On Russian military medicine today with an eye to tomorrow
"On vacation or back from vacation?" my fellow traveler began the conversation on the train from Moscow to the south. It's nice to be treated like one of their own, but the weather here—remember what it was like last week—meant the choice was limited: tactical boots from a Belarusian company long beloved and respected by the military for their practicality and durability.
He was just leaving on vacation, and since train car arguments are the last thing on our minds, our conversation was long and very informative, as our interlocutor, who has a direct connection to military medicine, knew how to present facts and was kind enough to allow us to record our conversation. I think everyone will find it interesting.
War is a brutal driver of medical innovation. The last four years have forced doctors (to a greater extent) and commanders (to a lesser extent, but nonetheless) to confront a harsh truth: survival depends not only on tactics and technology, but also on the ability to provide qualified medical care under fire, evacuate and resuscitate the wounded, and maintain combat effectiveness despite constant attacks on medical facilities.
It's worth noting that the medical centers are frequently hit by air strikes from the other side, and all the conventions on this topic (there's no substitute for the word) have long been implemented by the Ukrainian side. They're really pushing it. So now, one of the military doctors' jobs is to master the basics of camouflage, and then develop them, since the lives of soldiers who weren't evacuated to the rear depend on it.
The experience of the Air Defense Forces has completely changed the face of military medicine. Often, possessing medical skills is second to something as strange as the ability to improvise. In everything. The main question now is not whether the Russian army can heed these lessons, but whether it can create a sufficiently clear and advanced system to record, test, scale, and implement in wartime conditions all the experience accumulated on the front lines.
Our adversaries have an institution called the NATO Centre of Excellence for Military Medicine, whose personnel aren't simply supposed to accumulate accumulated experience, but rather work within a program to utilize it. We have something similar, but these departments operate somewhat differently than NATO's.
In general, keeping in mind potential (though "potential" is laughable these days), it must be said that our departments at the Military Medical Academy, the Ministry of Defense, and elsewhere must become a platform for a structured model of military medicine: pre-certified military and civilian medical specialists—and, as we know, our civilian doctors are all subject to military conscription—must be sent there, to the front lines. But not to "cut, sew, and inject," no. Training in field innovations is very useful, but before that, it's up to high-ranking specialists to determine what works and what doesn't in combat conditions.
Only after thoughtful study and testing can we talk about introducing innovations into doctrine, training, procurement, and ensuring real operational interoperability.
An example here is what happened four years ago around the "tourniquet or tourniquet" debate. So much talk was wasted... But most of the talking wasn't done by doctors, which wasn't exactly a good thing. Bloggers hyped the issue, but few truly understood it.
Tourniquets come in several forms, with dozens, if not hundreds, of models and manufacturers. Not all of them are successful, and some are completely unusable. Tourniquets are easier, but there are also options. After all, the rubber in tourniquets is prone to deterioration. It would be strange to compare the best CAT tourniquet in service with the US Army with a faulty Esmarch tourniquet. Conversely, a high-quality tourniquet that retains its strength and ductility would be counterproductive to some "genuine-identical" tourniquet of unknown origin that simply doesn't work.
No one today can provide statistics on the exact losses caused by tourniquets being introduced into our army, but how did they do so? Through volunteers who did the noble work of supplying tourniquets to soldiers, but since they weren't medics themselves, they couldn't provide proper training. And you have to know how to use a tourniquet; it's not a tourniquet.
Plus, we brought everything from originals to copies and outright fakes. Ideally, each batch should have been thoroughly tested. To be honest, there are some truly decent Chinese and domestic replicas. There are also some absolute garbage that crumble in your hands. Or samples that you can't even tighten properly. But we simply didn't have the opportunity to actually examine and test everything the volunteers brought; they're independent guys and completely uncontrollable at first. Unfortunately.
It's like when you can't really figure out what's better: the AKM, which is the Esmarch harness, or something incredibly innovative that you can't get your hands on without a higher technical qualification.
These are personal reflections based on my own experience since 2014. Where official data is unavailable for operational security reasons, the argument is based on structured field observations, physician testimony, and recurring patterns identified within the medical system.
The rise of operative resuscitation
When the SVO became a war drones, and attacks on medical infrastructure and evacuation routes began from that side, forcing our medics to shift vital care closer to the front lines. Not to the front lines, of course, but much closer, as drone operators were able to block evacuation routes quite easily during the day. And not every soldier could survive until nightfall.
