In June 2026, members of the World Extreme Medicine Fund (WEMF) team will join military medical personnel, operational planners, and multinational healthcare units in Estonia for NATO Exercise VIGOUROUS WARRIOR 2026. Held between 10th to 19th June, Vigorous Warrior is NATO’s largest multinational military medical exercise, bringing together allied and partner nations to test medical readiness, interoperability, evacuation capability, casualty management, and healthcare delivery under operational pressure.
Representing WEMF at this year’s exercise are Mark Hannaford, Luca Alfatti, Travis Kaufman, Alex Gaspar, Medical Commander for The Army of Ukraine Roman Kuziv, and David Stanton, in partnership with the Arkansas Colleges of Health Education’s Center for Global Health and Operational Medicine as well as the Centre for Subversion, Unconventional Interventions and Threats from the University of Nottingham.
Far more than attendance at a multinational exercise, this reflects a much wider change happening across operational medicine, one being accelerated by the realities emerging from Ukraine and the growing recognition that traditional assumptions surrounding casualty evacuation and battlefield medicine are rapidly changing.
Operational Realities Changing Military Medicine
For decades, many military medical systems have operated around the assumption that casualties could be rapidly evacuated through relatively protected evacuation chains towards higher levels of care. The conflict in Ukraine has challenged that assumption entirely. Recent research published in Military Medicine examining lessons from NATO’s Vigorous Warrior Medical Evacuation Workshop highlighted the operational realities now shaping large-scale combat operations. Participants reported evacuation timelines regularly extending beyond 12 hours due to unsafe routes, destroyed infrastructure, and the deliberate targeting of ambulances and medical facilities.
These conditions exist on a considerably larger scale in Ukraine, where contested airspace and persistent threat to medical assets have extended evacuation timelines well beyond anything the systems embedded into conventional large scale forces were designed to accommodate. At the same time, limited availability of blood products far forward, degraded logistics, and contested operating conditions continue to place increasing pressure on forward medical capability.
These conditions change how casualties must be managed. Medicine has always had to operate within the constraints of logistics, mobility, communications, operational resilience, and environmental pressure wherever we care for patients. As all of these become squeezed to breaking point, clinicians and responders are increasingly required to stabilise, manage, and sustain critically injured patients for prolonged periods in difficult and resource-limited settings.
What Is Prolonged Casualty Care?
At it’s core, PCC focuses on the delivery of extended medical care when evacuation is delayed or unavailable. Rather than relying on rapid transfer to definitive care, clinicians must continue managing complex casualties in austere environments for significantly longer periods than traditionally considered. This requires a practical and sustainable approach to patient care that meets combat medics where they are and acknowledges the realities of the responsibility they must shoulder.
In Ukraine, these operational pressures have accelerated the development of adaptive medical practices. Aerial systems used for persistent surveillance and direct attack have made forward deployment of damage control resuscitation and surgery no longer viable. The seniority and resource concentration such capability requires makes it simultaneously too valuable to risk and too visible to an adversary that deliberately targets medical infrastructure. The far forward medical system has had to become decentralised and capable of operating under sustained threat. This has produced a compression of responsibility onto junior medics. It is no longer adequate to consider PCC training beyond their scope, when necessity means they are already managing patients with complex injuries and co-morbidities across extended evacuation timelines.
This situation exposes a doctrinal gap that matters beyond Ukraine. Existing Joint Trauma System Prolonged Casualty Care Guidelines were developed primarily for well-resourced groups doing specific tasks, rather than large scale conventional force operations in high-intensity peer conflict. The operational environment in Ukraine has tested those guidelines against conditions they were not designed for, and the adaptation required is being led by the operational experience of those junior medics in Ukraine. The PCC training WEMF delivers draws on these guidelines while incorporating operational feedback. The exchange runs in both directions: students who are themselves instructors take adapted approaches back to more junior medics in their units, extending the reach of each course well beyond its immediate cohort.
The conflict has also reinforced the importance of interoperability, distributed medical infrastructure, resilient communication systems, and flexible casualty management pathways that can function despite degraded environments and uncertain evacuation. The result is a significant evolution in how operational medicine is being approached across both military and austere civilian environments.
Why Vigorous Warrior Matters
Exercise Vigorous Warrior exists to stress-test these realities in a multinational setting. Organised bi-annually by the NATO Centre of Excellence for Military Medicine, the exercise brings together hundreds of personnel from NATO and partner nations to train across the full casualty pathway, from point-of-injury care through evacuation, surgery, field hospitals, and definitive care systems. The 2024 exercise in Hungary involved over 1,600 personnel from 35 NATO and partner nations and focused heavily on interoperability, casualty flow synchronisation, mobility of medical assets, epidemic response capability, and operational coordination under pressure. Participating nations were able to test experimental doctrinal concepts and multinational medical integration in highly realistic operational scenarios.
For organisations like WEMF, involvement in this environment reflects a commitment to practical operational learning and the ongoing development of austere medicine capability informed by direct experience.
From Operational Experience to Capability Development
Many of the lessons now influencing NATO medical thinking are not theoretical. They are emerging from direct operational experience, including work undertaken by Alex Gaspar and Travis Kaufman alongside Ukrainian collaborators and wider operational medicine networks. That work has included delivering PCC training in Eastern areas of Ukraine, specifically because the medics who needed it can get to the training and be back in their positions without undue delay to the medical operations of their units. Future operational medicine must assume contested environments, delayed evacuation, degraded infrastructure, uncertainty, and the deliberate targeting of medical capability as baseline conditions rather than exceptions.
The lessons we learn inform casualty care beyond military settings alone. The degradation of evacuation chains, logistics, and access to definitive care that characterises high-intensity conflict is also the starting condition in disaster medicine, remote healthcare, humanitarian response, and complex civilian emergencies. Understanding how to manage casualties under those constraints, and how to train people to do so in the environments where they actually work, is the common thread connecting military and civilian austere medicine.
Looking Ahead to Estonia
As Vigorous Warrior 2026 approaches, WEMF’s involvement reflects the organisation’s continued focus on collaboration, operational medicine, humanitarian capability, and practical learning in some of the world’s most demanding environments. Over the coming weeks, we will continue sharing insights into Prolonged Casualty Care, operational medicine development, and the evolving challenges shaping casualty care in austere and high-threat environments.
To learn more about Exercise Vigorous Warrior, visit the NATO Centre of Excellence for Military Medicine and SHAPE NATO Exercise Overview.
Further reading on operational lessons emerging from Ukraine can also be found in the recent Military Medicine research publication discussing NATO medical evacuation doctrine and prolonged casualty care development.