definitive treatment, the patient is then referred to a Role 3 medical unit. These are typically military hospitals, central district hospitals, and similar facilities. Here, specialized medical care is provided by medical specialists in inpatient settings. For long-term treatment and to determine the need for rehabilitation, the patient is referred to a Role 4 healthcare facility. These are usually military medical clinical centers, regional clinical hospitals, specialized institutes, and similar establishments. In addition, where such a need exists and where foreign partners have the capacity, in complex cases, the patient may be referred for treatment to a hospital abroad. For this purpose, the Command of the Medical Forces of the Armed Forces of Ukraine submits a request to the Ministry of Health of Ukraine, which in turn identifies a healthcare facility abroad capable of providing care to the wounded service member.

Through the implementation of the concept of the Integrated Healthcare Environment, in cases where military hospitals are overloaded, wounded service members are promptly redistributed to civilian multi-profile hospitals.

The final stage of recovery is long-term rehabilitation, which takes place in rehabilitation hospitals of the Armed Forces of Ukraine, civilian healthcare facilities, and healthcare institutions abroad. The objective is the maximum possible restoration of impaired or lost functions and enabling the service member to resume a full and active life.

The military medical system is a complex yet reliable structure, in which every element — from tactical pre-hospital care on the battlefield to rehabilitation in a rehabilitation center — functions in a synchronized manner.