Wartime Medical Response for Healthcare Workers | Dr. Marco Ha

Dr. Marco Ha · Author and medical reviewer

Pediatric surgery, trauma surgery, disaster medicine and international humanitarian medicine · Last medically reviewed August 4, 2026

Verify professional credentials·Editorial and sourcing policy

War affects the health system, not only the trauma case mix

Wartime care is not difficult merely because blast, penetrating and burn injuries increase. The care system itself becomes a casualty. Roads and ambulances are delayed; unstable power affects imaging, operating rooms, oxygen generation and electronic records; inadequate water impairs hand hygiene, cleaning, dialysis and sterilization; blood and antibiotics cannot be replenished on schedule; and staff worry about their own families. A hospital may receive a sudden wave of casualties and then face weeks of lower-volume but complex trauma, interrupted chronic care, communicable disease and psychological stress.

The ICRC's 2025 Emergency Lifeline material documented more than 3,000 incidents affecting health services during 2023–2024. Damage to facilities, transport, staff and supply lines turns otherwise treatable disease into fatal illness. An emergency plan must therefore cover water, power, oxygen, communications, information systems, waste, mortuary capacity, security and replenishment—not only an overflow area in the emergency department. Facilities also need defined triggers for sheltering in place, partial or vertical evacuation and suspension of high-risk services.

A 2026 study of emergency-department staff operating a wartime mass-casualty plan found that concerns about staff safety, mobilization and evacuation impeded execution, while alternative information sources and frequent realistic exercises helped. The sample included only 19 personnel and cannot represent every hospital, but the operational lesson is important: a triage map cannot work if staff do not know whether their family is safe, where to report or which route remains usable.

Incident command: define who decides, who reports and what triggers escalation

Every shift should recognize the same incident-command structure. A hospital incident commander sets strategy and resource priorities; clinical operations, nursing, logistics, safety, communications, public information and patient movement have named leads and alternates. Each role needs a brief action card for the first 15 minutes, first hour and subsequent operational periods. A long plan stored in an inaccessible office is not usable under pressure. A backup command location is necessary if the primary site loses power, connectivity or physical safety.

Activation should combine threat and demand: anticipated arrivals exceed current capacity, casualties will continue, a critical utility is damaged, or staff availability drops. Once activated, a fixed reporting rhythm should cover the verified threat, actual and expected arrivals, emergency capacity, operating rooms, critical-care beds, blood, oxygen, available staff, transfer restrictions and the next decision point. Unconfirmed information should be labelled with its reliability so that one forwarded message does not cause unsafe movement or unnecessary cancellation.

Command also protects non-trauma care. Name teams responsible for obstetric, pediatric, stroke, cardiac, dialysis, cancer, infectious-disease and mental-health continuity. State which clinics can be deferred and which treatments must continue. WHO's 2026 Lebanon response plan places trauma, surgery, blood and critical care alongside noncommunicable disease, maternal, child and nutrition services, illustrating why visible war injuries must not absorb the entire system.

Staff safety and attendance capacity are clinical resources

Each worker needs three answers: where to report, how to communicate an unsafe route or inability to attend, and how dependent-care responsibilities are managed. An institution can maintain a protected contact tree and alternative channels, distinguish functions that require physical presence from those that can support remotely, and understand child, elder and disability caregiving constraints. Rotas need rest and handover, not the same small core team working until exhaustion. External volunteers and returning former staff require rapid credential verification, a defined scope and supervision.

Before staff enter an ambulance bay, exposed collection point, damaged structure or contaminated zone, conduct dynamic risk assessment. Surgical masks, respirators, chemical protection and ballistic equipment are designed for different hazards. No item covers every threat. Protective equipment can reduce hearing, vision, communication and manual skill while increasing heat stress, so safe work-rest cycles and a buddy system may be necessary. Personnel without CBRN competence cannot make themselves safe merely by purchasing a suit.

Safety includes psychological and moral injury. Child casualties, resource allocation, colleague injury and uncertainty about family create acute stress. Briefings should explain threat, role and limits. After a shift, provide rest, hydration, food, practical peer support and access to confidential professional care without forcing immediate emotional disclosure. Persistent insomnia, dissociation, panic, guilt, harmful substance use or self-harm thoughts require active support and possible duty modification.

