A bleeding casualty tends to become hypothermic even in warm scenarios; think of a casualty hit by small arms fire, or artillery splinters, bleeding at -10°C. How can medics “work” on him or her? How to maintain the casualty warm awaiting evacuation, which in peer-to-peer confrontation is definitely more critical than in operations other than war, those that western armies have been confronted to in the last decades, where the lack of air defence from opponents, save some small arms fire and the minimal risk of some shoulder-launched surface-to-air missiles, allowed extensive use of CASEVAC (Casualty Evacuation) helicopters?
This issue and many other were raised during a workshop at the 1st International Mountain Troops Summit, held in Grenoble on February 12th and 13th and organised by the French Army 27th Mountain Infantry Brigade (27 BIM) and by COGES Events. Titled “Explore the Specificities of Medical Care in Mountainous and Cold Environments” the workshop was presented by two female medical officers, Col. Natacha and LTC Capucine, both with a wide experience in military operations as well as in expeditions in extreme cold areas, in support to the High Mountain Military Group, GMHM the French acronym, based in Chamonix and part of the 27 BIM. One of them is now serving in Paris at the Armed Forces Medical Service and oversees adapting the military health service to cold environment operations, the Arctic scenario becoming more and more relevant.
The French military health system deploys teams at all levels, from the forward line on the battlefield, moving back through facilities with increasing capacities, which means Role 1, Role 2 Forward, and Role 2 field structures, the medical evacuation chain exploiting all possible land and air platforms and, “perhaps drones tomorrow,” one of the speakers said.
“We are going to detail the constraints that this [cold] environment brings and, behind them, the challenges that need to be met. Because today, we don’t have all the solutions,” the speakers announced.
It was made clear that under the medical standpoint “cold is an enemy. It is an enemy in the care of the injured or sick. It is an enemy on several levels.” And not only for the casualty, but also for the caregiver. “We cannot make the same gestures, we cannot act in the same way in a very cold environment. Why? Because there are gestures that require a technique, a finesse of gesture that is constrained in a cold environment.” Another major issue is the health product. “Is the health product safe if it freezes? Is it still effective? Or will it even become harmful?”
Cold has also an influence on specific equipment which is used by medical teams. When freezing, rubber tubes used for infusions tend to become rigid and to break. Not to speak about the batteries life used in resuscitating equipment.
And finally, if there is one last aspect, cold is also an enemy for the operational capacity of the forces. Beside war injuries, cold generates what is known as non-traumatic pathologies, ranging from non-freezing ones, such as trench foot, a major issue in Ukraine, to freezing pathologies, such as frostbites. All these impacts the capacity of the military to effectively cope with his operational duty.
To allow the caregiver to properly operate on the casualty, the first issue is giving him or her sufficient sensibility for the principal tool, the hands; solutions such as a layered glove system, possibly with one heated element, are being studied, taking in count hygienic issues.
The same is true for electrically powered medical equipment; considerations are being made about heating battery compartments, with batteries heating themselves but also “eating” themselves.
Heating might also be needed to avoid liquid medical products to freeze; warming them up after they have frozen is not practicable. “Pharmacists tell us that we should not use medical products that have frozen, because these might become dangerous,” the speakers explained. Exploiting body heat is something everybody does to keep his or her smartphone working when confronted with very low temperatures; this is the solution currently adopted, but one thing is doing it in a peacetime environment, this becoming a different story when wearing body armour, and when considerable amounts of fluids must be carried. The shift from operations other than war to peer-to-peer confrontation does not affects only the scenario, but sadly also the number of casualties. Therefore “heated backpackable” pharmacies might be needed. As anticipated, a similar problem applies to plastic materiel, that tends to become brittle; here research on new materiel might help solving the problem.
Another issue is how to take care of the wounded without exposing his or her body to the cold; undressing the casualties is not possible, hence new methods must be found to cope with simple issues, such as taking the core temperature. Some “future soldier” programmes considered equipping the individual soldier with health monitoring systems, but apparently no armies have yet adopted that solution. The French medical corps is equipped with dedicated materiel for “wrapping” the wounded, in subsequent layers, and to isolate the casualty from the cold surface, this worsening however capability to reach the body for treatments. Hence the need to have a “hot spot” close to the front, such as a vehicle, possibly purposely equipped; at which level this will be feasible, section, platoon, company, it is still under discussion. New systems are also being considered for the first part of the evacuation process; “we are looking for a stretcher that can be transformed in a sarcophagus, that completely wraps up the wounded, isolating him from the weather as well as from the ground, and that can be dragged on the snow or carried. And that is sufficiently light to be carried by the combatants,” the speakers told the audience.
The reduced reliance on CASEVAC helicopters means that the casualties might remain longer with frontline medical personnel, hence the need not only to have greater amount of fluids, medicines and batteries, but also to have more specific equipment. This is normally used in rear facilities and is often not suited for field use, ruggedised systems being needed.
Beside looking for new equipment, the French military medical service is also considering adapting its doctrine to the new cold weather reality.
“Today our doctrine aims at taking care of the casualty as close as possible to the injury point, bringing to the front a maximum number of teams and resources. We are wondering if this would be sustainable in a cold environment? If in cold weather operating at the front becomes harmful, then we must review this doctrine, without forgetting however what we did in the past in other types of scenarios, that might well come back,” the two medical officers stated.
Training, for medical personnel as well as for combat personnel, is a key element for coping with cold. As LTG Bertrand Toujouse, the Commander of the French Land Operational Forces, said at SITM 2025, while the 27 BIM represent the specialist unit for cold weather operations, this capacity must be spread onto the whole Army, and on the whole of the medical corps the two Medical Officers added. And in both cases, it must involve both surviving as well as operating.
Both specialists in the cold, the two medical officers note that in the “SAFE MARCH RYAN” [1] scheme, the H (for Hypothermia) comes last in MARCH and suggest that it should be given a higher priority.
Cold is definitely an enemy, even for the best-trained soldiers. “I followed a team of 15 members of our High Mountain Group in a raid in Greeceland,” one of the medical officers told the audience. These remained for 15 days at temperatures between -15°C and -30°C, and although it was not a combat mission, all of them suffered some cold-weather injuries, such as frostbites. While at those temperatures probably nobody would dare to fight, it is clear that specialised training is a key element for defeating “General Winter”.
File photos courtesy 27 BIM, Forsvaret © F. Ringnes, and P. Valpolini
[1] The SAFE – MARCHE – RYAN tactical first aid protocol is an essential method for maximizing the chances of survival of seriously injured people, whether they are victims of an intentional incident (such as an attack or a shooting) or an accidental incident (such as a collapse or a road accident). It is broken down into three complementary steps: SAFE, which consists of assessing and securing the situation in order to eliminate any immediate threat to victims and rescuers; MARCHE, which focuses on treating critical injuries in an order of priority, starting with the control of massive haemorrhages; and finally RYAN, which deals with less vital secondary injuries (such as eye injuries) while preparing the safe evacuation of the injured person. Here are the three phases:
SAFE Stop the burning process/ Assess the scene/ Free of danger for you/ Evaluate casualties
MARCHE Massive bleeding control/ Airway/ Respiration/ Circulation/ Head-Hypothermia/ Evacuation
RYAN Reevaluate effectiveness/ eYes/ Analgesia/ cleaN