MEDEVAL Course in Tartu

In line with the NATO Warsaw summit 2016, where NATO member states decided to enhance the cooperation and military presence in the Baltic area, LTC Oscar Meijboom, together with Lt Eva Damasdi, Adina Anghelache ROU, Lt Marzena Dudaryk POL, Maj MARIEKE van Deemter NLD and LTC Ruzica Pavic-Kevric HRV, conducted the mobile MEDEVAL course in Tartu, Estonia, from 7-11May 2018. For the live Evaluation we had a complete deployed Estonian R2B available, the same one that was deployed in Vigorous Warrior 2017. The great support of the Estonian Medical Forces, the enthusiastic students from 12 different Nations and the professionalism of the course staff contributed to the succes of this second  MEDEVAL course of 2018.
The next MEDEVAL Course will be conducted in Sarajevo, Bosnia and Herzegovina, from 5-9November 2018.


LTC Dr. Stefano de Porzi (ITA)


The past two decades we have witnessed civilian organizations and the military experience/support in an increasing number of civil-military interactions. However the legitimacy and effectiveness of using the military for humanitarian aims have not always been clearly defined.

At the Riga summit on 29 Nov 2006 NATO Heads of State and Government stated the Alliance to improve its practical cooperation with NATO members and partners, relevant international organizations and non-governmental organizations in order to collaborate more effectively in planning and conducting operations.

At the Bucharest Summit in 2008 it was endorsed a set of pragmatic proposals to develop and implement NATO’s specific contributions to an international comprehensive approach, i.e., the Alliance has to improve its own crisis management instruments and strengthen its ability to cooperate effectively with other actors.

The idea of “Smart Defense” was then introduced during the Lisbon Summit in 2010 and later agreed at the Chicago Summit in 2012. It implies pooling and sharing capabilities, setting priorities and coordinating efforts within NATO better.

Regarding provision of medical support at the civil-military level, operations conducted in recent years have shown the urgent need for a common doctrinal basis in order to conduct medical support based on agreed standards and procedures.

Several reports on lessons learned analyses on medical civil-military Interaction have been achieved so far driven to identify constraints that impact on the use of NATO multinational medical capability and to identify best practices/lessons from civil-military interaction that could inform changes to policy/doctrine/procedures.

Such reports propose that now is the right time to establish a new chapter in civil-medical interaction where civilian and military actors are considered as complementary in a real comprehensive approach which might lead to mutual support within any place to mitigate medical emergencies in theatre areas.


In order to address/investigate in more details the civ-mil medical interaction, the Supreme Allied Commander Transformation (SACT) has identified a need for experimenting in NATO exercises in order to assist in the development of emerging concepts, doctrine and technology. The term “experimentation” being used to include any activity liable to a controlled investigation, brought to an exercise to foster the development of NATO concepts of capabilities across the spectrum of DOTMLPF-I (Doctrine, organization, Training, Leadership, Materiel, Leadership, Personnel, Facilities-Interoperability).

The Military Medical Centre of Excellence (MILMED COE) was tasked by ACT to introduce the Concept Development and experimentation (CD&E) within the NATO Vigorous Warrior 2017 LIVEX, a biennial military medical exercise which was conducted in 2017 in Germany by MILMED COE in close cooperation with ACT and NATO nations. The aim of the VW Exercise is to train and evaluate the interoperability and maneuverability of NATO and partner Nations ‘medical support system in an Article V operation, including responsiveness to a possible biological incident, in a civil context, in order to be prepared to medically support Joint Multinational Operations.

The exercise created excellent opportunity to engage military medical elements in an effort to develop and enhance NATO’s scarce capabilities, as well to ensure that new NATO medical concepts are being exercised/tested across the full capability requirement spectrum.


During last year’s Vigorous Warrior 2017 (VW17) Exercise, the three themes regarding Experimentation were: Interoperability/Modularity, Civil-Military Cooperation Interface and Bio-Responsiveness.

Regarding the experiment design of the VW’17 Civil-Military Cooperation Experimentation Activity, it was depicted a civ/mil medical personnel integration in order to enhance NATO resilience in Article V. OPS, through mutual civ/mil medical understanding, cooperation and support.

In the exercise two experimental units were involved. Emergency modules of a German (DEU) Role 2 Enhanced military Treatment Facility (R2E MTF), and a Rumanian (ROU) Civilian Ambulance Emergency Team. The objective of the exercise was meant to observe interaction between military medical assets and non-military entities, to collect information and analyses of data and lessons learned and finally to initiate a concept development to proceed in the experimentation procedure.

