Introduction
In both the current Ukrainian conflict and in future wars, casualty numbers can and will be overwhelming to first responders, given the limited resources relative to the potential scale of casualties. Despite US involvement in prior wars and conflicts across the globe, there is a paucity of literature on combat mass casualty incident (MCI) response. Existing research on military MCI response primarily focuses on specific interventions performed,Reference Schauer, April and Simon1 or the limitations of current triage methods,Reference Vassallo, Beavis and Smith2, Reference Rush, Lauria and DeSoucy3 leaving a gap in truly understanding the lived experiences of medical responders (medics, physicians, and advanced practice providers) during MCIs. Filling this gap is crucial toward improving support for MCI medical responders and to provide guidance that could save more lives.
In civilian MCI response, the primary goal is saving lives. Conversely, military MCI response juggles 2 objectives: patient care and operational mission support.Reference Annas4 These potentially conflicting goals can create ethical dilemmas and complexities for military medical providers, further highlighting the critical need to understand their individual experiences.
Research of civilian MCI responseReference Kamler, Taube and Koch5-Reference Ryan, George and Liu7 reveals a tendency of medical first responders to abandon formal triage categories during chaotic situations when they need them the most. This underscores the need for a unified and practical approach to MCI triage that can effectively guide medical decision-making in these chaotic and challenging situations. Triage, or sorting, is the allocation of resources based on the initial patient assessment and available resources,8 as well as the dynamic and ongoing process of re-triage. By investigating the experiences of providers who have managed an MCI, we can potentially identify triage strategies that will be more effective and not be abandoned during real-world scenarios.
The Ukrainian conflict, with its multidomain battlefield environment,9 offers a unique opportunity to examine MCI response in a complex and dynamic setting. This conflict highlights challenges faced when uninterrupted superiority in any domain (land, sea, air, space, and cyberspace) cannot be guaranteed, forcing a reliance on specialized units and potentially unmanned capabilities. These factors increase the likelihood of casualty incidents overwhelming available resources (supplies and providers), leading to an increased number of casualties. Lessons learned from Ukraine can inform the development of more effective medical care strategies for future conflicts.
While the media has reported various accounts of Ukrainian health care providers during an MCI, their experiences have not been researched in-depth. The purpose of this qualitative study, therefore, was to leverage qualitative research design to explore the experiences of military medical personnel who have responded to MCIs in the Ukrainian conflict.
Methods
Our research team selected the descriptive phenomenological tradition of qualitative research design to explore and report the experiences of our participants. This tradition focuses on clearly and accurately portraying how participants experience a phenomenon, or their “lived experiences,”Reference Sundler, Lindberg and Nilsson10 without adding in any outsider perspectives or interpretation.Reference Shorey and Ng11 In accordance with best practices and to maintain this authentic perspective, our research team actively bracketed our own biases so we could objectively portray the participants’ experiences and perceptions.Reference Sinfield, Goldspink and Wilson12, Reference Thomas and Sohn13 This study was approved by the Uniformed Services University Institutional Review Board (IRB) and underwent human subjects review by the First Lviv Medical Union in Ukraine.
Our study sample was a convenience sample of 10 participants. Two of the 10 were excluded as their MCI experience was not from this current conflict but based on former training and experiences. The remaining 8 participants were medical personnel who responded to MCIs in Ukraine during the current Russia-Ukraine conflict. Members of our research team (AFH, CS, SLR, MG) conducted 90-minute, in-person, semi-structured interviews with volunteer participants. The interviewers were all board-certified, emergency physicians with prior experience in mass casualty response. One additional collaborator on this study (NM) is a Ukrainian clinician who provided sponsorship for local human subjects review and later contributed to the review and refinement of the manuscript to help ensure contextual appropriateness of the final product.
The interview questions were developed by the experienced team of military physicians and PhD researchers. Inclusion criteria included medical personnel who responded to one or more MCI during the current conflict in Ukraine. The interviews took place in the Fall 2024 at the conclusion of the Mass Casualty Response Symposium, hosted by the Combat Casualty Research Program in Warsaw, Poland. All symposium attendees were invited to volunteer for the study, and interviews were conducted after the symposium concluded. No participants refused to participate or dropped out of the study.