Resilience requires degraded modes for power, water, oxygen, communications and supply

Backup systems must be operational rather than decorative. Test a generator under realistic load and verify that fuel can reach it. Label the circuits that remain live. Calculate oxygen by flow per hour, not merely cylinder count. Place paper forms in clinical zones rather than a locked administrative store. For each essential system, write how long it can continue, who monitors it and at what threshold services must be reduced. If oxygen will last 12 hours, decisions should occur while eight hours remain—not when the alarm sounds.

Electronic-record failure creates identity errors, duplicate medication and lost transfers. Assign a durable unique identifier and link the wristband, triage card, specimens, imaging and transfer paperwork. A bed number or physical description is not sufficient identification. Minimum paper documentation includes arrival time, mechanism, triage category, key interventions, medicines and blood, allergies, reassessment and destination. A designated recovery team enters records later while preserving original timestamps and corrections.

Surge must expand space, staff, supplies and process together

Mass-casualty capacity is not simply the number of additional beds. A corridor bed without nursing, oxygen, monitoring, cleaning, medicine, light and a destination only relocates risk. Predefine zones for arrival screening, immediate intervention, delayed care, minor injury, expectant or palliative care, contaminated patients, family information and decedent management. Patient, staff, supply and waste movement should cross as little as possible.

Expand roles within competence instead of removing all professional boundaries. Trained teams can perform repeated functions: an airway team, a hemorrhage and access team, and a documentation and tracking team. Nonclinical personnel can support wayfinding, supplies, communication and family liaison. High-risk procedures continue to require qualified staff and supervision. Keep second- and third-wave rosters because an event may continue for days; summoning everybody during the first hour creates a later staffing vacuum.

WHO's MC-IITT, action cards, standard forms and patient tracker provide a common framework, but every facility must test it against its entrances, specialties, theatres, imaging, blood bank and referral network. A 2026 evaluation in Somalia supports the feasibility of standardized WHO mass-casualty training in a constrained setting. Course scores, however, are not patient outcomes. Institutions should track activation, triage consistency, lost patients, mortality, cancelled essential care and staff exposure.

Mass-casualty triage needs a common objective, retriage and traceable decisions

Routine medicine seeks the best outcome for each patient. When demand temporarily exceeds available resources, mass-casualty triage seeks the greatest overall clinical benefit from constrained capacity. It is not a judgment of a person's worth. It considers physiology, reversibility, resource need and current capacity. The triage officer needs authority, training and support and should not simultaneously perform complete treatment for every arrival.

The first pass identifies immediately reversible threats, permits limited lifesaving actions and assigns a clinical zone. Triage must be repeated on entry to the zone, after deterioration or improvement, before transfer and whenever resources change. Labels must mean the same thing across prehospital and hospital teams. WHO tools include immediate, delayed, minimal and expectant or palliative concepts; exact categories should follow the approved local system. An expectant or palliative category does not mean abandonment. Provide relief of pain, dyspnoea and fear, warmth, dignity, company and reassessment.

Adult physiological thresholds and hurried communication may disadvantage children, pregnant people, older adults, disabled patients and those who speak another language. Plans need pediatric tools, weight estimation, family identification, interpretation and functional support. A walking patient may still have inhalation injury, intracranial bleeding, occult hemorrhage or a mental-health crisis. Minor-care zones require observation, warning-sign instructions and retriage.

The first clinical cycle: a shared framework for reversible causes of death

In a relatively safe area, prehospital teams may use MARCH or a similar sequence for massive hemorrhage, airway, respiration, circulation and hypothermia or head injury. Hospitals commonly use ABCDE while integrating resuscitation, imaging and surgical decisions. These are cognitive frameworks rather than competing slogans. Interventions must match training, patient age, injury and institutional protocol. An untrained reader cannot use this article to perform an invasive airway, chest decompression, transfusion or operation.

Control compressible hemorrhage with direct pressure, wound packing and appropriate tourniquets while considering occult pelvic, thoracic, abdominal and long-bone bleeding. Record tourniquet time and repeatedly confirm position and effect. A tourniquet does not exclude proximal bleeding or prevent hypothermia. Resuscitation emphasizes early hemorrhage control, appropriate blood components and avoidance of excessive cold crystalloid that worsens dilution, acidosis and hypothermia. Ratios, permissive hypotension and antifibrinolytic decisions vary with brain injury, pregnancy, pediatrics and local protocol.