The effects/capabilities were assessed as follows:

-Host Nation Support (HNS) potential
-Modules potential split/merge
-(new) Module Integration
-(new) Module performance coordination with the rest of the adopting MED unit/MTF
-Medical logistics effectiveness
-MASCAL procedures
-Blood products management
-Initial Operational Capabilities (IOF)/Final Operational Capabilities (FOC)
-Cross training Performance
Modified modules ‘performance had to be compared to the standard performance of originally trained & integrated modules.
Surgical modules key personnel were designed to be shifted/replaced in three trials:
-50% personnel replaced
-100% personnel replaced
-All personnel, but one replaced

The last phase due to shortage of time was not conducted.

The analyses outcomes of the trials compared the different conditions and treatments associated with those outcomes from which conclusions and recommendation were extrapolated.

Before the exercise /experimentation took place, the evaluation team had the chance to observe daily routine and performance of MTFs.

The experimentation activity was conducted in two phases as follows: 

-Trial A. The ROU Pre-Hospital Emergency Ambulance (EM) personnel was tasked to replace urgently the original EM Module staff of DEU R2E for diagnostic and treatment of emergency cardiac case patients. The DEU R2E Emergency Module Personnel were not available at the moment to take care of the patients and had to be replaced by the civilian ROU ambulance team, whose support to treat casualty was challenged to work in an unfamiliar environment.
-Trial B. The ROU Pre-Hospital Emergency Ambulance doctor-as single available emergency provider-had to lead the DEU EM nurses Team during treatment of a second emergency cardiac case.

Each scenario ended with an appropriate patient hand over/take over for the responsible physician.

After the briefing of such simulated cases, the civilian participants were invited to fill out an Attitude Questionnaire on the previous procedures.

The aim of the exercise, in which the civilian pre-hospital staff worked in unfamiliar environment was meant to observe/assess/collect:

-How could accidentally involvement of a civilian staff be integrated in a foreign military facility.
-How could the team leader coordinate the foreign team performance.
-How appropriate could be the medical care provided by team/s based on current international guidelines.
-How appropriately could be tested the Non-Technical Skill Performance of the team/s based on the Team Performance Observation Tool of Team STEPPS (Strategies and Tools to Enhance Performance and Patient Safety).
-To collect opinions from civilian health care providers about civ-mil cooperation as contribution of mutual resilience promotion.

The exercise was conducted on 14 September 2017 at the Lehnin Training Area (DEU) endorsed in the VW’17 LIVEX scenario.

During the preparatory phase instructors delivered a briefing to participants, in which all the information were provided about both the background situation and the clinical cases.

Experimentation team/s survey was then conducted with support of Role Players/Simulator/verbal interviews according to the tools available at the moment.

An anonymous Attitude Questionnaire was administered to participants at the end of both trial in a simple question list format requiring mainly YES/NO answers and numerical ratings.

The following areas were observed:

-Interoperability of clinical procedures.
-Interoperability of equipment.
-Communication between civ/mil personnel.
-Integration of the civilian emergency physician/staff.
-Integration of hosted healthcare provider’s staff within an unfamiliar medical facility.
-Integration /Interoperability of the paramedic facility team with the civilian physician.

Findings and Observations captured during the VW’17 EXP were thoroughly analyzed.

This allowed to set out lessons identified in order to optimize cooperation between civilian and military components in joint medical operations as specified in the following rows:

A) TEAM 1 (ROU Pre-Hospital EM Ambulance integrated into the EM Module of DEU R2E):

-Equipment: initial uncertainty of the team regarding EM devices. To prevent such a problem additional preparation and handover time is needed.
-SOPs: a need to build up a solid shared Standard Operating Procedure (SOP). A principle based approach to clinical-decision making was utilized by all participants, which apparently did not come up with negative outcome to patient.
-Communication: while the team of Health Care Providers shared a good professional interaction among them, some initial hesitation was showed with the MTF staff who was supposed to provide them clear and quick information about patient ‘condition.
-Clinical Procedures: Medical Guidelines shared by civilian team did not seem always updated according to international guidelines.
-Interoperability: a lack of common shared SOPs necessarily created unavoidable disorientation highlighted above all during the first phase of the procedure.

B) TEAM 2 (ROU Pre-Hospital EM Physician as single available healthcare provider who led DEU paramedic/nurses team in the second simulated emergency case:

-Equipment: the action of the MTF paramedic/nurse team acting in their familiar environment prevented any delay in the procedures for treatment.
-SOPs: as it was stated above the lack of common shared SOPs again determined a slowdown in the procedures.
-Communication: mastery of a common language is essential. Basic communication was sufficient enough to enable proper decision-making performance.
-Clinical procedures:  lack of common shared clinical procedure determined a slowdown in the process.
-Interoperability: due to the above specified considerations, interoperability in the second phase of the experimentation showed a lower level of outcome compared to the one in the first phase.

Questionnaire findings. Participants were informed that the experiment was designed to test the interaction and interoperability of merely civilian/military elements interacting together in a crisis situation. Comments on feedback from participants was reported.


