From Damage Control Resuscitation to Prolonged Care in Ukraine: Evolution of a Small Unit Training Program, 2023-2025

Following the immediate application of the principles of Tactical Combat Casualty Care (TCCC), Damage Control Resuscitation (DCR) is central to reducing preventable death in large-scale combat operations (LSCO), particularly where evacuation to damage control surgical capability is delayed. Beginning in 2023, the College of Remote and Offshore Medicine (CoROM) and Tactical Medicine North (TacMed North) implemented the Damage Control Resuscitation Ukraine (DCR-U) course to upskill Ukrainian frontline medics across the continuum from point of injury through prolonged casualty care (PCC). An initial report described the summer 2024 iteration. This article traces the pedagogical and clinical evolution of the program through subsequent iterations in December 2024 and November 2025, with a focus on integrating prolonged care best practices, the lethal diamond of trauma, and nursing-centric frameworks.

We conducted a narrative program evaluation using triangulated qualitative data from structured after-action reviews (AARs), faculty field notes, participant feedback, and curriculum documents. A mixed civilian-military approach was applied. The analysis examined changes across 3 domains: (1) curriculum content and time allocation, (2) pedagogy and assessment strategy, and (3) integration of clinical governance and national standards. Iterative modifications were mapped against Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs), the Prolonged Care textbook, and the Prolonged Field Care (PFC) Field Handbook.

Over 3 iterations, the program recorded 104 course completions: 94 main-course learner completions across 6 cohorts and 10 additional train-the-trainer completions. Across successive curriculum phases, DCR-U shifted from a primarily procedure-focused format to a longitudinal, systems-based curriculum emphasizing (a) the lethal diamond (hypothermia, acidosis, coagulopathy, and hypocalcemia), (b) 6-72-hour prolonged care planning, and (c) structured nursing frameworks (HITMAN/SHEEPVOMIT) for trend-based decision-making. Local Ukrainian instructors progressively assumed leadership of skills stations and much of the didactic teaching, supported by international faculty in advisory roles. HITMAN and SHEEPVOMIT became the default assessment and nursing mnemonics for simulated cases, linking tactical decisions to physiologic trends and nursing tasks. The course increasingly targeted mid-level providers and unit-level trainers, embedding a train-the-trainer model for scalability.

The evolution of DCR-U from 2023 to 2025 illustrates how DCR training in LSCO can be reframed as a prolonged care and clinical governance intervention rather than a stand-alone skills course. Embedding lethal-diamond resuscitation concepts, PFC nursing mnemonics, and national CPGs allowed Ukrainian partner forces to contextualize DCR within their emerging standards, while the progressive localization of instruction supports sustainability. Future work should formalize pre-course competency benchmarks, longitudinal outcome measurement, and integration with Ukraine's national prehospital training standards.