When the Dots Connect: A systems perspective of casualty evacuation and support for innovation

The Frontline Club, the gathering place for journalists, photographers, and everyone with an interest in international affairs, is built on a commitment to independent journalism, the freedom to report from the world’s most difficult places, and supporting events to encourage a deep dive into ‘frontline issues’. The Club provided the room, and the facilities to ensure that panellists in Kyiv and East Anglia were as present as those in London.

The event was much more than a showcase for medical innovation. It was a map of a system that still needs continuous evolution and integration. The evening was designed to give everyone in the room a view of what it would take to build one and innovations we can build on.

Nadia Yermiichuk and Kateryna Mishchenko from Lawyers Move shared an update on the evolution of frontline evacuation since the start of the full-scale war in Ukraine. Their continuous innovation in order to provide better casualty care as well as security for the medical teams illustrates the power of continuous adaptation and evolution be it from protecting against drones to addressing the risk of hypothermia.

The images below capture the range of innovations they have introduced into their evacuation vehicles, and patient care.

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The thread connecting every speaker was improving patient outcomes. It is well-accepted that the Lethal Triad is a spiral of three factors: hypothermia, which drives acidosis, and acidosis, which drives coagulopathy. Once under way in a casualty, the cycle is far harder to interrupt than to prevent.

Dr Jeremy Mauger, co-inventor of ThermoTraumaPort (TTP) and a clinician at East Anglian Air Ambulance (EAAA), had watched this happen repeatedly: patients who are warm at the scene but haemorrhaging and in shock deteriorate across four or five cold surface transfers before reaching a hospital bed. The clinical insight was clear and defined — and a gap waiting to be translated into a manufacturable device. Out of this was born the TTP.

If Mauger showed that there was a clinical gap which resulted in worse patient outcomes and possible death, Mary Anne Cordeiro, TTP’s CEO, articulated the cost of the solution. It took eight years from identification to backing by NIHR funding, angel investment, matched local capital, patent protection, and dual regulatory navigation across the UK, Europe, and the FDA.

She was candid about the lengthy timelines — and clear that TTP now represents a patented, FDA 510(k)-exempt and registered, robust solution that could be used for military and civilian deployment. TTP is proof that the pipeline, for all its friction, can be navigated. The question she left hanging was what it would take for the next device to travel that distance in a shorter time, not eight years?

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From device to data. The data generated in the golden hour — temperature, blood pressure, oxygen saturation — is among the most valuable clinical information in existence. And yet only 72.9% of pre-hospital clinical data reaches hospital records in controlled UK handovers; for pre-hospital hypotension episodes, the figure drops to 35.7%. The barrier is not technology — a standardised written form lifts retention from 33% to 99%. The barrier is governance: fragmented across 21 independent air ambulance charities with no shared data mandate. Fragmented governance means lost data; lost data means lost lessons; lost lessons mean deaths that could have been prevented. This is a leadership problem, and not a uniquely British one, as author of Transform! Mike Wright highlighted.

Significant operational data from conflict settings — Gaza, Ukraine — has not been systematically analysed. The infrastructure to learn from it does not yet exist.

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Hailie Uren and Solomiia Voitsekhovska, joining from Kyiv, delivered findings that demand a response well beyond Ukraine and the humanitarian community. Up to 37% of casualties arriving at definitive care carry pan-resistant infections — including organisms absent from samples just three years ago. The medevac chain explains why. Drone surveillance and contested airspace have turned rapid extraction into journeys of hours to days, with evacuation teams themselves targeted.

Wounds arrive contaminated; debridement is delayed; antibiotics are initiated before microbiology results return — and by the time they do, the patient has often already been moved. Broad-spectrum treatment at imprecise dosages, repeated across thousands of casualties, is itself a driver of resistance. With nursing ratios at 30:1, resistant organisms move from war-wounded to civilian patients in adjacent beds. Ukraine-associated strains are already documented in Germany, the Netherlands, and Poland. The proposal Hailie and Solomiia put to the room — CBRN decontamination principles applied from point of injury, treating war-wounded as if exposed to a biological agent — is peer-reviewed, published, and urgent.

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Professor Shehan Hettiaratchy brought the operating table into view: what inadequate medevac produces — impossible antibiotic management, delayed amputations, prolonged ICU stays. He has seen it in military theatres, in the NHS, and in Gaza with UK-Med in 2024. He argued for pushing the best technology as far forward as possible in the casevac chain, underpinned by a research framework that makes continuous innovation possible. The cost of not doing it is measured in preventable deaths.

The history of conflict medicine is a warning. Insights generated under the pressure of war have repeatedly been institutionalised in ways that strip out their content, then are forgotten in peacetime and relearned at the cost of the next generation of casualties. Roehampton pioneered integrated rehabilitation after the First World War — demonstrating that physical repair without psychological restoration is incomplete — and within a generation the model had been compartmentalised back into separate specialisms.

McIndoe, rebuilding burned RAF pilots at East Grinstead in the Second World War, showed that treating the injury without treating the person is a clinical failure; his approach was absorbed into psychiatry within a decade of his death. Alberto Cairo’s peer-staffed clinics in Kabul — rehabilitation services run by people who had made the recovery themselves, demonstrating over thirty years the impact of providing jobs and a sense of renewed purpose amongst amputees — remain widely admired and almost nowhere systematically replicated.

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The pattern breaks only when military and civilian sectors are inside the same innovation process from the beginning, building the evidence base together while the urgency still exists — not exchanging lessons after the fact, not waiting for the next crisis to prove what this one has already shown. The question is whether this time the system will be built before the lessons are lost. LSN’s Frontline Innovation series exists to make sure the conversation that answers that question keeps happening.

What made the evening particularly significant was the convergence in the discussion and how the presentations fitted together. Thermal management and infection control are not competing interventions — they are components of the same system. The clinical insights exist. The device exists. The data architecture is understood. The biosecurity evidence is published. The regulatory pathway has been navigated. Each piece is in place. What remains is the commitment for all participants in yesterday’s conversation to assemble them into a solution. Upstream decontamination and thermal stabilisation will together fill the gaps missing in the medevac system. Our task is to build that coherent system which combines the proposed protocol to break the contamination cascade as early as possible whilst reducing the risk of the Lethal Triad through solutions such as that illustrated by TTP.