As a result of the whole exercise/experimentation some recommendations were proposed:

-All the activities regarding future experimentation exercises should be merged in the whole planning process since an early stage, to provide a properly synchronized scenario along with regular exercise activities.
-Clinical cases should be equal for both trials as to make a better comparison baseline to evaluate variables properly.
-Appropriate SOPs necessarily should be shared in common in the civ/mil interaction.
-Regular common shared training should be mandatory to avoid critical interaction among groups of different academic back grounds to keep standards for the best practice.
-The medical team members have to be physical and mentally fit for extended shifts. The emotional component also plays a considerable importance because of the continuous acquaintance with the human suffering, mainly in situations in which a close-knit team will have to face and collaborate in a very short time with other subjects, such as to determine symptoms in persons not suitably trained as referable to “anxiety and increased arousal”. Team members could experience then a psychological impairment characterized by irritability, difficult concentration, sleep trouble, constantly tense and being on guard, which can interfere negatively with the outcome of their task.
-The proper knowledge about the use of DOTMLPFI- Approach (Doctrine-Operation-Timing-Materiel-Leadership-Personnel-Facility-Interoperability) by all participants seems to be crucial for further professional performance improvement.


From the performed analysis of the depicted first step of the experimentation concerning a civ/mil   cooperation/interaction we can conclude that for such common medical readiness /preparation a specific organization and training is required to enhance both capabilities and capacities. Let’s point out how the specific civ/mil education and training is addressing the above mentioned challenges:

-The civ/mil medical teams composition and training should be both well orientated to activities in war conditions. The medical support planning has to be focused on different scenarios also supported by computer simulated exercises as to prepare the team members for prompt and adequate activities in austere, complex and hostile environment.
-The teams should be trained for utilization of available means for providing the best possible outcome within scarcity of resources and under time constrains
-The military medicine is very well experienced in knowledge and policy regarding the levels of medical/surgical care to be executed, as well as the time and place of these procedures in the treatment process. This competencies are supposed to be merged into the civilian component.
-The clear Command, Control, Coordination, Communication and intelligence (C4I) Standard Operating Procedures (SOPs) of the military medical support should provide the required basis for coordination and communications between the teams.
-A common triage system as a basic platform for common medicine activities execution.
-A shared medical logistics system designated for assuring civ/mil teams sustainability in theatre environment.

To summarize the result of such above stated analyses the following are the areas proposed where the civ-mil cooperation could enhance the medical team capabilities:

-Theoretical education
-Planning activities
-Teams training.
-Management and execution.

To reach such outcomes would be necessary to set up :

-A unified doctrine
-Common organizational and clinical SOPs.
-Civil-Military medical interoperability.
-Civil-military medical emergency teams on high readiness in case of complex crises.


For COMMENTS please click here  
Your comments are highly appreciated. Please be informed that all comments are moderated and posted by MILMED COE. Thank you for your understanding.  

The Medical Messenger Point of Contact

MAJ Olga Poprádi-Fazekas (HUN)

MILMED COE Interoperabolity Banch


Mobile: +36 30 181 5928

The Medical Messenger Editorial Board

COL László Fazekas MD (HUN)

COL Salvatore Schmidt MD (DEU)

CAPT (N) Kimberly A. Ferland (USA)

CAPT (N) Jack Taylor MD (USA)

Col Péter Vekszler MD (HUN)

LTC Daniel Aron MD (ROU)

LTC Zoltán Tóth MD (HUN)

LTC Tamás Bognár MD (HUN)

MAJ Olga Poprádi-Fazekas (HUN)

LT Attila Magyar (HUN)


LTC Aron-Gheoghe ARON (MD) (ROU)

The goal of this article is to analyze two medical situations from the Romanian mission in Afghanistan, situations with significant relevance in the right of soldiers to choose their doctor versus the importance of mission accomplishment. This has historically been a significant dilemma for all military leaders. For Romania, as it continues to develop a modern and effective military medical system, this continues to be an issue which must be addressed.

      1.C.D., 26, male, 2012, Kandahar, Afghanistan

A 26 year old male soldier, with altered mental status, pallor, cold sweating and fine tremors, presents to the doctor, two weeks into his deployment. His glycemic level on presentation was 1200 mg/100. After administration of insulin, his blood sugar returned to normal. The remainder of his evaluation confirmed the diagnosis of diabetes mellitus. On further questioning, the patient admitted that he was a known insulin dependent diabetic. He managed to hide this because he was concerned about the effect of his condition on his military career. Back home, he had a civilian family medicine doctor, and he was taken care by a civilian diabetologist. Of course, during the annual military medical check, he had a normal blood glucose level. Since his blood glucose was normal no other blood tests, such as an Hgb A1C, was performed. He was declared healthy and he was cleared for deployment. During the mission he lost his insulin and his previously stable health status began to decompensate.


