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Casualty Estimation in the MPP-CMPEC3 Medical Planning Framework

Written by Lennart Bongartz and Denys Surkov. Post 3 of 7 in the CMPEC3 series. Published in Military Medicine. Follow for Post 4: Materiel.

The Number That Anchors the Medical Plan

Before a single medical kit is packed or a CASEVAC route is plotted, the medical planner must answer the hardest question in battlefield medicine: how many casualties, of what type, arriving when, and from where?

Casualty Estimation is the first and most foundational component of the CMPEC3 framework. Every subsequent planning decision — materiel quantities, personnel requirements, evacuation asset allocation, treatment facility positioning — flows directly from the casualty estimate. The MPP-CMPEC3 framework breaks Casualty Estimation into four sequential sub-components: Population at Risk (PAR), Estimated Casualty Rate, Casualty Injury Profile, and Casualty Flow Analysis.

Population at Risk

PAR defines the total number of people under the medical team’s responsibility within the area of interest. This is broader than it initially appears. It includes own forces, adjacent units, attached elements, civilian contractors operating within the area, wounded enemy combatants (per Geneva Convention obligations where applicable), service animals, and — in Ukraine’s operational context — the humanitarian volunteers and NGO personnel who frequently operate outside formal military governance structures. The involvement of medical NGO’s operating outside formal clinical and military governance, further complicates oversight and poses risks to operational security.

Accurately scoping the PAR prevents both under-planning (insufficient resources for actual demand) and over-planning (diverting scarce assets to groups not under medical responsibility). In a large-scale combat operation involving multiple SOF elements, conventional units, and host-nation forces, the PAR must be agreed and documented — not assumed.

Estimated Casualty Rate

Defining this number is an analytical act, not a concession of failure.

The MPP framework requires that the casualty estimate for units below Brigade level converges on a single agreed-upon number of casualties against which the medical plan is resourced.

This number should be informed by the tactical mission type — attack, defend, patrol, ambush — as well as the medical estimate derived from the MDMP, available trauma registry data, or operational experience. Where two or more  COAs are under consideration in the Brigade planning process (e.g. most likely and most dangerous enemy COA), separate casualty estimates are developed for each, time allowing. The authors acknowledge that formulating a casualty estimate is challenging. A key question is at which echelon this estimate should be calculated. When absent or unreliable, we still advise doing a brisk but decisive casualty estimation to begin planning and to avoid “paralysis by analysis”.

Casualty Injury Profile

The Casualty Injury Profile characterizes likely wound patterns based on mission type, enemy capabilities, insertion method, and environmental factors. It involves selecting the probable ratio of Immediate, Delayed, Minimal, and Expectant triage categories.

For longer-duration missions, the profile should be divided per operational phase: for example Disease and Non-Battle Injuries (DNBI) during pre-staging, and battle casualties during execution.

Special considerations — hypothermia, chemical agents, altitude physiology, etc — are added based on mission-specific hazards.

The injury profile directly shapes materiel planning: a mission with a high proportion of penetrating trauma and blast injury requires different forward surgical and resuscitation capability than one dominated by DNBI and climate-related disease.

Casualty Flow Analysis

Casualty flow analysis estimates when and where casualties are likely to occur across the operational timeline and area of operations. This drives Casualty Collection Point (CCP) placement, evacuation route selection, and the distribution of medical assets across the battlespace. As the authors observe, “assume casualties can occur during any phase of the operation and determine efficient treatment locations and evacuation routes when constructing the evacuation scheme.”

This analysis is the direct precursor to the medical map overlay — the tangible planning product that makes the casualty estimate spatially actionable.

Medical plans must also realistically account for the limit trigger and maximum trigger thresholds, that determine when for example casualty redistribution is initiated or mission feasibility should be reassessed, respectively. This will be addressed in the Constraints & Limitations section.

#MilitaryMedicine #CMPEC3 #CasualtyEstimation #MedicalPlanning #NATOMedical #SmallUnitForces #CombatMedicine #LSCO #ForwardMedicine #MedicalMissionAnalysis

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From Combat Mission to Medical Mission Statement

By Lennart Bongartz & Denys Surkov. Post 2 of 7 in the MPP-CMPEC3 series.

The most dangerous sentence in military medicine is “we’ll figure it out when casualties arrive.” Step 1 of the MPP exists to prevent exactly that — by forcing the medical mission to be defined before the first shot is fired.

The Medical Planning Process begins not with equipment checks or route planning, but with a question: what is the medical mission?