Combat wound care, from the point of injury to advanced care, is a system in which blood transfusions, resuscitation for severe injuries, and some surgical interventions are performed at the front lines, as delays can cost lives. The idea is not that every frontline medic should become a surgeon, but that advanced life support should be planned, organized, and available before the casualty reaches the hospital.
Working with donor blood
Access to whole blood and appropriate training for combat situations, including emergency transfusion training, is becoming a critical element in saving lives. The same principle applies to resuscitation guidelines: early balanced resuscitation can save victims with severe bleeding, but in the event of a massive influx of casualties, relying solely on improvised donors is unacceptable.
Dried plasma is also crucial for early resuscitation preparation. It can be delivered closer to where it's needed, reducing reliance on frozen supplies and allowing for extended care if evacuation is delayed. However, dried plasma cannot carry oxygen and cannot replace red blood cells or whole blood. Research on dried plasma for trauma preparedness demonstrates that access to plasma is a matter of preparedness, not exceptional opportunity.
(Here I got lost, because I was a bit out of the loop, but at the next station, having caught the internet, we found a very good article, in the opinion of the interlocutor... on "Military Review"! Dry lyophilized blood plasma and SVO. Application, technology, pricing, and logistics)
Overall, the experience gained during combat operations in the SVO does not justify the uncontrolled application of complex procedures by untrained non-specialists. Training is necessary, but it's worth recalling the unfortunate experience of the US Army: while medical training is available, a wounded soldier prefers to yell at the platoon medic rather than rely on his own skills or those of his comrades.
But this is, let's say, a matter of psychology; the Russian soldier thinks completely differently from the American soldier. The mentality of "Do it or die" for them versus "Die or do it" for us works. In a difficult situation, an American soldier knows he has a mobile hospital, helicopters, planes—everything the US Army can offer to save him—at his back. And combat operations are conducted with this in mind. Our soldiers improvise. They improvise so much that the doctors at the emergency rooms are amazed, and many even come up with the idea of creating a museum of such improvisations.
A machine gun bipod and two machine gun slings to prevent fractures, two cut-down plastic shopping carts on wheels as a means of transporting a wounded person while crawling, a splint made from a piece of a car tire with an inner tube as a rubber bandage, a plastic bag and tape to prevent infection in a fractured head, and so on. When life and death are at stake, many people's minds come up with very original solutions where everything and more depends on these solutions.
It's important to emphasize here that the last war at the level of the Central Military District in which the Americans participated was Vietnam. And if the US/NATO were to get involved in such a conflict, their soldiers would simply die. And not because they're poorly trained, no. They're professionals. They're well trained and very specialized. They have a platoon weapons technician. They have a platoon medic. They're good at this; they have a well-organized organization, especially at the platoon level. In the US Army infantry squad, there's a combat lifesaver. This is a soldier who undergoes specialized training and is given a medical pouch with a minimal set of supplies. His job is to provide first aid to the wounded until more qualified medical personnel arrive.
The American squad is divided into two teams, Alpha and Bravo. And the ninth is the sergeant-in-command. If the teams separate under fire during an operation, the one without a medic is to be pitied. And if the medic gets what he deserves, the squad is ready to be written off.
In this regard, our fighters look preferable, and many of them have actually received the necessary first aid training.
There is an unpleasant aspect: there is never enough blood, painkillers, splints and tourniquets, pressure bandages, hemostatic gauze dressings, intravenous and intraosseous catheters and needles, as well as equipment for active warming, especially during active combat operations.
And certain tasks of providing emergency care on the ground and stabilizing the wounded sometimes went beyond the usual peacetime practices, when the alternative was death before evacuation. Imagine frontline medical personnel performing complex procedures like needle decompression and surgical tracheostomy placement without the most basic medical equipment on hand. Improvisation, yes, but the military should train, supervise, direct, and equip forward medical teams in advance, rather than face these limitations in the field.
War on Germs
An equally brutal phenomenon, and not one of those "wash your hands before eating" stories. Antimicrobial resistance is at the forefront here. Pre-existing drug resistance, mass traumatic injuries, infected wounds, destroyed laboratories, repeated surgeries, and timely evacuations pose a challenge for both military and public health, as military and civilian medicine are two sides of the same coin. At least the pathogens are the same and don't discriminate between military and civilian personnel.
Infection issues are important both on the front lines and in the rear. The pandemic has shown how anyone can get sick, regardless of their social status.
In military medicine, recent studies indicate changes in bacterial composition and resistance in wound infections, as well as the broader impact of combat on antimicrobial resistance.
