Are we ready for war? Part 1: The clinical challenges of modern conflict

St Emlyn’s briefing | October 2026

Ed – this is a long read which is not our usual style, but there is much to be covered here. I hope you make it to the end (and some great references and further reading).

War in Europe is no longer something we can regard as a historical event or a problem happening somewhere far away. The war in Ukraine has reminded us that large-scale conventional conflict is still possible, and that the consequences for healthcare systems can be enormous. For those of us working in UK emergency medicine, I think it’s time we started considering what this might mean for our patients, our clinical practice and the skills we may need in the future. I’m not suggesting that war involving the UK is inevitable. I sincerely hope that none of the scenarios discussed here ever come to pass. However, the possibility of a major conflict affecting UK healthcare is sufficiently serious that we should begin thinking about it now. Recent advice in the UK to stockpile suipplies has brought this to the public’s attention, but in the background there has been a lot going on to prepare for the potential impact of conflict affecting the UK.

I was recently sent three excellent articles in the Bulletin of the Royal College of Surgeons of England that linked to a bunch of other stuff I’ve been doing in the last 12 months or so. They address the reception of military casualties into the NHS, the changing nature of battlefield injuries and historical lessons from preparing London’s hospitals for the World Wars. These papers are, in my opinion, essential reading, and I’ve included the references below. They also provide a useful starting point for a wider conversation about emergency medicine and preparedness for conflict.

This is the first of two (probably more) St Emlyn’s articles. In this post, I’ll concentrate on the clinical challenges of modern warfare. In Part 2, we’ll look at the wider implications for our emergency departments, hospitals and the NHS. One of the things we’ve always tried to do at St Emlyn’s is encourage people to think about emerging challenges before they become part of everyday practice. This is one of those occasions.

There is already work taking place nationally involving the NHS, Armed Forces, Royal Colleges and other organisations. I anticipate that more formal guidance, educational resources and recommendations will emerge over the coming months. Those will be the appropriate sources for authoritative advice and coordinated action. When they arrive, please refer to them, not us. In the meantime, I don’t think we need to wait to start thinking. We can familiarise ourselves with the clinical challenges of contemporary warfare, reflect on our existing knowledge and skills, and begin conversations within our departments. We also need to think about where injuries may occur. That’s most likely on the battelfield, but with modern warfare techniques the possibility of events on UK soil should not be discounted.

This article isn’t intended to provide clinical guidance or tell departments how to organise their response. It’s intended to get us thinking about what we might need to learn, practise and prepare for.

You can review the video below following recent wargames in the UK.

Modern warfare is changing the nature of injury

Most UK emergency physicians have experience of trauma, but comparatively few have extensive experience of battlefield injuries. Our trauma systems have developed around civilian injury patterns, with rapid access to imaging, operating theatres, interventional radiology and specialist teams. Warfare produces a different spectrum of injuries, often involving multiple mechanisms simultaneously. The war in Ukraine is particularly instructive because it combines conventional weapons, artillery, mines and explosives with newer technologies such as drones and precision-guided munitions. The resulting injuries are not necessarily entirely unfamiliar, but their frequency, complexity and combination may be very different from those we encounter in routine civilian practice.

There are also differences in the circumstances in which patients are injured and treated. Delayed evacuation, limited access to definitive surgery and prolonged periods of care in austere environments can significantly change the clinical picture by the time patients reach hospital. I’ve met a number of clinicians who are working in Ukraine and the evacuation chain, is more akin to the first world war, than something like the Afghanistan conflict. I’d strongly recommend a read of Wounded, by Emily Mayhew, who describes casualty evacation processes in the first world war, that gives an insight into what that was like then, and perhaps what it is like now in parts of Ukraine.

Blast injuries and fragmentation wounds

Blast injury is an obvious area where we may need to refresh our knowledge. Although most emergency physicians will have learned the principles of primary, secondary, tertiary and quaternary blast injury, relatively few will have extensive experience of managing patients with multiple mechanisms simultaneously.