This matters most when medical personnel are not involved in mission planning, as is the often the case in Ukraine (and maybe to some degree in NATO partner forces as well?). Without a defined medical mission, medics respond to events rather than preparing for them. Commanders assume medical support is available; medical teams assume permission to act. Neither assumption holds under fire.

First, understand the combat mission

In many circumstances, the medical commander will not be given a precise medical mission statement. Therefore, it may be necessary to start by deriving a medical mission statement. Step 1 mirrors the TLP’s “Receive the Mission” step. It begins by understanding the combat Commander’s Intent. If absent, formulate a mission statement using the five framing questions — Who, What, When, Where, and Why? This process guarantees that the medical team follows the tactical commander’s strategy, preventing medical units from making independent plans or acting outside those orders.

Then, shape your medical mission

The second element that shapes the medical mission statement are a set of goals and/or specified clinical and evacuation timelines. These should be concrete and grounded in human pathophysiology. The best known example is the NATO “10 minutes-1 hour-2 hour” timeline for POI-care, DCR and DCS, respectively, while SOF is motivated to adhere to “Immediate-30minutes-60 minutes”

Although these timelines can be demanding, failing to define them—or relying on vague terms such as “as soon as tactically feasible”—creates ambiguity. This establishes unclear expectations, and hinders effective coordination with the combat units. “Letting things slide” because of (expected) friction serves no-one.

Balance priorities

The mission statement also forces explicit resolution of three competing imperatives: prioritizing evacuation, prioritizing treatment in place, and prioritizing safety of medical personnel. No single imperative can dominate unconditionally — overemphasis on any one degrades the others. The mission statement defines their balance for the specific operation.

With the medical mission defined and clinical timelines set, the planner proceeds to CMPEC3: the structured analysis of the mission variables. Later, assessment of the medical support plan (by wargaming or TTX) will uncover gaps in planning, identify whether above goals can be achieved and which adjustments are needed.

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The Medical Planning Course to implement the CMPEC3 framework

Teaching medical planning with the CMPEC3 framework

🪖 From *problem framing to *solution to *proof of concept — our latest paper is presently published in AMSUS – The Society of Federal Health Professionals Military Medicine Oxford University Press 📄 Full paper: doi.org(/)10.1093/milmed/usag137 (clickable link in comments)

Modern warfare in #Ukraine has exposed a critical gap in medical doctrine: Small-unit leaders — company level and below — are left without a structured medical planning framework precisely where the fight is most dangerous.

Since 2023, we’ve been working to close that gap, and this publication marks an important #milestone in that effort.

From “problem” to “solution”

The arc of our work:

Firstly, doi.org(/)10.1093/milmed/usaf217, we diagnosed the problem: NATO military medical planning doctrine lacks the granularity needed for small-unit operations, and cultural and organizational barriers compound the challenge.

Secondly, doi.org(/)10.1093/milmed/usaf607, we proposed the solution: the Medical Planning Process (MPP) — a TLP-derived, doctrinally grounded planning cycle for small-unit medical leaders, with the #CMPEC3 mission analysis framework (Casualty Estimation, Materiel, Personnel, Environment, Command, Control & Communications) at its core.

The MPC as Quality Improvement

Thus, in our newest report, we show results of first systematic implementation: the Medical Planning Course (MPC), delivered to 66 Ukrainian military medical personnel — combat medic graduates, senior enlisted, and officers — across multiple formats in Ukraine.

What we found:

✅ A basic medical CONOPS and evacuation scheme can be constructed within hours of structured practice.

✅ Students unanimously recognized the value of structured planning — including those initially skeptical.

✅ Real combat experience in the room, from veteran faculty and peers, validated the CMPEC3 components directly.

Likewise, the challenges in implementation were equally instructive: time pressure from command, the limited fit of NATO Roles of Care in the Ukrainian context, and the need to anchor planning in clinical triage and DCR/DCS rather than fixed-capability.

All in all, the most significant outcome was not a metric — it was a mindset shift. Personnel who arrived skeptical about the feasibility of planning left convinced of its value, with a completed plan in hand.

This is proof of concept of instructional utility and face validation.

The next steps are already being taken: formal validation, scalability, and integration into national doctrine and guidelines.

Grateful to work alongside this exceptional team: Denys Surkov, JOHN M QUINN V, EMT-P, MD, MPH, PhD, CIME, Casper F, Dimitry Kovtunenko, Dimitry Sherman

Tim Bongartz MD, MS, CTropMed, Al Giwa, LLB, MD, MBA, MBE, FACEP, FAAEM, and Professor Martin Bricknell CB OStJ.