As a gunner in his platoon, this soldier’s decompensated medical condition during a combat mission not only jeopardized his life, but also those his colleagues. The mission was also compromised since a medical evacuation is usually criteria for an “abort mission”.

      2. M.R. , 30, male, 2013, Zabul, Afghanistan

This patient came to see the doctor after two months of deployment, describing a dry cough for about 10 days, episodic fever, fatigability, irritability, and profuse sweating. On examination he was found to have warm and wet skin, tachycardia (HR-120-140 bpm), blood pressure of 150/90 mmHg, normal respiratory examination, no lymphadenopathy, and no other significant findings. After this initial assessment, hyperthyroidism syndrome was suspected, and the patient was evacuated at ROLE 3 MTF in KAF for further investigation. After further testing, hyperthyroidism was excluded, but a suspicious finding was noted on his chest x-ray. Subsequent chest MRI showed bilateral apical formations as well as mediastinal lymphadenopathy. Tuberculosis could not be excluded, so this patient became a significant epidemiological threat. The patient was immediately isolated and aggressive anti TB triple therapy was strongly recommended. If his therapy was initiated without a positive confirmation of TB infection, any chance for a correct and complete diagnostic work up would become impossible. The patient would be considered infected, under treatment, and forced by the law to complete the entire anti TB treatment regimen back in Romania. Considering the length of therapy with aggressive antibiotics, the patient would be exposed to significant side effects, without having a clear confirmation of   the infection. Furthermore, a TB patent is socially stigmatized, with significant impact on his personal life, on his family and on his career.

Given the fact that there were strong clinical arguments against infection, for example normal X-ray before deployment, vaccination, tuberculin reaction negative, no bacteria in sputa, the battalion doctor deferred treatment in consideration of another more likely pathologic process like sarcoidosis. The patient was evacuated in Romania, where the TB infection was excluded and the final diagnostic was sarcoidosis. Being a self-limited disease, the patient was cured, and able to continue his career, and his social and family life.


Suspicion of highly contagious diseases in a high risk population, is a major threat for public health. Decisive measures should be applied rapidly and effectively. On the other hand, these measures should be balanced with a complete assessment, considering the patient interest, as well.


Analyzing that two medical cases in an operational environment, two apparently opposite ethical meanings can be observed:

  1. Hiding a disease can jeopardize the life and health of soldiers during missions, and also can impact the mission accomplishment.
  2. During missions, the individual’s best interest can be affected by collective force health protection, especially if there is limited access to a second opinion.

The soldier’s best interest, their right to benefit from the best medical care and the best medical decisions can be affected by one of the main functions of the medical system during the missions: force health protection.

So, here is the ethical dilemma: Is the limitation of the right to choose their doctor in the best interest of the soldier? Are the rights of the military community more important than the rights of the individual soldier? Is the military medical system able to provide the best medical care for all soldiers in all circumstances?


Institutional and individual interests should be not divergent. On the contrary, they should be in a synergistic and complementary position.

An effective medical system should be able to provide both, the best medical care for all soldiers and the best medical protection for the troops.

A permanent and accurate system for monitoring individual health status should be a goal to achieve.

Medical decisions should serve the best interest of all the patients and force health protection measures should be well grounded with solid objectives arguments.


 For COMMENTS please click here  
Your comments are highly appreciated. Please be informed that all comments are moderated and posted by MILMED COE. Thank you for your understanding.  

Well written and very interesting article that I think the NATO medical community will also find interesting.  My comment is related to the question of a soldier being able to choose his/her doctor.  In these 2 case examples, that did not seem to be one of the issues since one soldier was hiding a diagnosis and the other was a “new” FHP issue.  Otherwise, thank you for sharing!

CAPT (N) Kimberly A. Ferland (USA)


Your questions are really burning and thought-provoking. I would look these problems from another aspect at. It is clear that Military Medicine needs the clear picture of medical status of all soldiers.  But to deprive someone’s personal rights –is avoidable in the military too, it is sensitive issue, especially as you write – the military is not always able to provide (although this is the goal) the same level of medical care as the civilian one.  In my reading the solution would be the establishment of a single healthcare data storage system to which the military doctors have access to their patients/soldiers health data and vice-versa. (e.g. Leishmanial symptoms often occurs 6-12 months later after the exposure; or PTSD). Another issue would be conscious thinking of the soldiers, this is the foundation of Force Health Protection. If a soldier thinks himself invulnerable (I’m better than the others, they are losers! or To take medicines is weakness) makes the military unit vulnerable and threatens not only the operational effectiveness but soldiers lives. So all soldiers have to develop conscious thinking during their military training from the very beginning.

LTC Dr. Tamás BOGNÁR (HUN ) 



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