Due to language differences between the research team and some participants, we invited our participants to choose whether or not they would like a translator to assist them during the interview. These translators were trained in qualitative research methodology and were briefed on all confidentiality measures.Reference Kapborg and Berterö14 Our study sample was a convenience sample of 10 participants. Two of the 10 were excluded as their MCI experience was not from this current conflict but based on former training and experiences. All interviews were audio-recorded and then transcribed using an automated transcription service. Because our participants returned to war zones without reliable internet connection or mail services after our interactions at the symposium, we were not able to engage in member checking.
Research team members followed the steps of descriptive phenomenological data analysis to analyze the interview transcripts.Reference Sundler, Lindberg and Nilsson10 First, we engaged in bracketing by discussing our biases and how these biases may impact our interpretation of the interviews.Reference Thomas and Sohn13 Members of our research team (AFH, RC, CS, MG) then immersed themselves in the data, reading each interview transcript closely to fully understand the participants’ experiences.
Initial coding was performed using an open coding method by one investigator, who identified recurrent patterns across transcripts. The initial codes included: tactical, resources, communication, preparedness/training, protocols, movement, triage, and stress. A second investigator reviewed the coding framework to confirm consistency. These codes were then applied across all 8 transcripts. After all transcripts were coded, the research team clustered the codes into 4 overarching themes based on frequency, conceptual overlap, and relevance to the study’s aim.Reference Sundler, Lindberg and Nilsson10 Given the clarity and recurrence of the themes and the relatively straightforward nature of the dataset, a formal qualitative analysis software tool was not used. However, a summary code-to-theme mapping is included in Supplementary Table 1 for transparency. While our sample size (n = 8) is small, the consistency of themes across participants suggests that we reached sufficient saturation to support initial insightReference Saunders, Sim and Kingstone15 and present a “rich, thick description” of the essence of our participants’ experiences in the Ukraine conflict.Reference Younas, Fàbregues and Durante16
Results
Summarized demographic data of our participants can be seen in Table 1.
Participant demographics and categories of mass casualty incident
Analysis of the interviews revealed 4 key themes: (1) need for preparedness and training, (2) variability of triage, (3) importance of communication and teamwork, and (4) resulting psychological strain.
Theme 1: Need for Preparedness and Training
When describing their experiences, the participants consistently emphasized the crucial role of preparedness and training for effective MCI response. Participants stressed the need for comprehensive and continuous training encompassing triage, medical procedures, communication protocols, and psychological preparedness. One participant stated emphatically, “I’m a big fan of trainings.” Describing the most beneficial training experiences, 1 participant reported: “I think the most important training that we had was just working together and working through problems of whatever scenario that we were thrown into, whatever exercise we were doing or real world, all the mascals that we had up to that point.” Another commented, “it’s unit rehearsals on the medical level and also with everybody else,” highlighting the need for both specialized medical training and integrated unit training involving medical personnel. A prevailing sentiment among interviewees was the importance of fostering a culture that prioritizes ongoing training.
Several participants likewise expressed concern that medical training is sometimes overlooked or undervalued by military leadership, leading to gaps in readiness. One provider noted: “In our experience, training is usually neglected. The providers are really, like, skeptical about this, like, ‘Oh, we are taking real casualties. Why do we need the training?’” Another mentioned, “Medics are considered kind of second thought.”
The importance of realistic and context-specific simulations for enhanced preparation was also frequently discussed. One participant emphasized the value of repetition in training sessions: “First sessions are chaotic, but subsequent ones improve as responders adjust to what’s expected.” Others highlighted the need to update training to reflect the current operational reality. For example, one described how “our scenarios based on Iraq and Afghanistan didn’t match what we faced—no ambushes or IEDs, so they felt irrelevant.”
Finally, while acknowledging that training cannot fully prepare for every real-world scenario, participants still believed it significantly improved their ability to manage such situations. One person noted: “We cannot prepare 100% because you never expect what may happen. But proactive preparation allows you to better react to the event.” Other participants also recalled the importance of training in the moment when facing a mass casualty, with 1 responder saying: “Because like people in a high-stress situation, like, you go into the little black box. And inside that little black box, it’s every single piece of training you had to a high enough level to stay in the black box. Then your brain kind of forgets everything else.”