RCEM Learning – Blast Injuries

Primary blast injury may affect gas-containing structures, particularly the lungs and ears. Secondary blast injury from fragments can produce multiple penetrating wounds, while tertiary blast effects may cause blunt trauma, fractures and traumatic amputations. Burns, inhalational injury and other complications can occur alongside these injuries.

Fragmentation weapons may produce dozens of penetrating wounds across multiple anatomical regions. Relatively small external wounds can conceal significant internal injury, and retained fragments may be difficult to identify without appropriate imaging. We learned in the Manchester bombing that early and comprehensive CT is an invaluable tool here.

Consider a patient arriving after an explosion with multiple small wounds to the chest, abdomen and limbs. They might initially be haemodynamically stable but have reduced hearing, chest discomfort and a swollen painful leg. This patient needs more than a superficial wound assessment. The combination of mechanisms means that we need to have a systematic approach to look for occult penetrating injury (can be really tricky – and I’ll admit I’ve missed a few), blast lung injury, vascular damage and other associated injuries. Initial physiological stability does not exclude significant pathology. Eye injuries, tympanic membrane damage, traumatic brain injury and hearing loss may coexist with more immediately obvious life-threatening injuries, and it’s not uncommon for these to be missed initially (lots of reasons) and so secondary, tertiary, quartenary surveys are really important. These can be overlooked when attention is focused on haemorrhage control and major penetrating trauma (initially) or later when patient move between facilities.. Or when patients present late (as the battlefield may be in a different country).

For emergency medicine, we should refresh our understanding of blast mechanisms, recognise the potential for multiple simultaneous injuries and ensure that our assessment and imaging pathways are appropriate. I would definately download and read the UK Clinical Guidlines on the management of major incidents and Mass Casualty events. There’s some really useful principles in there about the management of war type injuries. We should also think about incoporating these injury patterns into trauma education and simulation, particularly in hospitals where penetrating trauma is relatively uncommon.

Complex extremity injuries and traumatic amputations

We don’t see much in the way of high-energy extremity injuries in the UK, but we do in war injuries. Explosive weapons can produce extensive tissue destruction, contamination, vascular injury, open fractures and peripheral nerve damage. Traumatic amputations may occur alongside other life-threatening injuries, and the extent of tissue damage may be considerably greater than is immediately apparent.

Traumatic amputation with extensive soft tissue damage is possible, and these patients need really good prehospital and initial management (tourniquets, control, debridement etc.) and then repeated operations and staged management.

In the Manchester bombing we saw that many of these patients required multiple, staged surgical management rather than a single definitive operation. Damage-control surgery, repeated debridement, reconstruction and rehabilitation will likely extend over weeks or months. And then comes the rehab and social, financial, psychological support which we provide in major trauma centres, but with a limited capacity. There are also important implications for patients with severe but potentially salvageable limbs. High-energy injuries may involve complex combinations of vascular, skeletal, nerve and soft tissue damage, requiring coordinated decisions between multiple specialties.

For emergency physicians, we need to have the skills to recognise limb-threatening injuries, and all the resuscitation skills around that. including the impact of treatments such as prolonged tourniquet use. We should also consider whether our current trauma training adequately reflects the complexity of these injuries, rather than concentrating predominantly on the initial resuscitation phase. EM may need to provide a greater scope of assessment and management of these injuries. How much could EM contribute to the initial and ongoing management of these injuries?

Burns, crush injuries and combined trauma

Modern conflict may also produce substantial numbers of patients with burns and crush injuries, often combined with penetrating or blunt trauma. Explosions in vehicles, buildings and enclosed spaces may cause thermal injury, inhalational injury and blast trauma simultaneously. Structural collapse can produce prolonged entrapment, crush injury, rhabdomyolysis and acute kidney injury. In civilian practice it is rare that we see these combinations, and when we do they are managed in specialist centres, frequently diverted away from the majority of emergency departments. That may not be the case in war. So there is logic in revisiting our learning and training around these presentations and to reinforce the need to maintain skills in the early management of burns, crush injury and complex multisystem trauma. In a major conflict, access to specialist burns units, renal replacement therapy and critical care may also be constrained by demand. We may well be required to manage more locally, and only send the particularly complex to specialist centres.