Airway and breathing assessment must recognize facial and neck trauma, inhalation injury, tension pneumothorax, open chest injury, hemothorax and blast lung. An apparently alert patient can deteriorate. Conversely, an intervention requiring sustained sedation, ventilation and staffing has system consequences; experienced teams balance physiological urgency and sustainability. Prevent heat loss from the point of injury by removing wet clothing, insulating from the ground, covering the patient and warming blood and fluids. Trauma hypothermia occurs even in hot climates.

Blast, penetrating and crush injury: mechanism can hide serious injury

A blast can combine pressure-wave injury, fragment penetration, body displacement, burns and inhalation exposure. A small external wound does not ensure minor internal injury. Ear, lung, bowel and brain effects, multiple fragments, contamination and delayed symptoms require attention. Enclosed-space blast, hypoxaemia, haemoptysis, abdominal pain, altered consciousness and multisystem injury raise concern. Imaging and laboratory testing do not replace serial physiology and examination; bedside ultrasound and repeated clinical review become more important when resources are constrained.

Penetrating-injury care focuses on hemorrhage control, contamination, organ and vascular injury, and deciding between operation and transfer. Do not casually remove an embedded object in the emergency department; it may tamponade bleeding and requires planned removal where resuscitation and surgery are available. Wound appearance does not reveal the entire path. Assess anatomy, neurovascular status, chest, abdomen, pelvis and global physiology. Antibiotics, tetanus, debridement and re-exploration depend on wound type and contamination; immediate tight closure of every war wound is unsafe.

Collapse and prolonged compression may cause crush syndrome, rhabdomyolysis, hyperkalaemia, kidney injury and limb ischaemia. Rescue and clinical teams should coordinate before and after release and monitor cardiac rhythm, electrolytes, urine and perfusion. Dialysis may become a system bottleneck, so renal, critical-care, pharmacy and transfer teams need early involvement. Fasciotomy is not a prophylactic response to every swollen limb; it requires clinical diagnosis and surgical judgment about timing and tissue viability.

Burn and CBRN events: prevent secondary contamination of the facility

For burns, stop the burning process, remove items that are not adherent, cool appropriately and prevent hypothermia. Estimate depth and area, assess facial, neck and inhalation injury and look for associated blast or penetrating trauma. Major burns consume repeated operations, dressings, infection-control capacity, nutrition and rehabilitation long after the initial bed is assigned. Teleconsultation and staged transfer with a burn centre may be safer than sending all patients simultaneously.

For chemical, biological, radiological or nuclear exposure, identify potentially contaminated patients outside the main entrance when circumstances permit. Establish hot, warm and cold zones and a one-way decontamination flow that protects staff and prevents secondary emergency-department contamination. Clothing removal, gentle irrigation, specimen handling and waste containment depend on the agent and authoritative hazard information. Antidotes, protective levels and ventilation differ widely; do not guess an unknown agent from odour alone.

Pre-event planning should name a CBRN lead, alternative entrance, security, decontamination equipment, protection, wastewater pathway, toxicology consultation and public-health notification. Exercises must test donning and doffing, heat strain, communication, privacy and continuation of lifesaving care—not merely erect a tent. Self-decontamination before arrival reduces but does not eliminate the need to ask about place, time, material and symptoms.

Damage-control resuscitation and surgery: preserve theatre capacity for the right objective

For severe hemorrhage, damage-control resuscitation combines rapid bleeding control, appropriate blood therapy, calcium and coagulation attention, and prevention of hypothermia and excessive crystalloid. Damage-control surgery abbreviates the operation to control hemorrhage and contamination, followed by physiological restoration and later reconstruction. It is not the mandatory operation for every war injury. Oversimplification can unnecessarily stage a procedure that could safely be completed, or keep an unstable patient in a prolonged reconstruction.

Operating priority should be a shared surgical, anaesthetic, emergency, critical-care, blood-bank and nursing decision. Consider reversible mortality risk, procedure duration, blood and the postoperative destination. If no ventilator, critical-care nurse or evacuation exists after the operation, the theatre has only moved the bottleneck. Each case needs a defined goal and stopping point, streamlined equipment and anaesthesia, preserved capacity for the next case and postoperative retriage.