The unsung heroes of this are the Ukrainian medics and commanders who gave their time — in a warzone — to make this possible.

#MilitaryMedicine #CombatMedicineTraining #NATO #CMPEC3 #MedicalPlanning #Ukraine #TCCC #SmallUnitTactics #DoctrinalDevelopment #LSCO #MedicalEducation #Casualtycare #MPP #ArmedForcesofUkraine #MilitaryEducation

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The Medical Planning Process and the CMPEC3 Framework

The Medical Planning Process & CMPEC3 framework

March 4, 2026

New post on LinkedIn

A series on Small Unit Medical Planning

by Lennart Bongartz and Denys Surkov

They need standardized and strong tools to plan and execute their operations, as improvisation just won’t make the cut in a high-tempo, high-casualty LSCO environment

Ukraine’s military medical system carries a heavy legacy of post-Soviet cultural tendencies, and has struggled to deliver coordinated casualty care at the frontline. Medical teams are routinely excluded from mission planning, commanders retain ad hoc control over CASEVAC assets, and the After-Action Review culture essential for improvement is largely absent. As we and our co-authors document in the Commentary (Military Medicine, 2025), these are not isolated incidents but is largely a systemic issue. In some instances, Ukrainian medical teams have adapted at an amazing pace, up to the point where they outpace NATO.

Firstly, many of the adaptations to tactical combat casualty care (TCCC) have been codified in Ukrainian medical practice guidelines and provide valuable lessons that helped shape TCCC Guideline updates primarily for point-of-injury (POI) care. On the other hand, a fatalistic attitude towards timely evacuation and thus escalating treatment can be observed, both in Ukraine and in the West. The proliferation of (fiber-optic) drones has created a zone up to 35-50 km deep, where any movement is detected almost instantly. This has led some to conclude that evacuation times of 72 hours or more is the standard planned parameter.

However, we posit that this overlooks the fact that inefficient medical planning is the rule rather than the exception, and that worst-case scenarios tend to get the attention. Where effective tactics, techniques and procedures (TTPs) have been applied – that actually make these medical interventions and casualty evacuation (CASEVAC) fall into place – they had not yet been adequately identified or appraised.

Striving for long-term impact

Accordingly, to ensure long-term systemic change, we started building a medical mission planning approach for our Ukrainian colleagues, not only to reduce the need for improvisation but also as an approach to gather future medical planning data. To liberally quote Michael Hetzler: “90% of what we do in medicine is reactive, but 80% of our succes depends on planning.”

Nor is NATO immune to this problem. The “command transformation” process in Ukraine has been arduous, and many even propose to reverse the flow of learning. Its own doctrine designates the Brigade as the lowest echelon for tactical planning (per APP-28). Below that — at company, platoon, and small-unit level — standardized guidance to plan medical support is heterogeneous, often audience-specific or even outdated. Existing handbooks differ in structure and analytic framing, making cross-unit interoperability difficult and reproducibility unreliable. In a multinational LSCO environment with high casualty rates and contested logistics, this gap could prove to be operationally dangerous.

Building on established practices

The answer is not to abandon proven methodology. The U.S./NATO planning methodologies like the Troop Leading Procedures (TLP) and mission analysis frameworks like METT-TC(I) and factor analysis exist because structured planning under cognitive load outperforms improvisation. This is exactly what the Medical Planning Process (MPP) and CMPEC3 framework aim to provide. Developed through multinational operational analysis and field-validated in Ukraine, the approach closely aligns with above-described methodologies but refocuses them for the medical leaders and providers. By closely mirroring TLP, the MPP helps to align small-unit medical commanders with their tactical counterparts, creating mutual trust and benefit. The CMPEC3 framework allows for comprehensive mission factor analysis to formulate actionable outputs, leading to medical concept of operations (CONOPS).

The upcoming series of posts walks through the main components of the construct, from mission framing to contingency planning.

Further reading:

→ Learn or Lose: Lessons from Ukrainian Training in Germany (MWI)

→ Batchinsky A, Gumeniuk K, Holcomb JB. Clues to survival in future LSCOs are to be found in the current war in Ukraine. Trauma Surgery & Acute Care Open. 2025;10:e001962. https://doi.org/10.1136/tsaco-2025-001962

→ Disruptive Medicine for Denied Battlespaces (Irregular Warfare Center)

→ Drone Warfare Requires a New Age of Battlefield Medicine (Military Times)

→ Seven Lessons for Military Planners (MWI)

→ RAND: Sustaining the Fight

→ Krueger Izaguirre, Cox, Lodi et al. To Conserve Fighting Strength in Large-Scale Combat Operations. Military Review. March 2025 Online Exclusive Article

→ Beldowicz, Bellamy, Modlin. Death Ignores the Golden Hour. Military Review. March-April 2020.