RCEM learning- BURNS

Drones and the changing battlefield

One of the most striking developments in Ukraine has been the widespread use of drones. Lloyd and Naumann describe how persistent aerial surveillance and drone attacks have changed both the nature of injury and the ability to evacuate casualties. Small explosive devices delivered by drones can produce complex fragmentation injuries, burns and penetrating trauma. Repeated attacks and the ability to target individuals or vehicles may also create additional risks for rescuers and medical evacuation teams. To date we have only seen them on the battelfield, but as the Ukrainian attack in Russia using lorries taught us, there is potential for drone attacks at distances remote from the battlefield (Operation Spiderweb).

An incident involving multiple drone-delivered explosive devices might produce casualties with fragment wounds, eye injuries, hearing damage and burns. Others may be injured while attempting to escape, including falls, vehicle collisions and crush injuries. The combination of mechanisms, number of casualties and possibility of further attacks creates challenges for both prehospital and hospital teams. Drones also produce more injuries in the upper body, head, face and neck, and so the impact on surgical specialities such as ophthalmology, ENT, Max/Fax may be greater than in past conflicts. As emergency physicians we should be capable of assessing and initially manging those sorts of injuries.

For prehospital clinicians, there are obvious implications for scene safety, the threat of secondary strikes and the protection of rescuers. For hospital teams, there is a need to understand evolving injury patterns and the possibility of receiving patients with complex combinations of trauma. Perhaps most importantly, drone warfare has contributed to another major change in battlefield medicine: the difficulty of evacuating casualties rapidly. More than anything else this is the part of this story that I find so difficult. The casualty evacuation process is changed completely by the use of drones, and the first hand stories I’ve heard from medics in the Ukranian war are difficult to hear.

Delayed evacuation and prolonged field care

One of the fundamental assumptions underpinning modern civilian trauma systems is that seriously injured patients can be transferred relatively rapidly to definitive care. The experience of Ukraine demonstrates that this cannot always be achieved. Persistent surveillance and attacks on evacuation routes can make casualty movement extremely dangerous. Patients may remain in the field for prolonged periods, receiving treatment in austere conditions before reaching surgical facilities. In the event of a war in Europe some patients may then undergo several stages of evacuation and treatment before eventually reaching the UK. This produces a different clinical challenge from the early trauma presentations around which many of our systems have developed.

Consider a patient injured by an explosion ten days previously. They have undergone damage-control surgery overseas and now arrive with an external fixator, multiple wounds, a stoma and a deteriorating physiological state. Their wounds may be infected, renal function may be worsening and they may be colonised or infected with multidrug-resistant organisms. This is not a conventional early trauma presentation. The patient may need complex infection management, infection prevention precautions, further surgery, critical care and coordinated multidisciplinary input. In the current NHS we might expect such a patient to be transferred speciality to speciality bypassing the ED and with plenty of notice and planning. A number of scenarios mean that this might not happen and the front door may be the ED.

Patients with severe extremity injuries who have received prolonged field care may present with extensive tissue necrosis, vascular complications, infection and the consequences of delayed definitive treatment. There may also be problems associated with prolonged immobilisation, nutritional compromise and psychological trauma.

We should be preparing clinicians to recognise and manage the consequences of delayed evacuation, staged surgical treatment and prolonged field care. This includes greater familiarity with complex wound infection, antimicrobial resistance, infection prevention and the complications of delayed definitive care. It also means understanding that the clinical needs of patients arriving from a conflict zone may differ considerably from those of patients presenting immediately after injury.

Infection and antimicrobial resistance

War wounds may be heavily contaminated, involve extensive devitalised tissue and require repeated surgical intervention. Delayed evacuation and treatment in austere environments can further increase the complexity of infection management. Experience from recent conflicts has also highlighted the importance of antimicrobial-resistant organisms in patients transferred between healthcare systems.