Ukraine publications from 2025 describe care from point of injury to Role 2+, prolonged casualty care and damage-control approaches; 2026 recommendations and conflict-zone trauma-system reviews emphasize data, tiered referral, training and civil–military integration. Much of this evidence is observational, qualitative or contextual. It can stress-test a Taiwan hospital plan that assumes rapid evacuation and abundant supply, but it does not prescribe one transfusion or operative threshold for every institution.

Prolonged casualty care and evacuation: assume transfer will not arrive on time

Roads, airspace, weather, receiving beds and security can delay transfer. A patient expected to remain for one hour may require care for 12 or 24 hours. Prehospital posts and smaller hospitals therefore need monitoring, repeated bleeding assessment, analgesia, antibiotics and tetanus where indicated, warmth, urine monitoring, nutrition, nursing, pressure-injury prevention and documentation. Prolonged care is not an intensive-care unit in a backpack; it identifies likely deterioration, sets reassessment intervals and defines transfer triggers.

A transfer record should include identity, unique number, injury time and mechanism, first and latest vital signs, key findings, tourniquet time, airway and chest tubes, fluid and blood, medicines, allergies, operations, contamination status and the next anticipated risk. Use a structured verbal handover and require readback. Transport needs staff, medicine, oxygen, power and a route appropriate to instability. A higher-level hospital on paper is not a benefit if the journey cannot support the patient.

A 2026 report from a Gaza trauma stabilization point described 1,928 presentations: 47% were trauma, most arrived stable, about 81% were discharged from the point and 19% referred. This suggests a community-proximate stabilization point can offload a hospital. It remains a single-site descriptive report whose results depend on location, safety, referral network and case selection; the percentages should not be adopted as universal targets.

Manage blood, oxygen and high-use material by burn rate, not shelf count

A hemorrhage event rapidly consumes red cells, plasma, platelets, fibrinogen, calcium and laboratory capacity. The blood bank needs emergency-release, sample-identification, redistribution, cold-chain and resupply procedures. Clinical teams need shared activation and stop criteria so that blood is not ordered twice or lost when a patient moves. Public donation requests should come from the official blood service; uncoordinated donors arriving at a hospital may impede access and consume staff.

Calculate oxygen by flow. High-flow nasal therapy, ventilators and anaesthesia consume at different rates. During central-system failure, cylinder exchange, secure mounting, transport, regulators and fire safety require labour. An oxygen lead should update estimated hours remaining each shift, while clinicians apply safe oxygen stewardship and address leaks before the final cylinder.

Pharmacy and logistics should maintain a high-use list and approved alternatives for hemorrhage care, anaesthesia, analgesia, antimicrobials, burn dressings, chest drains, external fixation, intravenous or intraosseous access, laboratory consumables and cleaning. Substitutes need advance review for concentration, dose, connectors and labelling. Improvised replacement during a crisis can create a new medication or equipment hazard.

Infection and antimicrobial resistance: debridement and antibiotics are not substitutes

Delayed care, contamination, devitalized tissue, repeated transfer, crowding and low water availability increase infection and antimicrobial resistance. Preserve hand hygiene, injection safety, cleaning and sterilization, wound review, timely debridement, tetanus prevention, indicated antibiotics and sampling. “War wounds are dirty” does not justify indefinite broad-spectrum treatment; inadequate source control cannot be corrected by antibiotics alone.

Maintain a simplified infection-surveillance system for wound cultures, resistant organisms, postoperative infection and clusters. When laboratory capability falls, use regional resistance data and a pharmacy or infection team to define empiric tiers, then narrow treatment when results return. Expanded capacity must include airflow, protective equipment and isolation pathways without delaying lifesaving intervention.

Children, pregnancy, older age, disability and chronic disease remain priorities

Children differ in airway, blood volume, temperature, drug dosing and psychological support. Prepare weight-estimation tools, pediatric airway and access equipment, warming, caregiver identification and reunification. A walking child may be unable to describe serious symptoms. For trauma in pregnancy, maternal resuscitation comes first while gestational age, fetal assessment and obstetric capacity are considered. Obstetric and neonatal teams should be engaged early.

Older adults can decompensate after apparently minor injury. Frailty, anticoagulation, cognitive impairment, hearing or visual loss and interrupted medication affect triage. Disabled patients need aids, accessible communication, caregivers and routes; difficulty speaking or moving is not a proxy for poor prognosis. Dialysis, insulin, oxygen, anticonvulsants and psychiatric medicines can create new emergencies within days, so continuity capacity must be planned beside trauma surge.

