EVACUATION OF A CRITICAL PATIENT

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Inna DEMITER

PHD, anesthesiologist of the charitable organization

"charitable foundation moas-ukraine", head of the department

Roman KUZIV

Lieutenant Colonel of the Medical Service

Commander of the Military Medical Clinical Center of the Eastern Region

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Evacuation of a critical patient is an important and necessary topic in modern military medicine. Evacuation stages, basic monitoring, and transportation challenges are on the main focus here.

MOAS teams operate along the entire line of contact. Depending on the needs of the specific area, MOAS doctors, paramedics, and drivers work as a part of combined medical units and forward surgical teams of the Defense Forces.

Currently, the vehicle fleet of MOAS includes 19 Class “C” ambulances. The lion's share of our work involves the evacuation of critically wounded from transfer points to Role 1, and from Role 1, 2 to Role 3.

A vital aspect of our work is the safety of personnel, which includes personal protective equipment, training in self-aid and mutual aid, a well-established logistics system, and effective communication. Continuous trainings, systematic analysis, and learning from mistakes help us to improve our performance.

Timely and quality evacuation of a critical patient between Roles is extremely important, as reducing the time for required therapeutic or surgical interventions prevents deaths from potentially treatable diseases, injuries, and wounds.

PATIENT EVACUATION CATEGORIES (ORDER OF THE MINISTRY OF HEALTH OF UKRAINE № 879)

 Category I or “urgent” includes patients with a limb trauma and a tourniquet applied; penetrating or other severe eye injuries, including burns. Significant injuries caused by improvised explosive devices. Gunshot or penetrating shrapnel wounds to the chest, abdomen, or pelvis. Blunt trauma to the chest, abdomen, or pelvis with suspected hemorrhage that cannot be stopped by direct pressure.

With progressive airway obstruction and respiratory failure. Unconscious wounded. Known or suspected spinal injury. In a state of hypovolemic or other type of shock. External hemorrhage that is difficult to control. Moderate or severe Traumatic Brain Injury (TBI) and burns > 20% of the total body surface area. Category I patients should be evacuated within 2 hours.

Category II patients (or Priority wounded) should be evacuated within 4 hours, including those with the following pathologies: isolated open limb fracture with controlled hemorrhage, significant soft tissue injury without massive hemorrhage, limb injury with an absent distal pulse, burns covering from 10% to 20% of the TBSA.

Category III patients, who should be evacuated within 24 hours, include wounded with: Concussion (mild TBI); Gunshot wound to a limb with controlled hemorrhage, and without a tourniquet applied; Mild shrapnel wounds to soft tissues; Closed fractures with an intact distal pulse; or Burns covering < 10% of TBSA.

ORGANIZATION OF MEDICAL EVACUATION

In order to organize the proper evacuation of casualties it is necessary to ensure the team's safety, communication between the departure and destination points, and to have a technically well-equipped vehicle available. According to Joint Trauma System, at minimum, twice the length of the transport should be planned for when packing items.

Before being moved the casualty should be provided with optimal resuscitation and a correct assessment to reduce or prevent the deterioration during or after evacuation.  

A key factor in safe evacuation is continuous monitoring, with timely correction of vital signs and the management of emergencies during transport. Additional resources should be involved if necessary, considering the evacuation route.

The final stage of transportation involves completing documentation and the patient transfer to the receiving party. 

CASUALTY ASSESSMENT BEFORE TRANSPORTATION

Assessment of the casualty before transportation should be conducted according to the well-known MARCH algorithm, where the letter M refers to Massive Hemorrhage. So, have all massive hemorrhages been controlled? If not, let’s try to achieve this goal: 

The letter A refers to Airway. If the patient has an impaired consciousness on stupor level, and you are unsure whether to intubate him before transport or not — then intubate. It is unlikely that the patient’s condition will improve during transportation.

At the letter R (Respiration), pay attention to possible chest injuries, re-check external respiration. Repeat the lung ultrasound examination.

The letter C (Circulation) corresponds to the concept of shock. Repeat hemodynamic monitoring, laboratory diagnostics, and check the blood volume (volemia) status, using ultrasound, urine output rate, and capillary refill time. Check whether all non-massive hemorrhages are controlled. If the patient has a massive hemorrhage, it can be surgically controlled - apply a provisional tourniquet to the affected limb (5–8 cm above the wound) for patient’s safety in case of re-bleeding during evacuation.

The final letter H stands for Head injury examination and Hypothermia prevention.Remember that hypothermia is one of the components of the Trauma triad of death (acidosis, hypothermia, and coagulopathy).

Important:Make sure that everything essential for the patient has been done at the current Role. Remember the Order of the Ministry of Defence of Ukraine № 598 from Sep 03, 2024 about scopes for pre-hospital medical care during military operation (with amendments from Sep 03, 2025 № 296).