#MilitaryMedicine #CMPEC3 #MedicalPlanning #NATOMedical #SmallUnitForces #LSCO #CombatMedicine #Ukraine #ForwardMedicine #MedicalDoctrine

Professor Martin Bricknell CB OStJ JOHN M QUINN V, EMT-P, MD, MPH, PhD, CIME Dimitry Kovtunenko Konstantin Gumeniuk Al Giwa, LLB, MD, MBA, MBE, FACEP, FAAEM

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Nieuws

MISSION REPORT

📯MISSION REPORT- MARCH/APRIL 2024

With the donations received by Stichting United We Stand in the special account for “First Responder Training UA” we were able to finance a 2-week long training mission comprising of 4 two-day courses and 1 one-day course.

During this time we were able to train 125 persons.

➡ 90 p. from National Police of Ukraine, KORD and ЛЮТЬ Brigade. See more on the official page of the NPU for the press release, and on Youtube

➡ 20 p. from State Emergency Service of Ukraine (ДСНС) in Lviv region.

➡ 15 youth from Lviv region and people from Сhаritable Foundation «MHP — Gromadi»

We also delivered a significant amount of tactical medical supplies, in cooperation with Protect Ukraine:

➡ 30 black C-A-T tourniquets and 30 6″ combat bandages

➡ 25 complete Bleeding Control Kit – Deluxe from Special Medics & Tactics containing: 1 C-A-T tourniquet, 1 Combat Gauze hemostatic gauze, trauma dressing, 2 FoxSeal, compressed gauze, gloves, trauma shears, rescue blanket and marker.


Our dream team did an excellent job by providing first-hand experiences and tips from the frontline from “Ice Queen”, the best trained foreign medic in Ukraine right now. Carlo was my co-driver again, and turned out to be an expert make-up artist for the fake wounds, with help at a distance from Miriam and Ingrid. Tamara was there, as always: Trauma actor, translator, talisman, and connoisseur of Ukrainian history and culture.

Julia and Chris were there representing Renegade Relief Foundation and were a huge help playing trauma victims for the students.

I can’t say things ran smoothly, especially because not all Ukrainians seem to value our teaching methodologies. The simulation scenarios are to be used judiciously. The context and goals must be stated clearly, especially because the course is medical, not tactical; and the debrief afterwards should be constructive and non-judgmental. A safe learning environment, both physically and mentally, is paramount. This is what we always strive for during our courses. Despite these challenges our team worked together closely, and provided a very solid and useful training to our students.

While I do understand that before a lot of “cowboys” were coming to Ukraine to make a profit on training courses, the people that are left and are still coming to Ukraine after more than 2 years deserve some respect and attention IMHO, instead of denying them the opportunity to show what they are all about. We are all about helping ukraine defend it’s freedom and that of Europe. And to provide the most relevant teaching based on feedback from Ukrainians themselves.
Furthermore, we provide our courses for free, we run entirely on donations and never make any profit from it.
🙏 💸 Please help us with your donation to be able to go back to Ukraine and keep teaching these life-saving skills:

https://qrcode.ideal.nl/qr1.ideal.nl/ac122995-6d16-4d10-a9a8-adce4954a60a

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Training nummer 5 !

Vorige week was het alweer de 5e keer dat we een training voor vrijwilligers konden opzetten!

Wederom weer een groep zeer gemotiveerde deelnemers, trainers en trauma-acteurs.

Helaas is er nog geen zicht op het einde van de oorlog in Oekraine en blijft humanitaire hulp noodzakelijk. Het blijft daarom ook noodzakelijk om vrijwilligers te blijven trainen en enigzins voor te kunnen bereiden op (medische) noodsituaties.

Tijdens de tweedaagse cursus behandelden we wederom de basale handelingen die zij kunnen ondernemen om levensbedreigende verwondingen ter plaatse te behandelen. Hiervoor volgen wij zoals gewoonlijk het basis M.A.R.C.H. acroniem. Lees hier meer over op onze homepage.

We oefenden ook weer persoonlijke veiligheid, situationeel bewustzijn, groepscommunicatie en bespraken verschillende manieren om zo goed mogelijk voor te bereiden op een missie. (TIP: maak een “no-comms plan”).