Theme 2: Variability of Triage
Various factors were identified as influencing triage decisions, but analysis revealed a prominent theme centered on the notable variability in how these decisions were enacted among different situations and personnel. Participants emphasized that effective triage systems are critical for managing large-scale incidents, but require strict coordination and adaptation to the specific operational context. As 1 interviewee emphasized: “Triage is a state of mind for us.”
Participants acknowledged the need for a standardized system, with one reporting: “Medics and soldiers must understand the algorithm of their actions and establish a common language to reduce errors,” no single standard system was reported by a majority. Some participants mentioned using formal triage protocols, but many did not. One participant described a system of dividing casualties into categories—“surgical, non-surgical, light, and heavy wounded,” while another described a system based on “moderate, severe, and mild” injuries. Still another divided patients by their ability to walk: “If we have patients who can sit up and walk, we have a tent for them and they can go there and wait for their evac.”
One medic also discussed their individual approach of working through each patient systematically, using the battlefield algorithm MARCH: Massive hemorrhage, Airway, Respiration, Circulation, and Head Injury/Hypothermia,Reference Kosequat, Rush and Simonsen17 “I have these three or four people. What I’ll do is go through the MARCH process, I’ll just do that for all four and that’ll be that. And that way there’s no, like, confusion of being like, I did everything for this guy.”
Several participants likewise noted that their triage approach focused on addressing the most critical patients first: “I started doing triage by handing out supplies from my bag to whoever needed immediate aid. One guy lost both legs—getting him help was my priority.” Another described a resource-conscious approach: “If they weren’t actively bleeding, if it was a gunshot wound and everything was cauterized, nothing was expanding good to go, then we wouldn’t wrap it.” In contrast, another simply reported attending to the closest patient first: “He was the closest to me and I started working on him.”
Participants’ descriptions moved beyond a single triage approach, with a frequent emphasis on the necessity of continuous triage. One participant reported, “So it’s not just triage of patient[s], it’s 100 triages.” Another commented, “But in any case, we will retriage them because it’s never [the] end of the story. You can’t stop the triage.” Participants described their process of re-evaluating patients and planning for evacuation, with one noting: “So while I’m thinking about all of that, looking at the injuries, dealing with them, I’m kind of categorizing out of the people I have in front of me who can stay the longest, who needs to go the quickest.” This was reinforced by another participant: “I go back through {and} re-reassess absolutely everything.”
Our participants ultimately noted that triage decisions are influenced by the resources available. For critically ill patients, considerations include the number of other patients present and available evacuation capabilities. One provider observed that patients seemed to call out: “I need, I need, I need, I need, I need, and is it reasonable?” However, another reported a tendency to treat the patients immediately at hand, “I don’t think I ever made … the decision of like, I’m not gonna use this because what if I need it down there? Because I hate the what if game.”
Theme 3: Importance of Communication and Teamwork
Another significant and frequently emphasized theme was the critical importance of communication and teamwork. Participants who had experienced MCIs emphasized the crucial role of communication, both from a systems perspective (effective channels and methods) and an interpersonal perspective (team and leadership communication). One participant stated, “If you have the communication, it’s not a problem to organize anything.” Challenges such as varying training levels, language barriers, and inconsistent communication tools were noted as hindrances to seamless coordination between teams and units. In addition, the reality of the situation introduces environmental communication barriers, contributing to difficulty coordinating efforts. As one participant illustrated, “The yelling was not on our part as far as craziness. It was the patients. And so we would have to talk over them to be able to have us heard or get the patients that are yelling out of, out of the way.”
Several participants reported difficulties communicating with military commanders. One reported, “We had no communication capabilities like the U.S., so we had to go to the commander to understand who was in charge, where stabilization points were, and where evacuation routes were located.” Notably, many of the medical providers were civilians prior to the outbreak of war in Ukraine. Participants noted the differences between civilian and military systems and the challenges of trying to integrate. One noted, “It’s completely different mindset, completely different, facilities. Everything is different.” Another noted that even with existing communication systems, it is important to “never think that the soldier understands you from the first time,” and ensure closed-loop communication and a “common language.”