ACTION ALGORITHM

Have the target parameters been achieved? If not, then develop a plan to optimize the patient’s condition according to the available resources and the tactical situation. Carry out corrections on-site, or take everything you need for the transportation. (For example, after examination of the blood volume status and determination of the hemoglobin level (Hb < 80 g/L), the patient requires infusion–transfusion therapy. Consider the treatment already provided and take blood products with you). Once the targets are achieved, record the parameters and load the patient on board.  

Ensure that the resuscitation parameters have been achieved. According to the Joint Trauma System Clinical Practice Guideline “Interfacility Transport of Patients Between Theater Medical Treatment Facilities” Resuscitation Goals include: 

1. Heart Rate 50-120 /min

2. SBP >90 mm Hg (MAP >60 mm Hg), and for patients with TBI > 110 mmHg

3. SpO2 > 92%, FiO2 required <50%

4. Temp > 95ºF/35ºC

5. Urine Output > 50 mL/h

6. Hemoglobin > 8.0 g/dL

7. Platelets > 50k/mm³

8. INR < 2.0

9. Base Deficit < 6

10. Lactate < 2.5 mmol/L

MONITORING DURING EVACUATION

The British organization Intensive Care Society in its guidance on: The Transfer Of The Critically Ill Adult, states that all monitoring and equipment must be suitable for use in the transfer environment. All portable equipment must be securely stowed to reduce the risk of injury in the event of an accident. Central venous catheterisation is not essential but may be of value in optimising filling status prior to transfer or may be required for the administration of inotropes and vasopressors.  Patients should be appropriately resuscitated and stabilised prior to transfer to reduce the physiological disturbance associated with movement and reduce the risk of deterioration during the transfer. Minimum standards of monitoring must be applied in every case. Monitoring should be continuous throughout the transfer. All monitors, including ventilator displays and syringe drivers should be visible to accompanying staff. Patients should be securely strapped to the transfer trolley by means of a 5-point harness (or similar). Reassurance, sedation, analgesia and anti-emetics should be provided as required to reduce patient discomfort and distress.

What level of monitoring is appropriate during transfer of a critically ill patient? When considering the safety of a critically ill patient, the minimum standards of monitoring required are: ECG, non-invasive blood pressure (or invasive, if needed), oxygen saturation (SpO₂), capnography, and temperature. Alarms should be visible as well as audible in view of extraneous noise levels. Portable mechanical ventilators should have, as a minimum, disconnection and high-pressure alarms, the ability to supply positive end expiratory pressure (PEEP) and variable inspired oxygen concentration (FiO2), inspiratory/expiratory (I/E) ratio, respiratory rate and tidal volume. (Source: https://ics.ac.uk/resource/transfer-critically-adult.html)

According to the updated safety standards for critical patients care and in the line with Helsinki Declaration on Patient Safety in Anaesthesiology, there must be: continuous presence of an anesthesiologist or trained personnel, non-invasive blood pressure measurement every 5 minutes (or invasive if needed), continuous SpO₂ and heart rate monitoring, continuous ECG, capnography for mechanically ventilated patients or during spontaneous breathing and sedation, and temperature measurement.

DOCUMENTATION FILLING AND PATIENT HANDOVER

Information accuracy and properly filling of transportation cards. Both parties should act collegially. Full information disclosure without concealing any details or mistakes. Errors should be discussed, analyzed, and corrected.

What happens after the patient has been successfully handed over to the receiving party? According to Patrol Police data, there were 3,202 road traffic accidents with injures in 2024.

Based on the Medical Forces and Sustainment Group “East” data, 38% of non-battle surgical trauma were due to road accidents. Evacuation teams often encounter such patients while returning to their base locations.

CLINICAL CASES

Clinical Case 1

During evacuation, various unpredictable situations may occur, related not only to changes in the patient's condition but also involving the transport vehicle itself.

The following situation once again confirms the recommendations of both the Intensive Care Society and the Joint Trauma System regarding the transportation of critically ill patients: evacuation should be well-coordinated, and at minimum, twice the length of the transport should be planned for when packing items.

After 30 minutes of route between Zaporizhzhia and Kyiv, the MOAS ambulance broke down, unable to continue to move with all its internal power sources were lost. There was a critically ill patient on board who required mechanical ventilation for respiratory failure (Grade 2–3), continuous infusion of vasoactive drugs, and uninterrupted vital signs monitoring. It is essential to have a sufficient battery charge on every medical device (ventilator, syringe pump, and monitor).

Thanks to the coordinated logistical efforts of the crew and the director, the nearest available team was dispatched to continue the long evacuation route.

And what about monitoring? How should blood pressure be measured in a patient with both upper limbs burns and one of them amputated? The correct solution would be - the invasive monitoring.  But is it still suitable when the existing arterial line was lost during patient transfer, and there is a hematoma at the insertion site? A large-bore IV catheter is placed on the contralateral limb, with infection signs. And patient’s handover was taking place at the transfer point? Therefore, the team decided to measure blood pressure non-invasively on both lower limbs, using two monitors simultaneously. This proved to be sufficient for hemodynamic control and adjustment. This case highlights the importance of balanced decision-making in any invasive interventions during patients’ transportation. With continuing intensive therapy, the team had successfully delivered the critically ill patient to point B destination without deterioration.

