NATO Medical Evacuation Workshop Report: Optimizing the Vigorous Warrior Live Exercise Series to Yield Observations and Experiences from Ukraine in Large-scale Combat Operations

INTRODUCTION: The conflict in Ukraine has exposed the realities of large-scale combat operations (LSCO), characterized by prolonged evacuation timelines, contested environments, and deliberate targeting of medical assets. These conditions challenge traditional NATO medical evacuation assumptions and necessitate adaptation of doctrine and practice. The Vigorous Warrior Medical Evacuation Workshop was convened to examine operational lessons from Ukraine and to identify implications for future NATO medical planning. MATERIALS AND METHODS: The workshop employed a hybrid educational format integrating plenary briefings, Ukrainian case studies, and syndicate-based scenario analysis. Participants were organized into 4 syndicates reflecting key stages of the casualty evacuation continuum, from point-of-injury care through forward resuscitation, tactical evacuation, and transfer to higher echelons. Syndicate outputs were synthesized using standardized after-action review methodologies and contextualized against existing NATO medical doctrine. RESULTS: Participants consistently reported prolonged evacuation times (often exceeding twelve hours) because of unsafe routes, destroyed infrastructure, and enemy targeting of ambulances and medical facilities. Variability in medical practices led to inconsistent triage and stabilization procedures, while limited blood product availability and inadequate cold-chain logistics constrained far-forward resuscitation. In response, Ukrainian medical units demonstrated adaptive practices, including forward deployment of damage control resuscitation (DCR) and surgery (DCS) closer to the point of injury, which improved survival outcomes. These adaptations effectively blurred the doctrinal boundary between Role 1 and Role 2 facilities, promoting a more modular and decentralized model of care. Additional findings emphasized the need for interoperable communications, secure casualty tracking, and mobile medical infrastructure to support operations under persistent threat. CONCLUSIONS: Workshop findings indicate that NATO medical doctrine must adapt to assume delayed evacuation, contested operating environments, and degraded logistics as baseline conditions in LSCO. Priorities include treating blood availability as an operational enabler, supporting forward damage control capabilities, improving interoperability and training across echelons of care, and accommodating forward surgical, robotic, and unmanned evacuation solutions. Continued collaboration with Ukrainian medical professionals remains essential to validating and integrating these lessons into alliance doctrine, ensuring greater resilience and survivability.