Qualitative assessment of point of injury to Role 2+ combat casualty care in Ukraine.

Background: The ongoing Russian-Ukrainian war created an extended battlefield with the prolific use of missiles and drones. Such tactics require placement of care facilities far from the frontline, thereby delaying definitive trauma care and necessitating prolonged casualty care (PCC). Methods: Between June 2023 and February 2024, we conducted qualitative key informant interviews with Ukrainian healthcare personnel using an expanded version of the Global Trauma System Evaluation Tool. Analysis focused on identifying and understanding casualty care from point of injury through Roles 1, 2, and 2+. We included 36 civilian and military healthcare or healthcare-affiliated participants. Sampling continued until thematic saturation was achieved. Results: Respondents indicated medics lacked a standardized formal training system for prehospital care across emergency services and regions. Reliance on "walking blood banks to collect fresh whole blood for blood banking and direct transfusion was noted frequently. Of respondents at Roles 1, 2, and 2+, 73% stated damage control resuscitation was done at their level, and 71% of respondents in these same Roles stated they were doing some level of damage control surgery. Security and the tactical situation were common limitations to prehospital care leading to PCC. Conclusion: The experience in Ukraine shows that, in the face of large-scale combat, the effectiveness of Role 2+ and lower facilities degrades very quickly. Future attention should be focused on improvements to prehospital care training, safe and timely patient movement in the absence of air superiority, PCC, blood supply, and medevac coordination. Efficient combat casualty care may require enhancing the capabilities of current Role 2+ units, or moving Role 3 facilities closer to the battlefront. Level of evidence: Level III.