CLINICAL CASES

Clinical Case 2

The MOAS vehicle fleet has a multifunctional medical evacuation bus with all necessary medical equipment, capable for three critical and three mild patients.

A simultaneous evacuation from three different regions was initiated. The operation began by medical bus departing from the Donetsk direction, transporting a critical patient to Dnipro. After handing the patient over to the medical staff at Mechnikov Hospital, the team received another critically wounded patient for the further evacuation. At the same time, two more critically wounded patients on mechanical ventilation were being transported from the Zaporizhzhia direction.

The MOAS team which was working in the multifunctional medical evacuation bus started the evacuation process of three critically ill patients to Role 4 medical facility on a distance of 700 km.

Well-established logistics. Effective allocation of human and technical resources. As a result — timely specialized medical care.

CLINICAL CASES

Clinical Case 3

 As a result of a road traffic accident, there were three casualties.

Patient 1: Active, agitated, with no visible injuries, with intoxication signs by an unknown substance.

Patient 2: Forced sitting position, closed chest injury, possible right-sided pneumothorax. Closed fracture of the right forearm bones.

Patient 3: Traumatic brain injury, skull fracture. Anisocoria, coma.BP: 90/50 mmHg, HR: 50 bpm, RR: 8/min, SpO₂: 90%.

After triage medical assistance was provided to the critical (red) patient first: Cervical spine immobilization and ambulance transfer on a spinal board. Primary assessment following the trauma algorithm. No massive hemorrhage detected. Airway obstruction and bradypnea with desaturation identified. IV access was established, followed by pre-oxygenation, induction, and tracheal intubation. Vital signs were measured, and bradycardia was corrected. Minor bleeding from the scalp was controlled. Continued support of vital functions.

Next, medical assistance was provided to the yellow patient: No massive hemorrhage or airway obstruction was found. Closed chest trauma with suspected pneumothorax. SpO₂ decreased to 90%, RR 20/min. O₂ therapy via the face mask. IV access, and analgesia was given. Lung ultrasound did not confirm the pneumothorax. After analgesia, the patient regained full diaphragmatic excursion, thus the external respiration normalized. Immobilization of the upper limb was performed with a SAM splint.

The green patient was left without immediate assistance. Given the condition priority, the decision was to move forward to the medical facility, leaving the Patient №3 at the scene with the Police. In 30 minutes the Patient №3 was also evacuated to a medical facility, due to the deterioration and suspected TBI.

So, in what order should assistance be provided to casualties? Let's analyze the situation. The triage at the scene was performed absolutely correctly and assistance was provided in accordance with the priority. It is important to emphasize the need for sufficient medical personnel depending on the number of patients requiring care. Therefore, additional medical resources were mobilized to assist the third patient

COMPARISON OF HEMODYNAMIC PARAMETERS BEFORE AND AFTER TRANSPORTATION

*p-value according to the Wilcoxon test

Considering the proper preparation, comprehensive pre-assessment, and continuous monitoring with appropriate correction during transportation, no significant difference in systolic blood pressure values was found. The median values indicate that hemodynamic parameters were maintained within the reference range.

Direction	Systolic arterial pressure before transportation, mmHg	Systolic arterial pressure after transportation, mmHg	p-value
Zaporizhzhia direction N=190	122,5 (110,0; 136,0)	121,0 (112,0; 132,0)	0,5823
Sumy direction N=127	117 (105; 126)	119 (108; 131)	0,0625
Donetsk direction N=565	120 (108; 130)	120 (112; 130)	0,1634

During the transportation of emergency patients, the following complications were observed: Massive hemorrhage: external, internal (n = 8), Hemodynamic instability (n = 10), Progressive respiratory failure (n = 3), Cardiac rhythm disturbances (n = 6). Based on existing emergency care protocols, local action algorithms were developed to manage various critical conditions that may occur during transport.

GENERAL PATIENT CHARACTERISTICS BY DIRECTION

p-value according to the Kruskal–Wallis or Chi-Square test

In 2025, the MOAS teams transported 2,784 emergency patients. For statistical analysis there were taken, a sample of 190 patients from the Zaporizhzhia direction, 127 patients from the Sumy direction, and 565 patients from the Donetsk region.

Indicator	Zaporizhzhia direction N=190	Sumy direction N=127	Donetsk direction N=565	p-value
Age, years	38,5 (31,0; 46,0)	38,0 (32,0; 44,0)	37,0 (30,0; 45,0)	0,2787
Evacuation duration, min	80 (70; 94)	60 (35; 257)	195 (110;230)	<0,001
Mechanical ventilation, n/%	108/56,8	110/86,6	552 / 97,7	<0,001
Vasopressors, n/%	55 / 28,9	51 /40,2	132 / 23,4	<0,001