Patients may have undergone treatment in several facilities, received multiple courses of antibiotics and been exposed to different healthcare environments before arriving in the UK. This creates challenges not only for individual patient management but also for infection prevention within receiving hospitals. Emergency departments may be involved in the initial assessment of patients with complex wound infections, sepsis and complications of previous surgery. Early recognition of the need for appropriate infection prevention precautions, microbiological advice and specialist surgical input will be important. The micro team will be doing a lot of work both in advising on agents, but also in helping us use them appropriately, and hopefully wisely after getting the right samples

We should consider incorporating these issues into clinical education and hospital preparedness discussions, particularly in organisations that may receive patients evacuated from overseas conflict.

Chemical, biological, radiological and nuclear injuries

Although the injuries currently being reported from Ukraine are predominantly conventional, we should not ignore the possibility of chemical, biological, radiological or nuclear incidents in a future conflict. CBRN preparedness is already part of NHS emergency planning, but the practical challenges remain considerable. This is a large topic and not one that we can explore fully here, but it’s certainly time to start thinking about how we might manage these types of incidents. Salisbury and the Novichock poisonings is a useful reminder that this can happen in the UK.

Departments should be familiar with recognition, initial actions, personal protection, decontamination arrangements and the continuation of essential emergency care during a hazardous materials incident.

Psychological injury and the longer-term consequences of conflict

One of the things that I ssee a lot on the major trauma ward is the psychological impact of trauma. Patients exposed to warfare may experience profound psychological trauma, bereavement, displacement and prolonged uncertainty. Some will have sustained traumatic brain injuries, sensory impairment or other neurological complications that interact with their psychological recovery. Others may present with symptoms related to prolonged exposure to violence, repeated injury or the experience of delayed evacuation and treatment. These problems may become apparent during rehabilitation or later presentations to emergency care.

We need to be aware of the potential for psychological injury alongside physical trauma, and of the importance of appropriate assessment, support and referral pathways. This is particularly relevant if the NHS begins receiving larger numbers of military casualties or civilians affected by conflict. The impact on staff should not be under estimated wither.

What should we be doing now?

I don’t think emergency physicians need to become experts in military medicine overnight, and I certainly don’t think individual departments should attempt to develop their own clinical guidance in isolation. However, there are sensible steps we can take now.

First, we should refresh our knowledge of contemporary battlefield injury patterns. Blast injury, fragmentation wounds, complex extremity trauma, traumatic amputations, burns and crush injuries are all relevant areas for clinical education. Maybe start putting a few elements of this into departmental teaching and journal clubs.

Second, we should consider how prolonged evacuation and delayed definitive care change the clinical presentation. Complex wounds, infection, tissue necrosis, complications of staged surgery and antimicrobial resistance deserve greater attention.

Third, we should incorporate these presentations into trauma teaching and simulation. So a sim of a patient with major trauma presenting at day 10 with complications would be an interesting and challening scenario for most departments, but I’ll bet you could learn a lot by doing it.

Fourth, we should maintain practical CBRN preparedness. Recognition, initial protection and decontamination arrangements need to be understood and rehearsed.

Finally, we should remain connected to emerging evidence and national guidance. Military medical experience is evolving rapidly, and there is much to learn from clinicians working in contemporary conflict environments. Keep your eyes and ears out for new guidance and when it comes read it, share it, disseminate it and practice it.

Final thoughts

The clinical consequences of modern warfare are complex, and the experience of Ukraine demonstrates that both injury patterns and the circumstances in which patients receive treatment are changing. Many of the underlying principles of trauma care remain familiar, but the combinations of injuries, delays to definitive treatment and demands on healthcare systems may be very different from our normal experience. We have an opportunity to learn from those experiences before we are required to apply that knowledge ourselves.

St Emlyn’s is not attempting to replace national guidance. RCEM, RCS and other organisations are already involved in discussions about national preparedness, and I anticipate that more formal recommendations and educational resources will emerge over the coming months.

Our role here is simply to encourage early thinking, discussion and learning.

In Part 2, we’ll move beyond the clinical challenges and consider what potential conflict might mean for our emergency departments and hospitals. That includes the reception of military casualties through RAMP, maintaining civilian emergency care, expanding clinical capabilities, major incidents, infrastructure failure and personal preparedness.