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Missie III – Kyiv, Oktober 2023

Afgelopen oktober zijn we voor de 3e keer voor trainingen naar Kyiv afgereisd. Wederom 6 dagen training, verdeeld in 3 blokken. Deze keer waren Miriam en Carlo weer mee, en hadden we versterking van Miriam’s collega en vriendin, Ingrid. Daarnaast ging Brett ook mee. Hij kwam speciaal voor onze missie over uit de UK.

Via Dmytro en Svitlana konden wij gebruik maken van hun grote bus om alle benodigde spullen te vervoeren. Miriam en Ingrid hadden meerdere dozen mee met “knip-kleding”, tweedehands (leger)kleding die de studenten kapot mogen knippen tijdens de scenarios. Daarnaast een hele voorraad aan siliconen, nepbloed en andere zaken aan om nep-wonden mee te maken.

Daarnaast zijn er meerdere dozen met tactisch medische materialen afgeleverd aan medics van het International Legion.

https://www.instagram.com/reel/Cy_FkLMs0FuJEnvwVsLCtM_YHOLOJwgaOkh_3U0/

De trainingen waren weer druk bezocht en we hebben zo’n 100 personen kunnen trainen in basic MARCH algoritme, verplaatsingstechnieken, communicatie en teamwork.

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Nieuws

Miriam in het nieuws!

Onze eigen Miriam in het nieuws! Check het hier:

GLD Nieuws 20 augustus 2023; GLD Nieuws is het dagelijkse nieuwsprogramma van Omroep Gelderland met aandacht voor nieuws, achtergronden, duiding en portretten. Presentatoren Erik van der Pol, Jasper Lindner, Sonja Booms en Cindy de Koning zetten het belangrijkste nieuws uit Gelderland op een rij. Meer over dit programma: https://ogld.nl/1eg3

Interview in De Gelderlander (Premium artikel) van 11 juli 2023.

Daarnaast waren Miriam en Lennart op 23 augustus te horen op NPO Radio bij Villa VdB. Lennart sloot via telefoonverbinding aan, wat het lastig maakte om de vragen goed te horen. Miriam was live in de studio en had een heel duidelijk en informatief verhaal!

https://www.nporadio1.nl/fragmenten/villa-vdb/78d089c2-2742-4c15-ad40-0a7080041d2c/2023-08-23-hoe-bereiden-trauma-acteurs-oekrainers-voor-op-ernstige-situaties

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Vierde MARCH-protocol training in NL

Op 19&20 augustus gaven we alweer de 4e MARCH-protocol first responder training.

Allereerst ben ik weer super onder de indruk van hoeveel onze studenten leren in die twee dagen! Ze komen binnen met heel weinig kennis, de meesten van hen hadden nog nooit een tourniquet in hun handen gehad. En om ze te zien groeien in die twee dagen is fantastisch om te zien! Van rondscharrelen als een verdwaalde 🐔🐥 in de eerste scenarios, naar het doelbewust volgen van alle stappen van het M.A.R.C.H-protocol in de juiste volgorde, effectief communiceren 📢ondanks de schrik 😱 en chaos😶‍🌫️, en het behouden van situationeel bewustzijn!


Het laat echt het belang zien van een goede basis in theorie en statische oefeningen gekoppeld aan adviezen vanuit de praktijk in 🇺🇦, gevolgd door scenariotrainingen van toenemende complexiteit. Wederom uitstekende grime, make-up en acteerwerk van onze trauma acteurs!

Onze volgende missie naar Oekraine zal in oktober zijn.
Houd updates in de gaten en steun ons financieel 💵💶 om alle operationele kosten zoals verband, gaas, dekens, tourniquets etc. te dekken 🙏

Doneer


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RTV Utrecht maakt verslag van de training

Joost Danvers van RTV Utrecht was vorige week aanwezig bij de training en heeft een prachtig verslag gemaakt van wat we doen, en hoe de deelnemers het ervaren.

https://www.rtvutrecht.nl/nieuws/3605381/lennart-uit-baarn-leert-vrijwilligers-in-oekraine-levens-redden

© 2023 RTV Utrecht

Overlevingskansen vergroten


Dat de deelnemers volledig opgaan in de oefenscenario’s is precies wat Lennart Bongartz beoogt. De Baarnaar wil ze leren hoe ze ondanks alle hectiek van een oorlogssituatie de overlevingskansen van slachtoffers kunnen vergroten door snel in te grijpen. “We doen niet alleen losse oefeningen, maar proberen met simulaties ook de realiteit te benaderen”, legt hij uit. “Van mensen die daarna naar de frontgebieden zijn gegaan krijgen we terug dat dit een van de beste trainingen op dit gebied is.”

© 2023 RTV Utrecht