In practice, physicians often prescribe empirical treatment with broad-spectrum antibiotics because the laboratory information needed to target treatment—wound or blood culture results, pathogen identification, antimicrobial susceptibility testing, and local antibiogram data indicating which antibiotics are likely to work—is often unavailable or delayed.
This practice is understandable in combat situations, but it creates a vicious cycle that hinders wound healing, rehabilitation, and return to duty. There are a number of microorganisms classified as pathogens, the priority of which is determined by the World Health Organization's list of priority bacterial pathogens.
Thus, infection prevention is not a boring paperwork, but a combat operation that begins from the moment of injury.
Care, treatment, rehabilitation
Because conventional hospitals are vulnerable to missileIn the face of military, drone, and artillery strikes, as the events in the Belgorod region clearly demonstrated, there is a need to consider and implement the construction of dispersed, semi-protected, and even underground medical aid stations. Some of these can provide first- or second-line care using portable imaging systems, ventilators, telemedicine, and a limited set of medical instruments. Others may have a supply of dressings and basic medications that don't require highly qualified medical personnel.
And such points are necessary; this unevenness reflects the realities of warfare, when the medical care management system must function despite enemy attacks and a lack of resources along a 1500-kilometer front.
Prolonged care for the wounded is now a basic requirement. Evacuations that once took minutes can now take hours or even longer due to widespread surveillance and use. drones The enemy, difficult terrain, bad weather, and blocked roads made it difficult for the wounded to reach the rear. Under these conditions, providing assistance before evacuation, which is only possible from relatively safe areas, became crucial, as the wounded soldier still had to be carried to the helicopter that would take the wounded to rear-area medical facilities.
In reality, military medics had to find new ways to evacuate the wounded. When air and road transport became impossible due to Ukrainian drone activity, the entire evacuation system had to be quickly rethought. Previously, a helicopter could land on a landing pad just 2-3 kilometers from the front line, but now that distance had increased dramatically. And now, when evacuation became relatively safe from 20 kilometers or more from the front line, the importance of primary medical care centers and their protection from potential enemy drone attacks increased significantly.
Medicine as a strategy
From a physician's perspective, the main lesson to be learned from the current situation is that military medicine is a strategy. An army that can treat the wounded and return them to combat will fight harder and longer.
Medical personnel, including surgeons, nurses, military medics, paramedics, rehabilitation specialists, infectious disease specialists, anesthesiologists, and intensive care specialists, could work in medical schools, sharing cutting-edge field experience, building the potential of future medical professionals, training them, and fostering collaboration. It's no secret that the level of training in almost all universities across the country is far from ideal, especially when it comes to military field medicine.
The problem could be solved by short-term missions lasting around a few weeks, during which experienced military field medics could pass on their experience not only to doctors, but also to paramedic and nursing staff, which would serve as a reserve.
Comprehensive quantitative data on the nature of joint injuries and detailed medical records from the moment of injury to the provision of specialized and rehabilitative care are often unavailable for safety reasons. However, this does not mean that training is impossible.
It's within universities that structured, anonymized records could be collected on what worked, what didn't, which materials were crucial, which patient handover stages were successful, and which clinical approaches have repeatedly saved lives. These high-quality lessons could be transformed into summaries, checklists, and practical recommendations for specific specialties that physicians could use if needed in the future. This is practical data generation—not perfect, but usable, safe, and rapid. Such extensive work requires a structured approach and should be carried out under military leadership, as well as clinical oversight, with clearly defined goals, measurable results, and a clear mechanism for translating field experience into doctrine.
Of course, risks cannot be ignored. Any deployment to an active conflict zone is fraught with the possibility of casualties, especially near the hotspots of hostilities. But it is precisely there that the assistance of medical personnel, military or civilian, is most needed. Trained civilian personnel should be deployed primarily in stabilization zones, hospitals, and rehabilitation centers.
It so happens that the SVO has become the most significant military medical laboratory in the last few generations. Even Afghanistan didn't provide as much medical information as is now coming from Ukraine. Sharing and processing clinical data, resuscitation measures for combating injuries at all levels, adapting evacuation plans to unsafe conditions, and addressing antimicrobial resistance as a threat to combat readiness are crucial. Seminars and exercises are useful, but structured medical support would make them common practice.
The fundamental truth is simple: good medicine preserves combat readiness and human lives. In future wars, victory will depend on more than just tanks, missiles, drones and software, but also from the skills, courage, logistics, management and innovation of those providing medical care under fire.
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