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References and further reading

1. Lloyd ER, Naumann DN. Looking after combat casualties in the era of drones. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.112.
2. Horne SJM, Naumann DN. Preparedness for RAMP: Reception Arrangements for MOD Patients. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.111.
3. Mayhew E. Hub City: how London prepared for the wars of the 20th century. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.114.
4. Ministry of Defence. Armed Forces, NHS and allies test UK battlefield injury response. October 2026.
5. UK Government. Strategic Defence Review 2025: Making Britain Safer — secure at home, strong abroad.
6. UK Clinical Guidlines on the management of major incidents and Mass Casualty events.
7. Armed Forces, NHS and allies test UK battlefield injury response https://www.gov.uk/government/news/armed-forces-nhs-and-allies-test-uk-battlefield-injury-response
8. Entire UK needs to step up to deter threat posed by Russia, Britain’s military chief will warn. https://www.forcesnews.com/services/tri-service/entire-uk-needs-step-deter-threat-posed-russia-britains-military-chief-will
9. Lawry LL, Mani V, Hamm TE, Janvrin M, Juman L, Korona-Bailey J, Maddox J, Berezyuk O, Schoenfeld AJ, Koehlmoos TP. Qualitative assessment of combat-related injury patterns and injury prevention in Ukraine since the Russian invasion. BMJ Mil Health. 2026 Mar 20;172(2):154-159. doi: 10.1136/military-2024-002863. PMID: 39904535; PMCID: PMC13018771.
10. Garcia-Canas R, Navarro-Suay R. Combat-Related Orthopedic Trauma in the Russo-Ukrainian War: A Systematic Review. J Spec Oper Med. 2026 Apr 3;26(1):22-0. doi: 10.55460/J.Spec.Oper.Med.2026.7V8D-PA9N. PMID: 41718681.
11. Dyball D, See CRZ, Bennett AN, Schofield S, Blissitt G, Orton L, Kemp H, Boos CJ, Bull AMJ, Sharp DJ, Graham NSN, Wessely S, Burdett H, Fear NT. Combat Injury, Limb Loss, Traumatic Brain Injury, and Psychosocial Outcomes Among Military Personnel. JAMA Netw Open. 2026 Oct 1;9(10):e2637592. doi: 10.1001/jamanetworkopen.2026.37592. PMID: 42837153; PMCID: PMC13643579.
12. Claireaux HA, Pallett SJ, Moore LS, Edwards AM, Jones JR, O’Shea MK, Ramasamy A. Conflict wounds and antimicrobial resistance: a systematic review on local antimicrobials to prevent infection after extremity open fracture. BMJ Mil Health. 2026 Sep 22;172(5):417-422. doi: 10.1136/military-2026-003255. PMID: 42230000; PMCID: PMC13638339.
13. Jonak K, Matysiak M, Choragiewicz T, Nowakowska D, Zimenkovsky A, Shybinskyi V, Sekh M, Karpiński R, Podkowiński A, Rejdak R. War-related eye trauma: a study of civilian and military cases from Ukraine’s ongoing conflict. Front Public Health. 2025 Feb 10;13:1489445. doi: 10.3389/fpubh.2025.1489445. PMID: 39995622; PMCID: PMC11848850.
14. Trent SA, Beaty L, Peers J, Simon S, Scovorodniev A, Kireeva I, Fishchuk R, Carlson NE, Ginde AA, Bills CB; Denver, Colorado. Clinical epidemiology, microbiology, and care of war-related wounds in Ukraine. J Trauma Acute Care Surg. 2026 Aug 1;101(2 Suppl 2026):S137-S142. doi: 10.1097/TA.0000000000005047. Epub 2026 May 1. PMID: 42065643; PMCID: PMC13412353.
15. Lancet: Health on the front line: 4 years of war in Ukraine. https://www.thelancet.com/action/showCitFormats?doi=10.1016%2FS0140-6736%2826%2900355-7&pii=S0140-6736%2826%2900355-7
16. Hodgetts TJ, Naumann D, Bowley D Transferable military medical lessons from the Russo-Ukraine war BMJ Mil Health 2025;171:101-104.

Declaration: I am currently Dean of the Royal College of Emergency Medicine. This article is written in my personal capacity for St Emlyn’s and reflects my own views, not necessarily those of RCEM.