The importance of a strong, cohesive team was a recurring theme. This included a clear understanding of roles and responsibilities, effective communication, and a mutual respect among team members, all of which contribute to efficient and effective mass casualty response. One provider recounted: “… my team had gone through so many mass casualties that we knew what each other was thinking and we knew what the other one was going to do.” Another commented, “It’s not sorting, it’s not triage, it’s not logistic. It’s only [the] team. If you have a good team, for dream team, it’ll be okay.”
Our interviewees finally reported challenges with inadvertently communicating information to the enemy due to the prevalence of drones in the operational environment. They noted the increased difficulties in maintaining operational security of information when casualties are involved. One reported: “they have everything on drone. They’re watching constantly. So there’s no hiding from the enemy anymore.”
Theme 4: Resulting Psychological Strain
The final theme that emerged from the participants of MCIs was the significant psychological strain resulting from these events. Most had to deal with extreme stress and challenging physical conditions, often risking their own safety to provide care. Participants noted the moral injury of being overwhelmed in an MCI and being unable to save all of those injured. One shared, “Two of my guys died before evacuation, and I think about it every day—it’s a weight I carry.” One provider reported, “I was injured and couldn’t walk but stayed back with my guys 30 meters from enemy lines for two hours, stabilizing them as best I could.” Whereas another reported, “It was mentally exhausting and trying, and I felt like I was barely treading water. I felt like my head was barely above water and being able to maintain everything.”
Many of the medical providers commented on the fatigue they experienced from dealing with mass casualties. One said, “It was exhausting working almost all day, but we built a good process that helped us manage the trauma workload.” Another reported, “It’s exhausting when you have mass casualties every day … the mental toll is enormous.”
Finally, our interviewees discussed the limited resources available to help providers manage stress after MCIs. One reported the difficulty accessing mental health care. Another noted negative coping strategies, “people want to reduce stress with alcohol.” Despite the lack of resources, the overwhelming sentiment was the understanding that there should be better methods to take care of people, as one participant put it, “[the] main resource of that war is people.”
Discussion
By identifying patterns in MCI response, gaps in education or training, and best practices, this study aimed to contribute to the understanding of MCI response and to inform future research related to understanding and improving upon MCI response. The participants in this study demonstrated a strong commitment to professionalism, not only in their willingness to share lessons learned but also in their desire to refine their approach to care as they returned to service. Their insights centered around 4 key themes: (1) need for preparedness and training, (2) variability of triage, (3) importance of communication and teamwork, and (4) resulting psychological strain associated with MCIs.
Preparedness and Training
Participants emphasized the necessity of comprehensive preparation and training, particularly the integration of both medical and non-medical components in MCI response. This focus aligns with Rush and colleagues,Reference Rush, Lauria and DeSoucy3 who stress that planning should encompass medical and non-medical roles, limited clinical interventions based on casualty numbers, and the availability of blood products. Additionally, contingency planning for surgical capacity and a walking blood bank is essential. These findings reinforce the importance of unit-level training that mirrors operational environments. Rather than focusing solely on specific triage algorithms, MCI training should prioritize adaptive decision-making and critical thinking skills.Reference Rush, Lauria and DeSoucy3 Realistic, scenario-based training that incorporates a range of medical and logistical challenges can help teams refine their processes iteratively.
Variability in Triage Execution
Consistent with previous research,Reference Rush, Lauria and DeSoucy3 participants reported significant variability in triage execution, including the lack of standardized algorithms and inconsistencies in category naming conventions. Despite this, they noted that triage remains fundamentally linked to subsequent life-saving interventions, including transport and evacuation. This underscores the need for training that moves beyond categorical assignments and instead emphasizes a focus on triage as a dynamic, action-driven process. First-pass triage should prioritize immediate life-saving interventions, while subsequent re-triage should refine patient categorization and care pathways. This staged approach, as described by Shackelford and colleagues,Reference Shackelford, Remley and Keenan18 is supported by data linking outcomes to time from injury and MCI response effectiveness. Participants highlighted the importance of re-triage, advocating for deliberate and structured integration of this process into training exercises.