Family reunification and missing-person inquiries need dedicated teams so resuscitation staff are not answering phones. Preserve photographs and identifiers for children and patients who cannot communicate, document the accompanying person and destination, and protect privacy. Publishing names, images or procedures can cause misidentification, violate dignity and disclose facility information.

Ethics and international humanitarian law: need, impartiality, dignity and accountable allocation

International humanitarian law requires care for wounded and sick people according to medical need without adverse distinction. Health workers, facilities and transport are protected while performing their medical function. Patient data, locations and staff lists may create security risks, so communications should follow local law, institutional policy and minimum-necessary disclosure. Healthcare workers must not participate in torture, inhuman treatment or non-medical discriminatory care.

When resources are inadequate, use a preapproved fair framework based on clinical reversibility and expected resource benefit, reassess decisions and avoid leaving the treating clinician isolated. Disability, nationality, occupation, social status or who demands most loudly are not acceptable hidden shortcuts. When treatment must be limited, explain honestly where possible and continue symptom relief, care and dignity.

An ethics support team can rehearse difficult situations: the last ventilator, one theatre, depleted blood, a staff relative, media demands, armed persons entering the hospital and refusal of transfer. The aim is a consistent process, not a predetermined answer for every patient. After-action review should encourage honest learning and distinguish remediable system failure from deliberate misconduct.

Training: short, repeated, multidisciplinary and designed to reveal failure

A 2025 multidisciplinary program in Ukraine included advanced trauma, trauma nursing, pediatrics, prehospital care, bleeding control, mass-casualty management and CBRN. Wartime readiness cannot be reduced to one surgical course. Physicians, nurses, EMS, pharmacy, laboratory, imaging, administration, IT, security, cleaning and logistics all need roles because failure of any link can halt care. Refresher practice and in-situ exercises must follow classroom training.

Tabletop exercises test command decisions; functional exercises test one system, such as offline registration or oxygen interruption; full-scale exercises test flow and coordination. Add one or two realistic constraints at a time: night shift, blocked entrance, failed mobile service, pediatric casualties, family crowds or inadequate generator load. An exercise is not a performance. Permit failure, assign each corrective item to an owner and deadline, and retest it.

Useful measures include alert-to-command time, arrival-to-first-triage, retriage rate, unique-identity completeness, tourniquet-time documentation, delay to critical intervention, theatre turnover, blood waste, unknown patient destination, staff exposure, interruption of routine emergencies and family-information response. Metrics identify bottlenecks; they should not become public blame rankings.

What 2025–2026 conflict evidence supports—and where uncertainty remains

Hildreth and colleagues' 2025 interviews with responders in Ukraine identified preparation and training, variable triage, communication and teamwork, and psychological strain. Work by Lawry, Holcomb and Samofalov considered point-of-injury to higher-level care, system assessment, prolonged care and damage control. These reports strengthen the case for common language, repeated training and planning for delayed evacuation. They are largely qualitative, observational or narrative and cannot estimate the mortality effect of one isolated protocol like a randomized trial.

The 2026 wartime-plan staff study highlighted personal safety and information uncertainty. A Somalia course evaluation shows that standardized WHO mass-casualty training can be implemented in a resource-constrained setting. The Gaza stabilization-point series suggests that forward stabilization may reduce hospital congestion. Sites, threats, patient populations and care levels vary substantially. Their best use is to ask, “Where would our plan break if Taiwan faced this constraint?” rather than copying a bed ratio or equipment list.

Conflict-zone trauma-system and military–civilian integration articles in 2026 emphasize cross-level data, shared training, capability tiers and continuous quality improvement. The responsible overall conclusion is that outcome depends on safety, time, system and clinical action together. No device or individual skill compensates for broken command, supply and evacuation. Local risk assessment, official planning, repeated exercises and learning from incident data remain central.

A 90-day starting plan for healthcare institutions

A clinic, district hospital and tertiary centre have different missions, but all can begin with six checks: safety, command, communication, paper records, essential supplies and transfer. A plan does not need to be perfect at first. It must be found on a night shift, used by someone who did not write it and revised after a realistic test. That is practical wartime health-system resilience.

How evidence is selected, updated and corrected: editorial and sourcing policy.