Communication and Teamwork
Effective MCI response hinges on both technical and non-technical communication strategies. Prior researchReference Kamler, Taube and Koch5, Reference Pepper, Archer and Moloney6 has shown that communication systems frequently fail during MCIs, requiring responders to adapt to environmental challenges such as noise, disrupted infrastructure, and compromised channels. Participants emphasized the need for realistic training that incorporates environmental fidelity, exposes teams to these challenges, and enables proactive problem-solving. Training scenarios should simulate communication breakdowns and encourage innovative solutions, ensuring teams are prepared to maintain operational efficiency even in adverse conditions.
Psychological Strain and Moral Injury
Despite their extensive experience, all participants acknowledged the overwhelming nature of MCIs. This lack of a cohesive approach risks increasing both patient morbidity and mortality while also exacerbating psychological distress among providers. Given the ethical and emotional weight of these situations, it is imperative to develop better resources for psychological support and moral injury mitigation. Prior research has demonstrated that brief resilience training can positively impact U.S. Service Members’ mental health and well-being.Reference Zueger, Niederhauser and Utzinger19, Reference Peterson, Moore and Evans20 Future studies should explore whether similar interventions could enhance the psychological readiness of Ukrainian military medical providers.
Addressing these challenges requires collaboration among experts in medicine, military ethics, moral injury, and prehospital care. Clear, standardized response pathways should be developed to guide first responders, acknowledging distinctions between those facing an acute, “rapid” MCI versus those managing a prolonged, “gradual” MCI in a hospital setting.Reference Gignoux-Froment, Martinez and Derely21, Reference Prescott, May and Horne22
Additional Considerations
Beyond these primary themes, our participants highlighted broader concerns that warrant attention. While only a single example, the war in Ukraine underscores the urgent need for improved interoperability between civilian and military mass casualty response systems. Effective communication strategies must be developed to ensure seamless coordination while maintaining operational security, particularly in environments where enemy detection is a constant threat. Additionally, military medical ethics, moral injury considerations, and psychological resilience training should be integrated into existing curricula and training programs to better prepare providers for the realities of mass casualty care.Reference Gignoux-Froment, Martinez and Derely21, Reference Prescott, May and Horne22
Limitations
Given the variability in each of the MCIs, as well as the different levels of training of each of the responders, our participants’ experiences varied. Further wide-scale quantitative research exploring the experiences of responders in Ukraine and other nations who managed mass casualties both on the battlefield as well as throughout all the levels of care may be helpful in providing additional insight into best practices for medical responders.
We recognize that not using qualitative analysis software and not constructing a formal coding tree may limit methodological transparency. Given the narrow scope and structure of our data, we believe this approach still yielded meaningful thematic results, but we acknowledge this as a limitation.
Finally, most of our participants were Ukrainian and did not speak English, and no members of our interview team spoke Ukrainian. We utilized qualified interpreters; however, some data may have been lost in translation.
Conclusion
The results of our study provide a wealth of insights into the challenges and opportunities for improvement in responding to MCIs. Further exploration of tailored training, efficient resource allocation, streamlined communication, and psychological support, future responses should be considered to better understand and address the complexities of these chaotic and high-pressure situations.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.10226.
Acknowledgments
This manuscript has been copy-edited using AI assistance (Gemini advanced) for grammar.
Author contribution
MG developed the research protocol. NM assisted in protocol review. AFH, CS, SLR, and MG conducted in-depth subject interviews. AFH, CS, RC, and MG performed the thematic analysis. AFH drafted the initial manuscript. AFH, RC, CS, BM, SLR, NM, and MG researched, reviewed, and edited the manuscript. All authors read and approved the final manuscript.
Funding statement
This research was supported by the Defense Health Agency (HU00012420112). This effort was awarded through MTEC solicitation MTEC-24-01-MPAI and is funded by the Combat Casualty Care Research Program (CCCRP) in accordance with Congressional direction to establish medical partnering with Ukraine specified in Sec 736 NDAA 2023 and Sec 721 NDAA 2024.
Competing interests
None.
Institutional clearance
This research was reviewed by the Human Research Protections Program Office at the Uniformed Services University: IRB 24-20345, and underwent human subjects review by the First Lviv Medical Union in Ukraine.
Disclosure
The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University or the Department of Defense. The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions, or policies of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The views and conclusions contained herein are those of the author(s) and should not be interpreted as representing the official policies or endorsements, either expressed or implied, of the U.S. Government.
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